But many young adults contend with acne, as it commonly persists into the twenties, and sometimes beyond that. Women are hardest hit — one-third of visits to dermatologists for acne are made by women over 25 years old.
Understanding what is happening in an acne pimple is a science unto itself.
“Acne is a complex inflammatory disorder of the skin,” says Andrea Zaenglein, a dermatologist at Penn State University.
Several elements of skin biology are involved, including the skin’s natural oils — particularly one called sebum, which is produced in hair follicles and increases with puberty; normal skin bacteria — particularly Cutibacterium acnes; skin cells called keratinocytes, which can turn sticky; and inflammation.
Doctors used to think that the skin’s pores got plugged first, and then bacteria moved in and caused inflammation, says Whitney Bowe, a New York dermatologist, describing what she learned in her medical training a decade ago. “Now, inflammation is considered one of the first steps.”
A multitude of contributing elements means acne can be targeted by a multitude of treatments. “We almost always use combination treatment,” Zaenglein says.
A common routine is to use a topical retinoid and a face wash containing benzoyl peroxide. Retinoids are anti-inflammatory and reduce pimples of all kinds — from small blackheads to larger pustules. Benzoyl peroxide kills acne-causing bacteria.
There is an over-the-counter retinoid gel available — adapalene (Differin) — in addition to the prescription products tretinoin (Retin-A), tazarotene (Tazorac) and a higher-strength adapalene. Benzoyl peroxide can be found over-the-counter in face washes and in cream form.
Bowe warns to ease your skin into an acne regimen containing retinoids. While it’s one of the most effective treatments for acne, it can cause some annoying flaking, burning and stinging of the skin. She recommends you use sparingly at first, maybe twice a week for a couple of weeks. If you don’t experience redness or peeling, then you can increase to three times a week for another two weeks, and then to alternate days.
One key thing to know is that your skin’s turnover is slow — six to eight weeks — so it will take time to see if your routine is working. Also, Zaenglein says, “You have to be really consistent.” Still she says that using Differin with a topical benzoyl peroxide is a “really good starting point” — and it’s cost-effective.
Other acne face washes contain salicylic acid, which can be helpful although most studies show it’s less effective than either retinoids or benzoyl peroxide products.
In addition to what’s happening in your skin, other factors play a role in acne, such as hormones — think puberty and monthly cycles. Stress is a factor — that’s why you might break out during finals week.
Diet may affect acne, but let’s stop blaming chocolate. “The data don’t support that,” Zaenglein says.
Indeed, there’s only weak evidence for any food type contributing to acne. Two top suspects are dairy products and high glycemic index foods — those that trigger a spike in blood sugar. Zaenglein warns that there’s a downside to limiting dairy, because that may mean limiting calcium and vitamin D — or might lead teens to replace milk with sugary drinks.
In general, eating a healthy diet including fruits and vegetables is probably good for your skin — along with the rest of your body — whereas eating fatty and sugary foods is probably not.
If OTC treatments aren’t working well, you might visit your doctor or a dermatologist who can prescribe stronger products.
“For mild to moderate acne, seeing a pediatrician or a primary care doctor is a fine first step,” Zaenglein says, noting that wait times to see a dermatologist can be long. “But if your acne is not responding, it’s best to see a dermatologist.”
If you have scarring or discoloration, Bowe says you should definitely see a dermatologist.
“Acne is what dermatologists do,” she says, adding that there’s no minimum amount of acne that warrants a visit.
“It doesn’t matter how much acne you have; it can still cause psychological stress,” she says.
Besides stronger products, doctors might prescribe hormone therapy for girls and women — either birth control pills or a drug called spironolactone.
Antibiotics used to be widely prescribed for acne. Zaenglein says when she started practicing, patients would stay on antibiotics indefinitely. “Now we limit use to three months,” she says.
That’s because skin bacteria can become resistant to antibiotics. So while antibiotics are still a useful tool, they are reserved for short-term use in patients who don’t respond well to other regimens.
Another prescription medication is isotretinoin (Accutane), which is an oral retinoid and is “highly effective,” Zaenglein says. But its use is restricted because of its potential for toxicity in pregnancy.
How about those acne myths?
“The biggest misconception,” Bowe says, “is that acne has to do with hygiene.” And it’s a myth that can lead to over-cleaning and scrubbing skin, which can make acne worse. “It’s not dirt that’s the problem.”
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