Acne: Types, Symptoms, Causes & Treatments

Acne Define
Editor's Note: This article has been recently updated with latest information and research studies.
 

Acne is defined as a chronic skin disorder in which the hair follicles become blocked and/or inflamed. There are several variants

of acne and they range from mild to severe. In almost all cases, acne appears on the face, but acne can also affect the neck, chest, and back area. Although usually not considered a dangerous medical condition, acne can cause psychological distress and even skin scarring. Teenagers are the most commonly affected group with around 85% of 16-18 year olds believed to have some form of acne. However, some people may suffer from acne well into their 30s and 40s even. Although acne usually clears on its own during one’s mid-twenties, it is important to treat* acne early on to prevent scarring and self-esteem problems. Most dermatologists agree that acne is not something we should ignore and given the many treatment options we have today, there’s no reason not to treat* acne. However, treating acne can be difficult in some cases, but most acne responds to current treatment options which include topical and oral antibiotics, cleansing products, moisturizers, and skin peels.

But despite the efficiency of these treatments, most people take a long time before they start treating their acne properly. This is mostly because acne is one of those disorders subjected to myths and misunderstanding which can be quite misleading. For instance, a commonly held belief is that acne is a result of poor hygiene. Because of such thinking, acne sufferers may start using harsh ingredients such as alcohol and sulfates in the hopes of clearing their skin of acne. But what these ingredients actually do is irritate the skin and make acne even worse. Acne is a complicated skin disease involving hormonal, dietary, and hereditary factors and for all these and many other reasons, acne requires a comprehensive approach. Treating acne largely depends on disease severity. Mild acne may only need a couple of adjustments in one’s skin care routine, but severe acne may require antibiotic use and frequent visits to the dermatologist’s office.

Understanding more about acne can help both patients and dermatologists tackle this common skin disorder effectively. Learning about acne will help you find a treatment that is individualized and as such, works best for your specific skin type. After all, not all acne is the same so the treatment of acne needs to be individually tailored. This article will help you understand the underlying mechanisms behind acne and what treatment works best in individual cases. The article will also touch on the latest research on acne the most effective treatment options of today. The more you know about this almost universal skin problem, the easier it will be for you to get on the right route to recovery.

What are the Types of Acne?

Avne Types Info


Acne is a chronic skin disorder associated with increased sebum (skin oil) production and that is characterized by the formation of comedones with or without inflammation. A comedo is a blocked and enlarged hair follicle that is commonly referred to as blocked pores, blackheads, or whiteheads. When a comedo forms, bacteria can get trapped in the follicle which leads to inflammation and the appearance of red bumps that we know as acne. In 1990, the American Academy of Dermatology developed a classification system for acne that is used up until this day. Depending on whether there is inflammation involved, acne is divided into three categories:

Mild Acne: People with blackheads or whiteheads are said to suffer from a mild form of acne. When people say that they have large or clogged pored, most don’t assume that their condition is a form of acne but just the way their skin naturally is. However, from a medical point of view, any type of skin change caused by excess oil production is considered to be a form of acne, including blackheads and whiteheads. Blackheads are “open” types of clogged pores where the debris caught in the pores becomes dark due to oxidation when coming into contact with air. In the case of whiteheads, the sticky substance in the pore does not reach the surface of the skin, but instead, becomes trapped within the hair follicle. Whiteheads appear as white or yellowish bumps in the skin. People with an occasional pimple here and there are also said to have a milder form of acne.

Moderate Acne: In the case of moderate acne, bacteria become trapped in the pore causing inflammation. Mild acne usually appears as inflamed and red bumps on the surface of the skin. These bumps are known as papules (red bumps) and pustules (pus-filled bumps). These types of skin lesions take a short time to heal, usually anywhere between a few days to a week. Along with mild acne, this is the most common type of acne affecting teenagers. Mild acne can also appear in adults from time to time. In women, mild acne can occur due to fluctuating hormones during PMS, pregnancy, or menopause. In men, excess testosterone and hormonal changes can also lead to acne. Acne can also result from certain medical conditions, dietary habits, or as a reaction to some types of medicine.

