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Ep 10: Your Acne Isn't Your Fault: The Science Behind Clear Skin

If you know me, you probably know that I’ve struggled with acne my entire life. I had severe, cystic acne for most of my teenage years and early 20s, and eventually I decided to go on Accutane because I was tired of trying all of the topicals. Because I’ve dealt with acne for so long, I’ve always been curious about it - why it happens, what causes it (is it mostly lifestyle, genetics, or diet?) and of course how to treat it. 


What is acne?


We all have these tiny glands near the surface of our skin called sebaceous glands. These glands secrete this chemical substance called sebum, which helps to lubricate our hair and skin and stop it from drying out (if you ever notice your hair getting greasy, that’s because of sebum). The sebaceous glands are attached to hair follicles, which are tiny holes in your skin that individual hairs grow out of. 


When the glands produce too much of this sebum, it can mix with the dead skin cells and form plugs in the hair follicle. If a plugged follicle is close to the skin’s surface, it can bulge outward and create what’s called a whitehead. The follicle can also be open to the skin, which creates a blackhead. 


Additionally, the bacteria that lives on your skin can sometimes contaminate and infect the plugged follicles, which can lead to papules, pustules, nodules, or cysts (these types of acne are usually deeper in the skin and more painful).   


What are the different types of acne?


There are many different types of Acne. The most common form is called Acne Vulgaris; this includes comedones, papules, pustules, nodules, and cystic acne. Acne generally starts as comedones

  • Comedones: A comedo is a hair follicle that has been plugged by excess oil and dead skin cells. If the comedo is open at the skin’s surface, it’s considered a blackhead. Blackheads look dark because of melanin and lipid oxidation, not dirt. If it’s closed at the surface, it’s a whitehead. They’re usually flesh colored bumps and don’t have visible pus. 


If the comedone ruptures, it can turn into a few other types of acne. For the sake of time and interest, please refer to our blog post for more details about these types of acne; I’ll also have a picture here and on the blog for reference. 

  • Papules: Comedones that have become inflamed. They look like small red or pink bumps on the skin’s surface, and they form when a comedone ruptures and bacteria from inside the comedone is released into the layers of skin. Your body responds to the bacteria by becoming inflamed. 

  • Pustules: Papules that have become infected and have a red ring that appears around a white bump (this is what we usually think of when we think of pimples). They can grow really big and can appear anywhere on the body, but they’re usually found on the face, back, and chest. Pustules are most commonly caused by hair follicles becoming plugged by excess oil and dead skin cells. 

  • Nodules: Nodules and Papules are often confused; the difference is that nodules form deeper within the skin’s surface. Nodules form when a bacteria called cutibacterium acnes becomes trapped in your pores, along with the excess oils and dead skin cells that contribute to all types of acne. They are usually hard and can be painful to the touch. They often turn into cystic acne if left untreated. 

  • Cystic acne: usually the most severe type of acne. Cystic acne is similar to nodules, but cysts are filled with pus instead of being hard to the touch. Cystic acne is most commonly found on people with oily skin. 

    • *Note that most dermatologists note nodules and cysts as “nodulocysts”- both sit deep under the skin’s surface and are inflammatory, but cysts have a visible pus cavity while nodules don’t. 


There are also types of acne like “nuclear” acne, fungal acne, steroid acne, folliculitis, and rosacea. They essentially all look like standard acne and just vary in their causes and treatment. 


Lasting effects of acne


After the pimple heals, it’s common to have hyperpigmentation and post-inflammatory erythema, which then has a whole different treatment plan

  • Post-inflammatory Erythema or PIE: A red, pink, or purple mark left on the skin after a pimple is gone. It happens because the small blood vessels under the skin, known as capillaries, will become dilated, inflamed, and then damaged when you get a pimple, and that’s what leaves the residual redness behind. (If you remember, Nat mentioned Erythema (not Edema) in our SPF part 2 episode)

    • PIE is most common in people with lighter skin tones like Fitzpatrick 1, 2, and 3. It can last for months, but it does eventually fade on its own. There are some things you can do to fade them faster. 

  • Post-inflammatory Hyperpigmentation (PIH): These are true scars that can cause a change in texture of the skin. It’s different from PIE because PIE describes residual redness, while PIH is an actual change in the pigment of the skin. 

