How to Deal with Acne » The Unclouded Path

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If you’re like most people, you went through the terrible, teenage experience that is acne. For some unlucky people, it can even continue long into adulthood. It affects hundreds of millions of people globally and is the 8^th most common disease worldwide. Naturally, because it’s so common, many myths about acne persist. Here are the facts to clear up the misinformation (hah, pun) and help you deal with acne.

What is Acne?

Acne is a skin condition that results in your hair follicles getting clogged with a combination of dead skin cells and sebum (skin oil). Then, bacteria inside the plugged follicle, like Cutibacterium acnes (C. acnes), multiply excessively and cause inflammation. The degree and location of the blockage results in the various bumps on the skin we associate with acne. Acne mainly affects areas of the skin where there are high concentrations of sebaceous glands (face, neck, shoulders, chest, and upper back).

Symptoms of Acne

Comedones (blackheads and whiteheads): These are just basic blockages near the surface of the skin with no inflammation yet. Whiteheads are plugs of sebum that haven’t broken through the surface of the skin (a closed comedo). Blackheads are the same thing except that the plug is exposed to the air (an open comedo). The air oxidizes the sebum, which makes it turn dark in color.
Papules: These are clogged hair follicles that have begun to get inflamed from the presence of excess bacteria. At this point, there isn’t any fluid visible at the tip, so it’s appears as a pink or red bump on the skin.
Pustules (pimples): These are papules that have pus at the center from the remains of immune cells that arrived to fight the infection.
Nodules: When the blockage happens deeper in the skin, a nodule forms. It’s essentially a papule but deeper, manifesting as a solid, often painful, lump under your skin.
Cyst: When nodules start filling with pus, you get a cyst.

What Causes Acne?

In a normal hair follicle, dead skin cells get pushed up through and out the follicle by the growing hair. With acne, the follicle produces too much sebum and keratin (a protein). This causes the dead skin cells to stick together, which can plug up the exit of the follicle or even the sebaceous gland duct. The resulting environment allows opportunistic skin bacteria like C. acnes to grow. As they grow, they form a biofilm, which makes the plug worse. Eventually, the walls of the follicle rupture and spread sebum and bacteria underneath the surface of the skin.

The body takes notice of this abnormal bacterial activity and starts an inflammation response. In addition, the bacteria change the chemical composition of the sebum, triggering more inflammation. All this attracts neutrophils, macrophages, and other immune cells to the hair follicle. The ensuing battle between the immune cells and the bacteria produces the pus often seen in acne.

While the mechanisms behind the symptoms of acne are pretty straightforward, scientists still haven’t found the exact underlying cause of acne. Contrary to popular belief, acne isn’t caused by dirty skin or sunlight exposure. In addition, the evidence for diet (chocolate or greasy foods, for example), smoking, and stress as causes are inconclusive. Instead current research suggests that about 80% of acne cases are a result of genetics. Hormone fluctuations (particularly androgens like testosterone) also play a role. It’s likely why acne is often linked with puberty and certain phases of the menstrual cycle.

Although they don’t cause acne, there are some things that can worsen the symptoms. These include stress, certain medications, things that rub against affected skin, humidity, and oily makeup.

Treatments

Since the exact cause of acne is unknown, the best you can do is treat the symptoms. Many treatments and therapies exist for different levels of severity. Some are available at your local pharmacy, while others require a prescription. For skin products, look for ones with “oil-free”, “non-comedogenic”, or “won’t clog pores” for best results. If you’re not seeing improvements with one treatment, you should try another treatment option or consider seeing a dermatologist.

Basic “At-Home” Skin Care

For mild to moderate cases of acne, basic skin care might be enough. This includes cleaning the affected area daily with mild soap (or some other mild, oil-free cleanser) and washing your hair daily with shampoo. Don’t scrub the affected area too hard since it could irritate your skin and make it worse. Also, avoid touching or letting things rub against the affected area (same reason).

Generally, you shouldn’t try to “pop” bumps caused by acne. You could let the area become infected, cause scarring, or push the stuff inside deeper into the skin, causing more damage. Even so, I’m kind of on the fence about this, at least for surface bumps. Those are very real risks, but if you know what you’re doing, getting the stuff out of them can, in my experience, prevent it from growing larger and damaging more of the surrounding tissue.

What do I mean by knowing what you’re doing? I mean washing your hands and the affected area with soap, disinfecting the affected area with isopropyl alcohol, carefully puncturing the tip (with a disinfected needle) and squeezing out all of the stuff inside, cleaning the area with water, and finally disinfecting the area with isopropyl alcohol again. Afterwards, make sure you don’t touch the wound as it heals. Sound like surgery? Well, that’s because it kind of is. When dealing with open wounds like this, it’s important to be extra careful in order to minimize the chance of infection and scarring.

This procedure only works for pimples, though. If you can’t see any whitish stuff in the bump or have a nodule or cyst, don’t even think about it. They’re too deep in the skin. Use another treatment option or let them heal on their own.

Benzoyl Peroxide

Benzoyl peroxide is usually available in lotion or cream form. Low concentration products are available over-the-counter, but higher concentration ones require a prescription. It’s often a first-line treatment option. It works by killing C. acnes and is also mildly effective at clearing up blockages and reducing inflammation. The side effects include increasing the skin’s sensitivity to sun and dryness.

