Many people think about acne as an adolescent problem, which it certainly is: 85% of teens and young adults suffer from acne. What is more commonly recognized is that it’s also an adult problem. 35% of women and 20% of men reported having acne in their 30s. 26% of women and 12% of men reported having acne in their 40s. This topic is near and dear to me: I had cystic acne in my early 20’s which my dermatologists helped get me through. The silver lining from this experience is that it I started to seriously consider a career in dermatology…and here we are!
In the family
There is thought to be a genetic predisposition to acne — which might be why you’ve noticed that it runs in the family. Unfortunately you can’t escape your genes; however, there are certain environmental factors implicated in acne.
Chocolate has long been blamed for causing acne and modern studies may explain why it’s been singled out. Food with a high glycemic load (translation: food that raises your blood sugar significantly) is linked to the development of acne. Foods in this category are mostly simple carbohydrates like white bread, white pasta, and sweets. Dairy consumption, especially low fat dairy products, is associated with acne prevalence and severity. It’s thought to be due to the hormones and the protein present in milk. Whey protein, a byproduct of cheese production, is thought to be especially bad, implicated in acne exacerbation.
Makeup and Medications
Certain topical products (moisturizers, sunscreens, makeup) may clog pores, causing or exacerbating acne. In the US, products may be labelled “non-comedogenic,” which is not a standardized metric: more on this later. Occasionally, there are other contributing factors: underlying hormonal dysregulation, medications, or high doses of B vitamins.
What exactly is acne?
You hear acne and you remember the pimple that nearly ruined prom, the blackheads on your forehead that you can’t stop staring at, and that cyst that you kept popping but just made it bigger. What exactly is acne? Acne is an inflammatory skin disorder due to a combination of factors: hormonal influences, inflammation mediated by an otherwise harmless bacteria called P. acnes, and abnormal skin cell turnover. There are different subtypes: non-inflammatory (blackheads, whiteheads) and inflammatory, which may consist of pimples (pustules) and larger cysts. Note that acne may also affect the back and chest. Acne can lead to post inflammatory hyperpigmentation (semi-permanent dark spots left in the wake of a pimple) or even permanent scarring after resolution of deep cysts or spots that have been picked at. Many women may notice that their acne flares around menstruation or is confined to the jawline, which is a sign of acne with a stronger hormonal influence.
Are you sure you have acne?
There are many acne mimickers. Rosacea is another inflammatory skin disorder, most commonly seen in people with lighter skin. Folliculitis may look like acne — it may cause pimple-like lesions on the face, chest, or back. There are actually several subtypes of folliculitis: inflammatory (sterile), bacterial, or yeast. Razor bumps are not the same as acne (a condition called pseudofolliculitis barbae, common in the beard area of men). There are other, less common conditions to consider. A dermatologist can help confirm your acne diagnosis during an evaluation. They can also determine whether there is an underlying cause to your acne, including but not limited to a hormonal condition or a medication that has caused your acne.
Dear acne, please get off my face
There are so many products — once you start looking, you may feel bombarded with different products. Instagram ads, infomercials, towers of acne products at your local CVS. How would anyone know where to start?
- Pick a regimen and stick to it, even when, at first, it doesn’t seem to be helping. Most treatments take 6-8 weeks to see an effect, even with prescription products. Don’t forget to wash your face twice a day as well as after exercising, using a clean washcloth each time to dry your face.
- I’d encourage you to schedule an appointment with a dermatologist who can guide you through your acne journey. They can tailor your acne treatment to your subtype and your personal preferences, using prescription strength products that are tried and true.
- Check your diet: avoid high-glycemic foods such as white bread, white pasta, sugary sodas, and sweets. Data supports this approach across the board and it is a generally healthy way to eat. Consider limiting your dairy consumption. Some of my patients have seen tremendous improvement, even clearance, in their skin after eliminating dairy only; others (including myself) saw no improvement after dairy elimination. My suspicion is that some are dairy sensitive while others aren’t.
- Utilize sun protection. Sunscreen, hats, and sun avoidance will both prevent and treat the postinflammatory hyperpigmentation left behind after the acne resolves.
- It’s okay to use moisturizer. Many of the acne products are drying and some people have acne but don’t have oily skin. I encourage patients to use moisturizer to help them tolerate them better. Make sure it’s labelled non-comedogenic or oil-free.
Ok, so now you’ve set an appointment with a dermatologist. They don’t have an opening for a month. Your acne seems to be getting worse. Luckily, in the meantime, you can get started on a good regimen using over the counter products.
Because P. acnes contributes to acne formation, using an antibacterial agent is important. Benzoyl peroxide (BP) kills bacteria without causing bacterial resistance as well as helps prevent blackhead formation. Watch for skin irritation/dryness (if this happens, you can use it every other day) and bleaching of clothing (so use a white towel and careful with your sheets and clothing). It should also be avoided during pregnancy.
- You can choose a gentle wash containing BP to use in the morning, such as panoxyl acne foaming wash which has 10% BP (same as prescription strength).
- Or you can a gentle cleanser, such as the Cerave foaming cleanser or hydrating cleanser (depending on whether your face is dry or oily) followed by benzoyl peroxide gel such as this one from Clean and Clear (also 10%).