  • Both PIE and PIH tend to resolve over time (especially with skincare and treatment) and people usually have a combo of PIE, PIH and actual scars. 


Scarring: You can also get actual scars from acne. This usually looks like pits or divots in your skin; it’s caused by damaged skin that has not healed correctly. Damage can occur from infection, squeezing your pimples or picking at your pimples. Picking at pimples can cause more inflammation, which can make scarring worse (which is why everyone says not to pick your pimples). 

  • When the deep layer of your skin called the dermist gets damaged, it can’t produce new collagen at the same rate that the collagen is breaking down. This leaves an area with less collagen, which leaves the skin weaker and less elastic, leading to a scar.  


Acne also has huge lasting mental effects, too. I know from personal experience just how debilitating acne can be to your mental health; it can affect your confidence, make you feel like something is wrong with you, and can even cause actual physical pain. We’re also told that you’ll eventually grow out of acne as an adult, and when that doesn’t happen, it can be really embarrassing. Plus, in the age of filters and FaceTune, there’s even more pressure to look a certain way, and that often does not include having acne. 


Acne can also cause a lot of anxiety and avoidance. When I had acne, my mood completely depended on how my skin looked. I would sometimes cancel plans because I felt so horrible about myself, and avoided going in public. As I got older I kind of got to a point where I didn’t care anymore and would go out in public with no makeup on even during the worst stages of my acne, but I would notice people staring at my skin, which was tough mentally. 


Acne can lead to obsessive, ritualistic or controlling behaviors, like skin picking, trying a bunch of new products (which can often make the problem worse), and becoming obsessed with the way you look. 


Even though acne can be really mentally tough, it can also have some positive effects. People with skin conditions are often more resilient and empathetic; they know how others feel and don’t judge other people’s appearances as much. They can also build more confidence centered around their personality, rather than their looks. It can help with setting boundaries, like telling people not to comment on your skin or that you aren’t interested in advice from anyone. It can also just generally help with disconnecting your self worth from the way you look, which is really hard to do in today’s society.


And listen, as someone who gave up on topicals and went straight to Accutane to clear my acne, I’m not saying that you shouldn’t seek treatment because you can “build mental toughness” by having it. But at least there are some positives to building your mental fortitude while you are on the path to clearing your acne. 


How much do age, hormones and genetics play a role in acne?


Acne most commonly starts in your teens because of an increase in a hormone called testosterone. When we hit puberty, our body starts to create more testosterone, and this leads to more acne. This happens because our sebaceous glands (remember those guys from the beginning of the ep?) have androgen receptors, which is like the “lock” for the “keys” testosterone and DHT. When those hormones bind to the receptors, it tells the sebaceous cells to grow, divide, and make more sebum. When these glands are more active, they are able to contribute to more acne.  


However, just because it’s most common in teenagers doesn’t mean it only occurs in teens. Interestingly, teenage acne is most common in males, but post-adolescent (or adult acne) primarily affects females. 


Hormones can be a HUGE contributor to acne. Many women find that their acne changes with certain phases of their menstrual cycle, and conditions like PCOS can cause acne. Hormonal birth control can also change acne (sometimes making it worse, sometimes clearing it up). 


There are so many other factors like diet, hyperhidrosis, stress, smoking, drugs, cosmetics, seasons and hormone disorders that can contribute to acne. One other one I’d like to highlight is genetics, because these can play a massive role in whether or not you have acne. 


There is a known correlation between certain genes and the severity of acne. I won’t go into it all, but in a study I read, there are three main types of genes that contribute: 

  • Inflammation control genes (controls how strongly you inflame)

  • Oil/hormone metabolism games (controls how much and what kind of sebum you make)

  • Tissue remodeling/scarring genes (how you heal, if you scar or your skin is smooth)


Certain genes also express more depending on your race or ethnic group, so certain races are more prone to acne than others. 


How much does lifestyle and diet play a role in acne?


This topic is VERY touchy because there are a million different sources saying a million different things. Also, I am not a doctor or dietician, so I relied heavily on Lab Muffin (who I trust) for this portion. This is just what I found in my research, but if you’re interested please ask your actual doctor. (Also go read Lab Muffin’s full article because it’s a great resource). 