Severe Acne: People said to be suffering from severe acne have a lot of papules, pustules, nodules, and cysts on their skin. While papules and pustules affect the surface layers of the skin, nodules and cysts affect deeper layers and because of this, they’re difficult to treat* and can be very painful. Nodules are large, painful, and solid lesions that can be several centimeters in diameter. Cysts are painful and pus-filled lesions that can cause visible scarring once the infection is over. But to put it simply, all cases of severe acne results in inflammation in the deeper layers of the skin and they usually take a very long time to heal(up to several months for one blemish). The damage caused by inflammation in severe acne can lead to permanent scarring. Treating this type of acne is complicated and professional treatment is needed.

Besides the classification of acne according to severity, acne is also classified by the type of lesion involved: comedonal, papulopustular, and nodulocystic. Where the first type is non-inflammatory, the other two are characterized by inflammation. Knowing what type of acne you are suffering grom will play a role in the course of your treatment. Inflammatory acne usually involves the use of antibiotics while non-inflammatory require the regulation of oil production and peeling agents to bring under control. Surprisingly, inflammatory acne is easier to treat* than non-inflammatory acne. Anyone who has dealt with acne knows how difficult it is to eradicate blackheads and whiteheads which in many cases become a lifelong problem. On the other hand, inflammatory acne disappears completely once successfully treated. But all types of acne need to be taken seriously. Acne can cause self-esteem issues in adolescents. Untreated acne can also lead to skin damage which makes it harder for the skin to fight environmental toxins.

What are the Signs and Symptoms of Acne?

Acne Signs and Symptoms

The signs and symptoms of acne vary according to disease severity. But in general, all acne is characterized by skin eruptions and lesions. Acne is usually found on the face, especially on the forehead, nose, and chin which are collectively referred to as the “T-zone”. However, acne can appear anywhere on the face and the location of acne seems to be different in adults and teens. While teens usually experience their first acne around the forehead area, adults are more likely to suffer from acne around the chin and jaw area. Acne can also appear on other parts of the body such as the neck, chest, and back but this is less common. The reason why acne appears specifically in this bodily areas is because the skin there has larger oil glands as well as a greater concentration of oil glands. So, acne will appear anywhere on the skin where the sebaceous glands are large and numerous with the face being usually affected. The only areas that cannot be affected by acne are the palms and soles because they do not have any sebaceous glands whatsoever.


Acne Signs:

  • Excessive oil production – If your skin is oily most of the time, then you are very likely to suffer acne. People with oily skin are more likely to suffer from acne than dry skin types. But those with dry skin can have acne caused by hormonal imbalances, improper cleansing, and poor immunity.
  • Blocked pores (opened and closed comedones) – If you notice that your pores appear enlarged and clogged, then this is a sure sign that you have mild acne. This form of acne is believed to account for around 60% of all acne cases according to some studies.
  • Inflamed papules and pustules – Red bumps on the skin are what most associate with acne. This form of acne is not as common as mild acne and appears in 7.6% of the general population. However, raised bumps may not always indicate acne as other medical conditions can lead to similar symptoms.
  • Nodules and cysts – The terms modules and cysts are often used interchangeably but they denote different things. Nodules are growths under the skin and they are very large and painful. Cysts are much smaller and are filled with pus. Both types of acne take a long time to heal, sometimes for up to a couple of months.
  • Post-inflammatory hyperpigmentation – Hyperpigmentation refers to any discoloration on the skin and it is a common result of inflammatory acne. Hyperpigmentation is also difficult to remove*.
  • Post-inflammatory scars – Acne scars are a result of severe forms of acne and require separate treatment. Today’s treatment options can reduce* the appearance of acne scars significantly.


Severity Signs and Symptoms:

  • Mild acne: Usually when there are no more than 30 lesions.
  • Moderate acne: Between 30 and 125 lesions
  • Severe acne: More than 125 lesions.

The numbers given above are rough estimates to make diagnosis easier. But you will probably know from looking at your skin if you have mild, moderate, or severe acne. Also, mild acne rarely causes scarring and hyperpigmentation, although it can lead to the appearance of enlarged pores. On the other hand, moderate and severe acne can lead to scarring and hyperpigmentation. Post-inflammatory hyperpigmentation is the medical term for skin discoloration. It often occurs as a result of inflamed skin producing more melanin as a response to the inflammation. The discoloration can range from light pink to dark brown and it is more commonly seen in dark skin types than those with fair skin. Scarring is another issue those suffering from severe and moderate acne face. It is a result of the pores swelling during inflammatory acne and this can cause a break in the follicle wall and infected material spills in the surrounding tissue which creates even deeper lesions. The skin then attempts to heal these lesions by producing more collagen fibers that usually appear different than the original skin.

