If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
What is acne?
Acne (acne vulgaris) is those annoying pimples, papules, whiteheads, blackheads, etc. that most people associate with puberty and the awkward teenage years. Acne can happen in your 30s, 40s, 50s, and even later. When it occurs after age 20–25, it’s called adult acne. As the most common skin problem in the United States, acne affects 40–50 million people at any one time, and nearly everyone has acne at some point in their lives (AAD, n.d.).
- Acne is the most common skin condition in the U.S., affecting 40–50 million people at any age.
- Acne occurs when skin pores get clogged with excess oil and dead skin cells, leading to inflammation and sometimes infection.
- Several causes for acne include hormones, stress, genetics, cosmetics, and diet (among other factors).
- The most common treatments for acne are topical treatments (like tretinoin or benzoyl peroxide) or oral medications (like antibiotics, birth control pills, and isotretinoin).
Acne is a skin condition in which a skin pore or hair follicle becomes clogged with oil (sebum) and dead skin cells. This causes redness and irritation in the skin in the form of a whitehead or a blackhead. In some cases, the clogged pore then also gets infected with a skin bacteria known as Propinum acnes (P. acnes), causing even more inflammation. Women in the U.S. tend to be more prone to adult acne than men, with approximately 12–22% of women get adult acne, whereas only 4–6% of men suffer from the condition (Tanghetti, 2014). While not dangerous, acne can cause permanent scarring, self-esteem and self-image issues, depression, and anxiety.
What causes acne?
Several factors can affect “breakouts” of acne, including hormonal imbalances, stress, diet, genetics, cosmetics, hygiene habits, medications, friction, and underlying medical conditions (AAD, n.d.).
Hormones play a significant role in adult acne. If your hormonal balance changes, you may develop acne. When women have an abnormal ratio of estrogens to androgens (male hormones), they can develop acne. Androgens are often responsible for acne in women as they increase the amount of oil produced by the skin, making women more likely to develop acne. Women are more prone to hormonal imbalances, especially around their periods, during or after pregnancy, around (or during) menopause, and after starting (or stopping) birth control pills.
There is a definite link between stress and adult acne. When you are under stress, your body releases certain hormones that stimulate more oil production. This increased oil makes you more likely to develop acne.
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Diet may affect acne, but the myth that greasy food causes acne is wrong. Some studies show that following a low-glycemic index diet may improve acne. Low glycemic index foods include most fresh vegetables, some fresh fruits, beans, lentils, and whole grains. Everything you eat changes the amount of sugar (glucose) in your blood to some degree. Meals that cause a high spike in blood sugars have a high-glycemic index, whereas low-glycemic index foods do not raise your blood sugar too much. Some research looking at how acne changes when diets are adjusted has found that eating foods with lower glycemic indices can improve acne. The theory is that having a sugar spike causes you to secrete more oils in your skin and increases inflammation. Other studies suggest that drinking cow’s milk (but not yogurt or cheese) increases your risk of getting acne. Scientists need more research looking at the relationship between diet and acne before making definitive diet recommendations.
If your parents or siblings had acne, it is more likely that you will have it, too.
Certain hair products or skincare products can worsen acne, especially if they are oily or tend to clog pores. When shopping for cosmetics for your hair and skin, look for products that have the following terms on the label:
- Won’t clog pores
Also, always remember to remove your make-up before going to bed.
Many people believe that acne is a result of dirty skin, but this is not true. If you over-cleanse your face, you increase your chance of having acne. Washing your face multiple times a day, face scrubbing, and vigorously rubbing your face after a workout are all habits that can irritate your skin and lead to acne forming. You should wash your face with a gentle cleanser and pat it dry. Also, avoid allowing your skin to become too dry. Using a non-comedogenic moisturizer can help keep your skin clear.
Medication side effects
Certain medications (like corticosteroids, antidepressants, anti-seizure drugs, and some types of birth control pills) can cause acne as one of their side effects (OWH, 2018). If you are taking medications that you think may be causing (or aggravating) your acne, be sure to talk to your healthcare provider.
Repeated pressure or friction on the skin, such as from a helmet, bra straps, or backpack, can lead to specific areas of acne.
Underlying medical conditions
Acne can sometimes be an indication of an underlying medical condition, like polycystic ovary syndrome (PCOS). If this is the case, once the medical condition is diagnosed and treated, the acne often resolves.