When it comes to acne and diet, it’s pretty clear that it probably does have a correlation - of course what you put into your body can affect how it looks on the outside. However, the studies we have on acne and diet are pretty unreliable because it’s SO hard to do an accurate study on diet. 


It’s even harder to do studies on women because of menstrual cycles, which can have an enormous effect on acne. Also, birth control and general female hormone cycles can also affect acne, so when you’re doing a study on women, it’s nearly impossible to control for these factors. 


Based on the evidence, it seems like the two things that might cause acne (I say might because the evidence is pretty weak still) are:

  • High GI/GL Diets, which are diets that have a lot of refined sugar and carbohydrates

  • Diets with a lot of dairy, particularly low fat and skimmed milk. It doesn’t seem like yogurt and cheese are linked, but Whey protein might be a problem. 

  • With both of these diets, the proposed way they could be leading to acne is through increasing the levels of insulin in the blood, which can lead to increased androgen hormones, specifically “male” hormones testosterone and dihydrotestosterone (DHT). Like I mentioned earlier, these hormones can increase the production of sebum, which can lead to clogged pores and therefore more acne. 


Basically, if you notice any foods you eat might contribute to breakouts, try not eating them for a short period of time to see if it works. But because diet and acne vary so much from person to person, you don’t need to stress about what you might see online. Just do what’s best for your skin!


What about the skin’s microbiome?


Our skin naturally has a bunch of bacteria on it, and the bacteria is called our microbiome. It’s basically an ecosystem, and when the ecosystem becomes imbalanced (called “disbyosis”), it can lead to inflammation, which can lead to acne. C. acnes is a type of bacteria that lives on human skin, especially in the oily areas like your face, chest, and back. This bacteria doesn’t automatically cause acne, but it can act like a trigger for acne by turning on certain immune pathways. Different strains of C. acnes behave differently in terms of how much inflammation they cause. 


A lack of bacteria can also lead to acne; in fact, if certain bacterial strains dominate and other strains are lost, your microbiome can become imbalanced, which has been linked to more severe acne. Acne treatments can alter which microbes live in the skin and at what amounts, so a lot of topical treatments (and sometimes even oral) have an effect on your skin’s microbiome and whether or not it’s leading to acne. 


What are the different treatments of acne?


First, we’ll start off with the drugs that are used to treat acne. These have to be prescribed by a doctor or dermatologist; none of this info is a recommendation, simply what I found online. 

  • Retinoids

    • These are derived from Vitamin A

    • Adapalene, tretinoin, tazarotene (you can get adapalene over the counter but you can’t get tretinoin or tazarotene at the drugstore)

    • These work by  increasing the rate at which your skin cells turn over, helping prevent clogged pores and calming some inflammation

    • They can be irritating and drying when first using, so you have to build up tolerance. You also need to use them consistently to see results, and you HAVE to use SPF when using these products. Please. I am actually begging you. 

  • Isotretinoin (commonly known as Accutane)

    • This is an oral retinoid 

    • It’s actually not fully clear how Accutane works, but it’s the only medication that addresses the four major causes of acne, which are too much oil production, inflammation, clogged pores, and bacterial overgrowth. 

    • It’s an aggressive route to take to clear acne, but it’s kind of known as the closest thing to a cure we have for acne. 

    • I will be doing a full episode on this in the future since I think a lot of people are curious about it. 

  • Spironolactone

    •  Spironolactone is an oral drug that has actually been used for decades as a diuretic to treat high blood pressure and heart failure. However, it also lowers the androgens in your hormones (remember we talked about how these hormones can lead to an overproduction of sebum, which can lead to acne?) Well, spironolactone reduces these hormones, therefore reducing excess sebum and acne. 

    • It’s a diuretic, so it can make you need to pee more often. Also, it’s used to treat high blood pressure, so it can lead to a lowered blood pressure. 

  • Antibiotics

    • Antibiotics can also be used to clear acne, because an imbalance of bacteria is a big contributor to acne. Antibiotics can be oral or topical. They usually work well, but they aren’t a great long-term solution for acne because of antibiotic resistance.