What are the Causes of Acne?

Acne Causes Info

Research has tried to determine the cause of acne for quite some time now. In fact, ancient Egyptian scriptures show that even Pharaohs suffered from acne and used a range of natural remedies in the hopes of getting clear skin. So, acne can be said to be a problem that has been bothering humankind since the dawn of civilization. But treatment for acne is flawed up to this day, although our understanding of acne has advanced substantially since the times of the pharaohs. Today, we know that at the core of acne is our hair follicles becoming clogged with a waxy substance produced by our own body. This substance that forms a comedo is a combination of sebum and dead skin cells. Normally, our skin produces a moderate amount of sebum that protects the hair and skin from environmental damage. Skin cells in the follicle also proliferate and are removed by the follicle through sebum production. When the skin produces too much oil and when skin cells shed more than they should, this leads to pore clogging and other unfavorable changes that could affect the health of your skin.

The basic explanation for acne development is that this skin condition is caused by excess sebum production and hypercornification. According to a recently published systematic review covering the research on acne conducted over the last 20 years, the following four essential factors contribute to the development of acne:

  • The Inflammatory Response – In the presence of pathogenic bacteria, the body causes inflammation in the area with the aim of eradicating those bacteria. When a pore gets clogged, bacteria start to proliferate and the body sends white blood cells to the area to remove* the bacteria causing the infection. The result of this immune response is inflammation and pus buildup.
  • Colonization with the bacterium Propionibacterium acnes – Research has found that this strain of bacteria is most responsible for inflammatory acne. The bacterium is a normal part of the skin’s surface, feeding on fatty acids found in sebum. The bacteria only cause problems when colonizing the skin.
  • Increased sebum production – Too much sebum gives acne-causing bacteria food to breed. Excessive sebum production is also very likely to lead to clogged pores which is why it is considered the primary cause of acne oneset.
  • Buildup of Dead Skin Cells (hypercornification) – Skin cells go through a cycle the end of which is dead skin cells accumulating on the skin’s surface. These skin cells together with lipids form a protective film called “stratum corneum” which means “horny layer”. This layer protects the skin from disease and dehydration. But when dead skin cells accumulate inside the hair follicle, this can lead to pore clogging and acne.

And although we know that the above-listed factors are behind the appearance of acne, they don’t really explain much about the essential causes of acne. Most acne sufferers would like to know why their skin behaves the way it does. In other words, they would like to know what is wrong with their body, environment, or skin care routine to make their skin produce too much oil and dead skin cells. Well, this is the same question that research has been trying to answer, but there is, unfortunately, no definitive answer to this. Studies have tried looking into hormones, food, skin care, stress, genetics, and other factors as possible acne culprits and all factors seem to contribute equally to acne.


Hormones
Most people develop acne for the first time in their life with the onset of puberty. Puberty starts when the secretion of sex hormones increases* which is roughly between 11 and 13 years of age. This is important to mention because oil glands have sex hormone receptors and they react to the presence of sex hormones by producing more oil. This also easily explains why acne commonly appears during puberty and is non-existent during childhood. Of all the sex hormones, the primary male hormone called testosterone seems to be more responsible in causing acne than the female hormones, estrogen, and progesterone. Both men and women produce testosterone but men have higher levels than women. In women, acne is more likely to occurring days before their menstruation is due because of a rise in progesterone which is known to worsen acne. Other than sex hormones, other hormones that also rise during teenagehood were found to cause acne. Insulin and growth hormone also stimulates the growth and maturation of sebaceous glands as do stress hormones such as cortisol.


Food
Diet and acne have been a controversial subject in the medical community in the previous century. Research has struggled for a long time to find a link between diet and acne, but today, things seem to be quite different. A study recently published in Clinical, Cosmetic, and Investigative Dermatology concluded that hyperglycemic carbohydrates, dairy, and saturated fats are the three major food classes found to promote acne. A diet high in these types of foods negatively affects the production and functioning of sex hormone binding globulin (SHBG) and insulin-like growth factor-I (IGF-I), both of which have a strong effect on the sebaceous glands.


