Most of us have experienced a terrible acne problem in our teenage years. It plagued us with self-consciousness and worry. Some are lucky enough to outgrow the “breakout” and just have acne from time to time, but there are those who have the misfortune of carrying their zit problems into adulthood. 

This is probably due to our misunderstanding of the concept of acne. To understand it better, we need to look at its science. 

Acne vulgaris

Acne is much more than just your standard red pimple with a little whitehead on top. There is a medical name for it: acne vulgaris. It is the phenomenon responsible for the presence of blackheads, whiteheads, and other types of pimples on the skin. 

Acne for most people is a broad, sweeping definition for all pimple breakouts on our face, chest, shoulders, and back. What we fail to understand is that there are different types of acne, and we mistakenly use the term “breakout” to describe its spread across the skin.

The worst part is that there isn’t a one-size-fits-all approach to nixing acnes for good. This is because there are several factors causing it to occur.

Causes of acne

Acne vulgaris encompasses a variety of skin issues known as “multifactorial diseases”, meaning the condition is caused by a combination of the effects of genes and their interactions with the environment. 

Here are the main factors of acne occurrence:

Excess production of oil

To understand acne, you have to start with human hair. Except on our palms and feet, our entire body is covered by hair shafts anchored by a follicle. Each hair follicle is embedded in the skin with a sebaceous gland filled with oil or sebum. Sebum protects the skin against dehydration and external factors. It also keeps the skin flexible and our hair shiny and soft.

The sebaceous glands grow in size during puberty and certain phases of life (menstruation, pregnancy, illness) because of increased hormonal activity. This in turn leads to increased sebum production. An increased production of sebum can cause ingrown hairs or a pore blockage, resulting in small pimples.

Hyperkeratinisation

The skin renews itself every 28 days. During this renewal process, new skin cells migrate from the bottom to the surface of the skin. The ‘corneocytes’ or the old, dead skin cells flake off the skin, giving way to the new cells. Hyperkeratinisation is the process in which the corneocytes stick on the skin’s surface and fail to peel off. This accumulation of the old skin cells cause pore blockage resulting in the development of primary acne lesions.

Bacteria

The bacterium Propionibacterium Acnes (P. acnes) is always present on the skin. However, it can grow inside the pores where there is an increased production of sebum, which then facilitates the development of acne. The bacteria cause inflammation. 

Inflammation

When the clogged pore bursts open, all the sebum and P. acnes bacteria spill onto the surface of the skin. The presence of large numbers of P. acnes bacteria causes your immune system to react, manifesting in inflammatory lesions.

Lifestyle

All of the factors above can be triggered by the unhealthy parts of our lifestyle: 

• unhealthy diet
• stress 
• certain medications 
• too much exposure to sun 
• poor hygiene 
• poor choice skin care products 

Treating our acne depends on what type of acne it is and what caused it. 

What are the types of acne?

Identifying which type of acne you have is key to successful treatment. There are two types of pimple: noninflammatory and inflammatory.

Noninflammatory acne

Comedones are referred to as noninflammatory acnes. They are hair follicles that are clogged with sebum and dead skin cells. They develop into bumps that are open (blackheads) or closed (whiteheads). Products that may trigger comedones are called “comedogenic” like some makeup. These normally don’t cause swelling.

Inflammatory acne

Pimples that are red and swollen are referred to as inflammatory acne. Sebum, dead skin cells, and bacteria are pushed deep within the skin, clogging up pores and causing inflammatory acne. The inflammation is caused by an infection deep beneath the skin’s surface. 

What are the 7 acne subtypes?

Noninflammatory:

• Blackheads (open comedones) – occur when a pore is clogged by a combination of sebum and dead skin cells. The top of the pore stays open, resulting in the characteristic black color seen on the surface.
• Whiteheads (closed comedones) – form when a pore gets clogged by sebum and dead skin cells. Unlike blackheads, the top of the pore closes up, looking like a small bump protruding from the skin.

Inflammatory:

• Papules – occur when the walls surrounding your pores break down from severe inflammation, resulting in hard, clogged pores that may feel like sandpaper. The skin around these pores is usually pink. 
• Pustules – can also form when the walls around your pores break down. However, postules are filled with pus. They are usually red in color and have yellow or white heads on top.
• Nodules – occur when clogged, swollen pores grow larger from enduring further irritation. They are deeper within the skin.
• Cysts – result from the combination of bacteria, sebum, and dead skin cells. They are the largest form of acne and the most severe.  These fluid-filled bumps often cause permanent acne scars when they heal.
• Milia – often called milia seeds. They form when too much keratin gets trapped underneath the skin, causing small, hard bumps that cluster around the nose, cheeks, and eye area. Milia is most common among babies.