Treatment options for acne
The good news is that many effective treatment options for adult acne exist. However, not every treatment works for every person, and it may take time to find the best option for you. Some therapies are available over-the-counter (OTC), while others may require a prescription or a procedure. Treatment can vary based on your age and the severity of your acne, and it may take several weeks before you see results. Levels of severity include (OWH, 2018):
- Mild acne: few pimples, whiteheads, and blackheads on the face and/or other parts of the body (chest, back, shoulders, etc.)
- Moderate acne: pimples, whiteheads, blackheads, and papules that cover ¼ to ¾ of the face and/or other parts of the body (chest, back, shoulders, etc.)
- Severe acne: extensive acne plus deep cysts or nodules, significant skin inflammation, pain or tenderness, and/or scarring
Topical medications can be applied directly to the skin both to treat an outbreak and to prevent new acne from forming. They may be used by themselves or in combination with other drugs. Options include (Zaenglein, 2016):
- Benzoyl peroxide: Benzoyl peroxide works by attacking the P. acnes bacteria that live on the skin and can cause acne. By decreasing the presence of this bacteria, benzoyl peroxide can improve your acne, sometimes as soon as five days after starting it. Benzoyl peroxide is available in strengths from 2.5% to 10% and as washes, foams, creams, or gels. Sometimes it is combined with other topical or oral treatments. Side effects include skin irritation, staining or bleaching of fabric, and allergic reactions.
- Topical antibiotics: Topical antibiotics work not only by attacking the bacteria that contribute to acne but also because many of these drugs have anti-inflammatory effects as well. They are often used in combination with benzoyl peroxide because using topical antibiotics alone can lead to antibiotic resistance. The most commonly used antibiotics are clindamycin and erythromycin. In general, most people tolerate these medications well.
- Topical retinoids: Topical retinoids are medications made from vitamin A (retinol). Studies have shown that retinoids are very effective in treating acne by unclogging pores, decreasing oil production, and reducing the inflammatory response. They are useful in both resolving acne eruptions and helping you maintain clear skin. The three most commonly used topical retinoids are tretinoin, adapalene, and tazarotene. Side effects include dryness, peeling, irritation, and redness. Retinoids can also make you more sensitive to the sun and more likely to get a sunburn. According to the U.S. Food and Drug Administration (FDA), some retinoids are pregnancy category C. This means that there aren’t good studies in pregnant women and retinoids should only be used during pregnancy if the potential benefit to the mother outweighs the potential risk to the fetus (FDA, 2014).
- Azelaic acid: Azelaic acid 20% works to unclog pores, kill skin bacteria, and improve inflammation. It can be used alone or in combination with topical antibiotics. Side effects include skin discoloration and irritation.
- Salicylic acid: Some studies show that salicylic acid helps to unclog pores, but clinical trials are limited.
- Dapsone: Dapsone 5% gel, helps to reduce the inflammation in acne. How it works is not well understood, but it seems to work better in women than in men. Side effects include redness, dryness, and orange-brown skin discoloration that can be washed off. It is pregnancy category C.
Oral treatments are usually used for people whose acne does not respond to topical medications or who have moderate to severe disease. Oral therapies are pills taken by mouth and have effects throughout the body (as opposed to topical treatments that are applied directly at the site of acne). Because of this full-body effect, oral treatments typically have more side effects than topical medications and are not usually used as the first choice for acne treatment. Oral medications include antibiotic pills, oral birth control, anti-androgen agents like spironolactone, and isotretinoin.
- Antibiotics: Oral antibiotics are used for people with moderate to severe acne. The tetracycline class of antibiotics is typically tried first. This class includes doxycycline and minocycline. Tetracyclines have both antibiotic and anti-inflammatory properties that make them useful in acne treatment. Side effects include increased photosensitivity, upset stomach, diarrhea, and skin discoloration. Pregnant women and children under eight years old should not use tetracyclines. Certain other antibiotics, like erythromycin and azithromycin, are also sometimes used for acne in people who cannot use tetracyclines. Side effects include nausea, vomiting, and upset stomach. Oral antibiotics should be used for the shortest time possible to prevent antibiotic resistance. Also, these medications are often combined with other treatments like benzoyl peroxide or retinoids to decrease the risk of antibiotic resistance (Zaenglein, 2016).