Skincare
Cleansing, exfoliating, applying makeup, removing* makeup, moisturizing, applying SPF, going out into the sun, and all the other things we do to our skin can have an effect on acne as well. Our skin is much more delicate than we think and the thing with using too many products on our skin is that it can disrupt our skin’s pH and protective layers. Using harsh cleansers and thick creams are known to contribute to acne as well. Sulfate-based cleansers can disrupt the skin’s natural pH which is around (5.5). This disruption can make it harder for your skin to ward off bacteria and the subsequent irritation can lead to even greater oil production. Using thick moisturizers containing ingredients with a high comedogenicity rating can lead to greater pore-clogging.


Stress
Some people may notice their acne getting worse when they’re feeling stressed-out. Because psychological stress leads to changes in hormone production such as an increase* in cortisol production, stress can also indirectly affect our sebaceous glands. A study published in a 2007 issue Acta Dermato Venereologica found a strong link between acne and the stress levels experienced by in school students. But a recent study published in the Journal of Dermatological Treatment explains that acne and stress may have more to do with the ways stress influences immunity than with cortisol stimulation of the sebaceous glands. Stress is known to impair our immunity and those with acne may see a worsening of their symptoms in times of stress as a result of their skin not being able to protect itself against bacteria.


Genetics
If both of your parents had acne, chances are you will too. Acne is considered a highly hereditary condition simply because we inherit our parent’s skin characteristics. In other words, if one of your parents had oily skin, there’s a 50-100% chance that you will too and this alone increases* your risk of developing acne. Recently published studies have even identified the genomes responsible for acne. Previous research found that 81% of acne can be attributed to genetic factors while the remaining 19% was due to environmental factors.


Other factors
Acne can be a symptom of diseases of the endocrine or metabolic system. For instance, polycystic ovarian syndrome can result in late-onset acne, usually around the chin. Diabetes may also cause acne in some by affecting insulin metabolism. Taking steroid hormones is known to cause acne in bodybuilders as is medication such as corticosteroids. Rosacea is a type of skin disease that can also manifest as acne.

Because medical experts usually cannot isolate just one cause of acne, treatment is limited to mitigating the symptoms. Acne is a complicated disease and we don’t know yet why some people develop acne while others don’t. We know that genetics, hormones, and the immune system have something to do with acne onset. Clearing acne can be difficult as a result of a definitive lack in our knowledge of the causes of acne. Luckily, we know the strain of bacteria causing painful pustules and we know that too much sebum can clog the pores. Both sebum production and bacteria proliferation can be easily controlled with the right treatment. It’s also comforting to know that “normal” teenage acne will in most cases clear on its own after some time. Most people don’t suffer acne once they’re in their twenties and may only have occasional issues with mild cases of acne. Those with late-onset acne and persistent acne may suffer underlying medical conditions. These people should see acne as a possible symptom of a serious condition affecting their hormones.

How to Treat* Acne?

Acne Treatment detail

As explained in an article published on the American Academy of Dermatology website, letting acne run its course is not always the best advice. The reason being that without treatment, there’s a chance you’ll develop discoloration and scars. Secondly, treating acne will boost* your self-esteem as most people with acne can’t help feeling insecure about their appearance. And lastly, there are so many effective treatment options out there that there’s no reason why you should not try and reduce* your acne. Both over the counter and prescription treatments can prove to be helpful for acne. If your acne doesn’t become better after trying out numerous drugstore acne treatments, consulting a dermatologist could solve your problems. Dermatologists usually recommend more than one acne treatment which, of course, depends on acne severity. Research shows that acne treatment is most successful when it is individually tailored which is yet another reason why seeking out the help of a dermatologist is a good idea. With that being said, here are some gold standards in the treatment of both teenage and adult acne explained.