Salicylic Acid

Salicylic acid acne treatment is usually in the form of lotions and washes. Low concentration products are available over-the-counter, but higher concentration ones require a prescription. It works by preventing bacterial from multiplying, breaking down excess keratin, and by promoting the shedding of surface skin cells (reducing the chance of blocking a pore) . Dry skin is the most common side effect.

Azelaic Acid

Like the previous two, low concentration products are available over-the-counter, but higher concentration ones require a prescription. It’s another topical medicine, and it has antibacterial and anti-inflammatory properties. It also helps reduce the accumulation of skin cells in the follicle. It can irritate the skin but is otherwise pretty safe.

Retinoids

These are a class of compounds that are related to vitamin A. The common topical ones are adapalene, retinol, tazarotene, and tretinoin. You need a prescription to get them. They reduce inflammation, renormalize skin cell life cycles, and reduce sebum. Side effects generally include skin irritation (sometimes causing initial flare-ups) and increased skin sensitivity to sun. Retinoids are sometimes used in conjunction with benzoyl peroxide.

Isotretinoin is another retinoid (pill form) but is only reserved for severe cases of nodular acne that don’t respond well to other treatments. That’s because it can cause serious side effects. Pregnant women can’t use it at all due to its potential to cause birth defects, miscarriages, and premature births.

Antibiotics

Prescription antibiotics for acne are usually applied to the skin (topical form) or swallowed (pill form). They kill bacteria that cause inflammation. Antibiotics are generally used as part of a treatment instead of alone. For example, many are often paired with benzoyl peroxide. The reason they aren’t used alone (and only for a relatively short time) is because antibiotic-resistant bacteria are becoming more common. Using antibiotics in conjunction with another treatment minimizes the risk that it will develop resistance. The bacteria would have to develop resistances to all of the treatments in order to survive, which is unlikely.

Since some oral antibiotics can cause birth defects, women who are using them must use contraception or not be sexually active during treatment and up to one month afterwards.

Oral Contraceptives (Birth Control Pills)

For women, combined birth control pills (those containing an estrogen and progestin) are an option. They reduce the production of androgens, which reduces sebum production. It’s generally similar in effectiveness to oral antibiotics, but doesn’t produce antibiotic resistance.

Anti-Androgen Agents

Anti-androgen agents like spironolactone are another option for women (prescription only). They block androgen receptors, which reduces the activity of androgens. They generally need to be taken with an estrogen to reduce the chance of side effects. Also, because of its hormone-based nature, women need to make sure they don’t get pregnant during treatment. Conveniently, women can take contraceptives at the same time, which can result in greater effectiveness.

Steroid Injection

For large cysts, your dermatologist might inject a corticosteroid like cortisone into the cyst. This usually results in rapid improvement and pain relief.

Light Therapy

These are relatively new procedures to treat acne. They’re generally for cases that don’t respond well to existing medication. Some use lasers to essentially vaporize the top layers of skin, opening up blockages and killing bacteria in the process. Others, like pulsed light and heat (LHE) therapy, use a combination of light and heat to kill bacteria and shrink sebaceous glands. Photodynamic therapy is another type of light therapy. It involves applying aminolevulinic acid (a light-sensitive chemical) onto the affected area, which seeps into the skin. Then, the dermatologist shines a blue light onto the area, which reacts with the chemical and kills the bacteria inside the affected area.

Yue’s Recommendation

Earlier in the year, I had a random breakout on my chin. I hadn’t had any acne for more than a decade, and yet I suddenly started getting new pimples on my chin nearly daily. I even ended up getting a small nodule or two. It was pretty ridiculous. I tried basic washing for a week with no improvement. So I decided to look around for an acne lotion. I found two that really helped out: the Rapid Clear Acne Defense Face Lotion and the Oil-Free Acne Moisturizer (Pink Grapefruit), both by Neutrogena.

I bought both in case one of them didn’t work. Both have salicylic acid as their active ingredient. Of the two, the Rapid Clear lotion is the stronger one with 2% salicylic acid. The other has 0.5% salicylic acid. So, I tried the Rapid Clear lotion first. I tried 2 applications daily at first, one in the morning and one sometime after dinner. Before each application, I washed my chin thoroughly with water to get rid of any dead skin and residue from the previous application.

I saw a noticeable reduction in the frequency of pimples after just 3 days. Within 2 weeks, I’d say the frequency was down by about half. As the frequency went down further, I also started just doing one application a day. After I finished using up the whole tube (50 mL) about 4 months later, the acne was pretty much gone.

One of the side effects listed on the package is dryness. It did make the skin on my chin a little dry, but it wasn’t too bad. So, I decided to use the Acne Moisturizer to see if it would improve the dryness. I mean what else was I going to do with it? I applied it once daily in the same way as the Rapid Clear lotion. Over the course of a few weeks, it restored the skin to its original condition and eliminated the acne completely. I’m still using it now, and the acne hasn’t come back.

Both lotions are oil-free and lightweight (you’ll forget you even put some on within an hour). Plus, they smell surprisingly good. The Rapid Clear lotion has a kind of floral/fruity smell and the Acne Moisturizer has a citrusy smell (I wouldn’t exactly call it grapefruit). The scents are light enough that they’re only noticeable for about 2-3 hours, but I liked them enough that they made me want to put them on every day. I definitely recommend giving these two products a try if you have mild to moderate acne.