Now let’s talk about the Over-the-Counter (OTC) treatments approved by the FDA. All of these have specific concentrations they have to be used at, as well as certain phrases that need to be added to the label. I won’t bore you with those details, but I’ve linked the monograph in the blog post in case you’re interested. 


  • Benzoyl peroxide

    • This kills C.acnes by reacting with the membranes in the bacteria. It can penetrate deeply into your pores, and can also loosen skin cells that are deep in the outer layer of the skin. It can also reduce inflammation, which is a big contributor to breakouts. 

    • It can cause irritation, dryness, and bleaching. You can start off by using it in a rinse-off product (like a face wash) and then move to leave-on treatments if your skin is able to tolerate it. 

      • It also interacts with tretinoin, so if you are using both of them in your routine, use BP in the morning and tretinoin at night. It doesn’t interact with other retinoids so you could also just use one of those instead of tret. 

  • Sulfur

    • Can help remove dead skin cells that can clog pores and lead to acne. It also has oil-absorbing properties that can help reduce excess oil, which, as we know, is a big contributor to acne. It’s also antibacterial. 

    • Basically, it works similar to Benzoyl Peroxide and Salicylic Acid, but some sources say it’s more gentle on the skin. It’s also commonly used in combination with resorcinol, which is another FDA approved acne ingredient that is rarely used on its own. 

  • Salicylic Acid

    • Salicylic Acid is an exfoliant and works by penetrating your skin and dissolving the oil and dead skin cells clogging your pores. 

    • It’s part of a class of exfoliants called beta-hydroxy acids, or BHA’s. More on that in a minute. 


Finally, let’s chat about other things that aren’t allowed to use the “acne” verbiage, but are commonly used for acne-like concerns (but they aren’t recognized as actual acne treatments). 

  • AHA’s 

    • Alpha-hydroxy acids, these work by exfoliation

    • Examples include lactic acid and glycolic acid. They generally work well for smoothing and softening the skin, as well as reducing the appearance of fine lines and wrinkles. 

  • BHA’s

    • Beta hydroxy acids

    • Like we mentioned, salicylic acid is probably the most common BHA. These ingredients are used for rough and bumpy skin, as well as psoriasis and, of course, acne. BHA’s are usually seen as less irritating than AHA’s, but it mostly depends on your skin type. 

  • Facials and extractions 

    • Many dermatology offices and estheticians offer chemical peels and extractions to help with acne. A lot of the peels they use have very high concentrations of Trichloroacetic Acid (TCA), Glycolic Acid, Salicylic Acid and Lactic Acid. These concentrations can be effective for acne if used properly. However, the FDA has not approved any chemical peel products, so it is VERY important that you only ever use these under the supervision of a dermatologist or licensed and trained practitioner. 

    • Estheticians also offer extractions, which is just popping the active pimples in a less invasive way than doing it yourself. I think this can be helpful, but it’s not always treating the root cause of the acne (kind of feels like playing whack-a-mole). 

  • Some other common ingredients are niacinamide, zinc, tea tree oil (not necessarily my first choice but some people say it works for them), Poly-hydroxy acids, clays, and probiotics. 

 

What is the best treatment for acne?


It completely depends on the person and their skin type. I’d probably focus on the FDA approved methods of controlling acne, but I know there are a lot of people who have found success with cosmetics in treating their acne. Ultimately it’s up to you and your skin type. Just make sure you patch test any treatment you’re using, document your progress with photos so you know if the product is actually working, and be patient. If a product isn’t working within 3-4 weeks, it’s probably time to try something else; but make sure you aren’t changing products too often, because that can also contribute to irritation and make the problem worse. 


Conclusion


Acne is a condition that affects millions of people, not only physically, but also mentally and emotionally. Bacteria, stress, age, genetics, and hormones are all contributing factors, so it can be difficult to narrow down what’s causing your acne. There are also many different treatments out there, ranging from cosmetic products to heavy-hitting drugs, and it can be hard to know what will work best for your skin. Acne can be extremely difficult to go through, but as someone who has had severe acne and made it out on the other side, I do believe there is an effective treatment for everyone - you just have to be willing to do the work to find it. 


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