Antibiotics
Antibiotics come in topical and oral form and are recommended for inflammatory acne. Clindamycin topical is an example of an effective antibiotic acne treatment. The drug is applied to the skin after cleansing and helps keep acne under control. Unfortunately, clindamycin can lead to skin irritation and peeling so it is not recommended for long-term use. Severe forms of acne may require oral intake of antibiotics. Taking antibiotics does come with its own risks such as allergic reactions, stomach upset, candida infections, and photosensitivity.


Topical Retinoids (Vitamin A Creams)
Topical retinoids are medicinal creams containing chemicals derived from vitamin A. These creams lead better skin cell turnover and they also control sebum production. Retinoids are often prescribed in conjunction with antibiotics in the treatment of acne and they’re known to reduce* the appearance of acne by up to 70%. However, not everyone responds well to retinoids and some may have to discontinue their use of retinoid creams due to skin sensitivity. Irritation, redness, and flaking are some of the side effects of regular retinoid use.


Alternative Antimicrobials
Chemicals such as benzoyl peroxide and salicylic acid are two of the most popular and safest acne treatments out there. Both reduce* inflammation and improve* the overall appearance of the skin. Benzoyl peroxide kills the P. acnes strain of bacteria by releasing oxygen into the hair follicle. P. acnes are anaerobic bacteria and cannot survive in the presence of air. Salicylic acid does not have the ability to kill bacteria but it does unclog the pores. Salicylic acid dissolves the oil plug in the hair follicle making it easier for other agents, such as benzoyl peroxide to enter the follicle. This is also why both ingredients are often used in the same product. The downside to both ingredients is that they have a mild bleaching effect which can increase* the skin’s sensitivity to sunlight. Wearing sunscreen daily can help protect the skin treated with benzoyl peroxide and salicylic acid.


Accutane (Isotretinoin)
Accutane is a well-known oral acne treatment that is very effective in treating the severest forms of acne. The drug is also a vitamin A derivative and it can be taken for up to 20 weeks. The drug works by dramatically reducing* the size of the oil glands, (up to 58%) and it also reduces* the amount of oil produced by the glands (up to 80%). This means less food for acne causing bacteria. Accutane also slows down skin cell turnover which reduces* the risk of pore clogging even further and it has a slight anti-inflammatory effect. Acutance can make acne worse initially, but the results are often positive in the long-run. However, this is a systematic drug, meaning that it affects every organ in the body because it is taken orally. The side effects of Accutane are numerous and can be severe so the drug should be administered with caution and the supervision of a professional.


Hormonal Therapies
Hormonal therapy can be an effective acne treatment for women regardless of the presence or absence of hormonal abnormalities. Doctors may suggest oral contraceptives as a way to keep acne under control. Combination and estrogen contraceptives are usually recommended in such cases while progesterone-only contraceptives can make acne worse. But to get the most benefits, doctors will usually recommend a combination of oral contraceptives with another acne treatment.

How To Mitigate Acne With Over The Counter Remedies?

Counter Remedies Acne

Not everyone is affected with severe acne. Those with mild acne can successfully treat* acne with over the counter remedies. Many drugstore brands sell products containing anti-acne ingredients and these are the things to look for when purchasing skin care products for acne-prone skin:

Salicylic acid is allowed in concentrations in up to 2% in drugstore products which is enough to reduce* comedos over time. Salicylic acid solutions may work best for non-inflammatory acne and when used as a cream or in tonic. Cleansers containing salicylic acid may not make much of a difference because this ingredient needs to stay on the skin in order to unplug the pores.

Other popular ingredients found in anti-acne products are zinc and talc. Zinc works as an anti-inflammatory while talc absorbs excess oil. You will often find these ingredients in liquid and powder foundations and other makeup products. But they’ll also added to mattifying creams and lotions.

Gentle cleansers that preserve the skin’s natural are the best option for those with acne. It is a myth that acne is a result of poor hygiene and that as such needs to be treated with harsh cleansing. This can only weaken the skin’s ability to fight acne-causing bacteria. Also, those treating acne on their own need to be careful with skincare products.

Those with acne need to keep their skin moisturized as much as those with dry and acne-free skin. But be careful when choosing your moisturizer. Water-based and gel moisturizer provide enough hydration without feeling heavy on the skin. Look for ingredients such as hyaluronic acid and glycerin as these don’t cause any problems to those with acne. Avoid natural oils, fatty alcohols, and moisturizers that just feel heavy.