- If you can’t tolerate the benzoyl peroxide or are pregnant, you could try an alternative antibacterial such as azelaic acid, which is naturally found in the skin and is safe to use during pregnancy. It inhibits bacterial growth and helps improve hyperpigmentation. Prescription strength is 15-20% but you can start with this formulation by the Ordinary that has 10% azelaic acid.
- Your dermatologist may prescribe other antibacterial agents that are available by prescription only
I talked about these last week — retinoids are Vitamin A analogs that are a dermatologists’ best friend. They do amazing things for your skin: are anti-inflammatory, help normalize skin turnover to prevent blackhead formation, decrease oil production, and improve the appearance of fine lines and wrinkles. I consider them to be a mainstay of acne treatment. I swear by tretinoin and tazarotene (which are available by prescription only) but you can get adapalene, which was previously a prescription only product, over the counter as Differin Gel. Note that these can cause irritation/redness and should not be used during pregnancy. A few tips regarding retinoids:
- Start slow. Retinoids may cause skin irritation that can take a few weeks for your skin to get used to it, but will eventually subside. To help you ease into it, start every other night and gradually increase to nightly.
- You can your antibacterial in the morning and your adapalene at night or put them both on together once a day. Note that if you have been prescribed tretinoin, it is inactivated by light and by benzoyl peroxide so should only be used at night by itself.
- What about other over the counter retinols? In general, they are less well studied than the medicated products that I have discussed so difficult for me to recommend as a physician, especially for treatment of acne.
- Note that retinoids help improve the appearance of postinflammatory hyperpigmentation and scarring.
Alpha hydroxy acids (most commonly glycolic acid) have also been shown to be helpful for treating acne and have a similar effect on the skin as retinoids: they normalize cell turnover and may improve skin thickness by increasing collagen density, helping with aging. Low dose of glycolic acid (1-10%) may be used at home whereas higher concentrations (up to 70%) may be used under the supervision of a dermatologist in the office as a “chemical peel.” You may also see salicylic acid in many acne products; this is an aspirin derivative that has a mild effect on normalizing cell turnover.
- Glycolic acid alone is considered to be inferior to a retinoid when used alone
- Glycolic acid should be used with caution in patients with sensitive skin and/or darker skin types, due to risk of irritation and risk of hyperpigmentation
Bottom line: I would opt for a retinoid as they are more effective than acids alone but encourage you to talk to your dermatologist about adding glycolic acid if a retinoid alone is not helping you (both for acne and anti-aging).
How do I make sure I’m not clogging my pores?
This is a bit tricky! A general recommendation is to start by choosing products labelled as “non-comedogenic,” which means that the ingredients have been tested and were shown to be unlikely to clog pores. It’s actually still problematic because there is not a standardized definition of what constitutes “non-comedogenic,” including no standardization of what type of testing should be done. For the gory details, read below.* The bottom line is that the non-comedogenic label should be considered as a guide, not a strict rule, to help you in selecting a product. You have to pay attention to whether a given product triggers your acne. Additionally, make sure your skin is very clean before applying topical products; although a product itself may not clog pores, it can trap oil and dirt present on your skin that may contribute to acne formation. For those whose acne is severe or resistant to treatment, I recommend sticking with oil free products, as these are the least likely to contribute to pimple formation.
What else can a dermatologist do for me?
Your dermatologist may recommend oral medications for treatment of acne. I reach for these for patients who have not responded to topicals or come to me with severe enough acne that we go straight for the big guns to prevent permanent scarring. Oral options include limited courses of antibiotics and systemic vitamin A analogs such as accutane (isotretinoin). Women may respond well to hormonal regulators such as spironolactone or certain birth control pills, especially if their acne tends to be worse around their period or limited to the jawline. Your dermatologist will determine which is the best option based on the type of acne, your other medical conditions, and your personal preferences.
There are also office procedures available: steroid injections for larger pimples/cysts, extractions of blackheads, light therapy, and medical grade chemical peels. Note that there are also many procedures available to address acne scarring, including microneedling, laser, microdermabrasion, or chemical peels. Your dermatologist can help you determine which procedures may be appropriate for you.
Mythbusters: Acne edition
- Scrubbing will improve my acne because it cleans the skin deeply. FALSE! Rubbing skin vigorously will cause irritation and make things worse. Avoid harsh scrubs or irritating products (such as alcohol-containing toners) to keep your skin looking its best. Clean thoroughly but gently.
- When using my acne creams, applying them as a spot treatment is best. Also false. Medicated topical products (even over the counter ones) should be applied over the entire face (or chest/back if that’s where you get your acne). These acne treatments not only treat active spots but prevent new ones from forming.
- Once my acne is better, I can stop my treatment regimen. False. Acne, especially adult acne, is unfortunately often a chronic problem. You’ll have to learn how to take care of your skin and commit to a plan. Acne may ebb and flow, which is why it’s helpful to work closely with a dermatologist who can guide you during flare ups.
Final word on acne
I think one message I’d like to come through in this newsletter is that it is not only reasonable but encouraged to seek professional help for this common problem. Acne is not just a cosmetic issue: it impacts quality of life and self esteem and adult acne tends to be chronic. Navigating treatment options, even for mild acne, may be confusing and complicated. There are excellent prescription strength products; whereas, despite the plethora of over the counter products, the options are limited.