- Birth control pills: Birth control pills can help clear acne in women by restoring the balance of estrogens and other hormones. Specifically, combined oral contraceptives, which are birth control pills that have both estrogens and progestins, are the most helpful with acne. While often used to prevent pregnancy, birth control pills can help treat acne by decreasing the androgen levels in the skin. There are four combined oral contraceptives that are FDA-approved for treating acne in women: estrogen and norgestimate (brand name Ortho Tri-Cyclen), estrogen and norethindrone (brand name Estrostep), estrogen and drospirenone (brand name Yaz), and estrogen and drospirenone and levomefolate (brand name Beyaz) (Zaenglein, 2016). It may take a few months before you see any effects on your acne after starting this therapy. Birth control pills should only be used by women who are not pregnant and do not want to become pregnant. The most common side effects include weight gain, breast tenderness, and breakthrough bleeding. Rarely, more serious adverse effects like blood clots and heart attacks may occur in some women. Because of these risks, birth control pills are not recommended for women over 35 years of age.
- Spironolactone: Spironolactone is another medication that affects hormone levels in women. It works by blocking androgens in the skin. Spironolactone is generally not used to treat acne in males because it can lead to breast development in men. According to the American Academy of Dermatology (AAD), spironolactone improves acne from 50–100%, and you may begin to see a decrease in breakouts and skin oiliness within a few weeks (AAD, n.d.). Side effects include painful periods, irregular periods, breast tenderness, and breast enlargement. Also, spironolactone is a diuretic, so you may find that you need to urinate more often. It also can affect your potassium levels, so you should avoid taking any potassium supplements while on spironolactone (AAD, n.d). Lastly, spironolactone is not recommended for pregnant women.
- Isotretinoin (brand name Accutane): Isotretinoin is a prescription retinoid medication that is taken by mouth and has been used for over 30 years to treat severe acne (Zaenglein, 2016). This drug treats skin bacteria, clogged pores, increased oil production, and inflammation. About 85% of people see a permanent clearing of their acne after one course of treatment with isotretinoin (AAD, n.d.). It can treat severe acne as well as moderate acne that has not responded to other therapies or is causing scarring and psychosocial distress, like depression, embarrassment, etc. Treatment usually takes 4–5 months or longer. It is imperative that any women of child-bearing age avoid getting pregnant before or during treatment with isotretinoin. It has a high risk of birth defects, so women need to use two forms of contraception during therapy and must be willing to have regular pregnancy tests (Zaenglein, 2016). Other possible side effects include dry skin, eye inflammation, dry eyes, dry mouth and nose, skin that is more sensitive to sun and dryness, mood changes, joint or muscle pains, liver problems, and more (OSW, 2018). Be sure to talk to your dermatologist before starting isotretinoin to discuss the risks and benefits.
Studies have looked at several procedures that can help with acne. While the data may be limited, there may be some benefit to some procedures, including:
- Steroid injections: If you have nodular acne (acne that forms cysts deep in the skin), you may benefit from injecting a steroid medication directly into the nodules to help them resolve. This therapy is effective and commonly used for people with larger acne nodules that do not respond to other treatments. Improvement in appearance and pain occurs relatively quickly with these injections. Side effects include thinning skin in the area of the injection (AAD, n.d.).
- Chemical peels: Chemical peels are minimally invasive procedures that may help with your acne. They work by using harsh chemicals to remove the outermost layer of skin, or chemical peels can go deeper, depending on the strength of the peel. Chemical peels typically use solutions of salicylic acid, glycolic acid, or retinoic acid. Chemical peels may improve the appearance of acne in some people, but the results are short-lived, and most people need repeat treatments (AAD, n.d.). Depending on the strength of the peel, side effects can include changes in skin coloration, infection, and scarring (Chien, 2020).
- Extractions: Whiteheads and blackheads that don’t improve with medical therapy can be removed by your doctor using special instruments. Side effects include potential scarring at the extraction site.
- Lasers/Light therapy: Several different laser or light therapies for acne exist, including pulsed dye laser, CO2 laser, photodynamic therapy, radiofrequency, and more. The data is limited, and more studies are needed.
Many at-home or natural remedies for acne are out there, but there is limited scientific data regarding these treatments. Some remedies are aimed at the causes of acne, like decreasing stress, staying hydrated to keep your skin healthy, and using sunscreen to avoid sun damage. Studies have also looked at the role that diet may play in acne. Some data suggests that avoiding drinking milk and eating a diet rich in low-glycemic foods may help with acne. Lastly, limited data suggest that tea tree oil, zinc supplements, probiotics, and fish oil may improve acne. More research is needed regarding natural therapies.
While acne can be frustrating, especially as an adult, many treatments are available. Your acne can be treated, but it may take some time to find the therapy that works best for you. Mild acne may improve with topical treatments purchased over-the-counter. However, you should consult a dermatologist if your acne causes you embarrassment or depression, does not improve, or causes dark spots or scars.