Lastly, sun protection is necessary if you are using any acne treatments. Almost all acne treatments tend to weaken the skin’s resiliency to sun damage.

How to Treat* Post-Acne Scars?

An important component of successful acne treatment is improving* the appearance of the skin. People who’ve suffered severe cystic acne are often left with visible scars, usually along their cheeks and other facial areas. These scars take time to become less noticeable and treating them early on can reduce* the psychological distress acne scars cause. Treatment options include:

Chemical peelschemical peels lead to skin resurfacing. This is a process in which the old skin cells on the surface peel and new skin cells emerge leading to the appearance of rejuvenated skin. Skin resurfacing using chemical peels has been a successful acne scar treatment but the experience itself can be uncomfortable as the process involves applying harsh chemicals on the skin that lead to redness, inflammation, and skin peeling.

Dermabrasion – Dermabrasion is another resurfacing procedure. The procedure involves blending the surrounding skin with the scars to create a more evened-out skin texture. Simply put, a dermatologist “sands” your skin during a dermabrasion procedure using a special instrument.

Excision – Some acne scars can easily be removed with surgical excisions. The procedure works best for large scars and may not be the best option for numerous scars.

Microneedling – This is also known as collagen-induction therapy and it has been successfully used for decades in removing* acne scars. The procedure involves rolling a device containing tiny needles across the skin which results in holes being poked into the skin. This causes small-scale injury to the skin that stimulates collagen production. The end result is evened-out skin. While you can buy a micron-needling device online, it is best to let a professional perform microneedling for best results.

Fillers – Skin fillers are not only used in reducing* the appearance of wrinkles, they work on acne scars as well. Commonly used fillers include fat transplantation, hyaluronic acid, and dermal fillers.

All About Acne

How to Treat* Hyperpigmentation?

Post-inflammatory hyperpigmentation is another common problem that is more likely to affect darker-skinned individuals. Inflammation from acne can lead to more melanin being deposited in the area and the result is an uneven skin tone. Removing* discoloration from the skin is difficult and can take much time before any progress is made. Dermatologists will usually recommend chemical peels, retinoid creams, and vitamin C serums as viable options in the treatment of dark spots caused by inflammatory acne. Using broad-spectrum SPF 30 and above daily is also important when trying to reduce* the appearance of hyperpigmented areas. This is especially true when you are using chemical peels containing hydroquinone, kojic acid, azelaic acid, and glycolic acid. All treatment options can reduce* the appearance of dark spots over time when used in conduction with sun protection.

Conclusion

Acne is an almost universal skin condition with most of the world’s population having suffered acne at some point in their life. Acne first occurs during puberty when our oil glands become active due to stimulation from the sex hormones. Since our oil glands continue producing sebum throughout our lives, many of us continue to experience milder forms of acne well into our 40s. But in most cases, acne clears as soon as we step into adulthood. Despite the chances of acne clearing on its own with time being high, dermatologists wouldn’t recommend not treating acne. If left untreated, acne can become worse and damage the skin. Scarring and hyperpigmentation which are the consequences of untreated acne are much harder to treat* than acne. To prevent such outcomes, it is important to address any acne problems as soon as the first symptoms appear. Another reason why not treating acne is a bad idea is that having acne can cause self-esteem issues. This is especially true for teenagers who are already prone to feeling insecure about their changing bodies. Today, we know more about acne than ever before in history and as a result, there are countless treatment options available. Acne treatment depends on the type of acne involved. When treated with the guidance of a licensed dermatologist, most people can clear their acne relatively fast. These treatments range from oral antibiotics to over the counter creams. But all are considered effective in keeping this common but annoying skin condition under control.

References

  • http://www.dermnetnz.org/topics/acne/
  • https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0025360/
  • http://www.acne.org/accutane.html

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Author

Expert Author : Dr. Ahmed Zayed (Consumer Health Digest)

Dr. Ahmed Zayed Helmy holds a baccalaureate of Medicine and Surgery. He has completed his degree in 2011 at the University of Alexandria, Egypt. Dr. Ahmed believes in providing knowledgeable information to readers. Other than his passion for writing, currently he is working as a Plastic surgeon and is doing his masters at Ain shams University.