What does hormonal acne look like?

It’s important to understand the difference between hormonal acne and good old-fashioned pimples. Hormonal acne is tied to fluctuations in your hormones such as estrogen, progesterone, androgen, and cortisol (stress hormone). It’s especially common in women.

For some people, hormonal acne takes the form of blackheads, whiteheads, and small pimples. They typically form at the bottom of your cheeks and around the jawline. More often than not, they become inflamed and develop into cysts that tend to pop up in the same place over and over again. 

How do you know what type of acne you have?

You will know what type of acne you have based on the severity of your acnes. Each type of acne has a different level of severity and causes. All this manifests to different appearances, volume, and pain level. 

Severity of acne:

• Mild – Blackheads and whiteheads are the mildest forms of acne. Mild acne treatment includes OTP topical medicine and may take up to eight weeks. You have mild acne when there are 

1. fewer than 20 whiteheads or blackheads,
2. fewer than 15 inflamed bumps, or
3. fewer than 30 total lesions.

• Moderate – Pustules and papules are more moderate forms of acne. Treatment for moderate to severe acne requires prescription medication and may take several weeks. You have moderate acne when there are

1. 20 to 100 whiteheads or blackheads,
2. 15 to 50 inflamed bumps, or
3. 30 to 125 total lesions.

• Severe – Nodules and cysts are the most severe and painful form of acne. This type of acne is more common in men than women. People with severe cystic acne have multiple inflamed cysts and nodules, and deep red or purple acne. Severe acnes leave blemishes that can be classified into two:

1. Acne conglobata which manifest in comedones, inflamed nodules, pustules, foul-smelling cysts, sinus tracts, and atrophic and keloid scarring.
2. Acne mechanica which manifest in red or pink bumps after wearing tight-fitting athletic equipment. It is also referred to as sports-induced acne. It is common among football and hockey players.  

How to treat your acne

There are a wide range of prescription oral and topical treatments.

Topical Treatment

Topical therapy is acne medication that is applied directly to the skin, like gels or creams. Over-the-counter and prescription topical products such as antimicrobial or retinoid creams can often help mild to moderate acne. 

• Salicylic Acid – works as a natural exfoliator and is also lipophilic (has an affinity towards oil). It dissolves debris and excess oil within the pore.
• Benzoyl Peroxide- treats acne from the source while reducing redness and inflammation. It acts as the first line of defense
• Sulfur – absorbs excess oil and dries out dead skin cells to help unclog your pores
• Resorcinol – dissolves whiteheads and blackheads. 
• Salicylic acid – eases swelling and redness that comes with comedones. It also opens blocked pores, allowing pimples to shrink.
• Sulfur – helps keep the surface of the skin dry of oils and actually helps peel off dead skin cells. 
• Tretinoin – works by affecting the growth of skin cells.
• Topical Corticosteroids
• Good skincare – A good skincare regimen goes a long way in getting and maintaining healthy skin. 

Systemic Therapy

Systemic therapy refers to acne medication taken orally or by mouth, like antibiotics. It is mostly used to treat moderate to severe acne.

• Minocycline,
• Doxycycline
• Oral contraceptives for hormonal-related acne 
• Spironolactone, an anti-androgen hormone pill
• Tetracycline and erythromycin 
• Isotretinoin – used only in certain severe cases, or when other treatments don’t work. Pregnant women can’t use this medication as it is linked to birth defects. Isotretinoin can cause dehydrated skin, eye dryness, and irritation.
• Niacinamide – reduces breakouts, cools down inflammation and prevents transepidermal water loss. It has a hydrating and soothing effect on skin

Aesthetic In-Office Treatments for severe acne

• Chemical peels
• Facials
• Laser treatment
• Dermal filler treatments
• Photodynamic Therapy To Combat Bacteria
• Drainage And Extraction To Remove Large Cysts
• Steroid Injections

Bottom line

You may have access to all these treatments, but don’t get too frustrated when they don’t immediately and completely solve the problem. It typically takes about 8- 10 weeks for an acne treatment plan to take full effect. You should also use caution in using too many acne products at once. This may dry your skin, making your pores create more sebum resulting in more acne issues.

Although mild acne may improve with over-the-counter treatments, more severe forms should be treated by dermatologists. They can give you a full and accurate diagnosis. They can also revise your current regimen and incorporate different treatments to maximize your results.