What's going on in acne?
Acne, sometimes better known as pimples, zits, blackheads/whiteheads, and so forth, is a very common (and irritating) cosmetic concern. If you do a bit of Googling, you can easily find numerous blogs and health related webpages loaded with tips and tricks on managing acne. However, just like how the facts are readily found, the fiction and the myths are equally abundant. In today’s article, we hope to give you a basic scientific understanding of what acne really is, why treatments work, and then we will try to clear up a few common acne myths.
How acne works
Acne can look quite different depending on who’s face it’s on, but the bottom line is that acne has plugged follicles and inflammation. Both of these stem from comedones, so let’s talk about these.
Wait! In order to understand comedones, I will briefly explain what hair follicles are made of. Hair follicles naturally have the hair shaft and the follicle (the hole where the hair grows from), but they also have other key structures like the sebaceous gland. Sebaceous glands are essentially your oil glands and produce sebum. P. acnes is a type of bacteria that live in your hair follicles and feed on the sebum that you produce.
Comedone is the official terminology for blackheads and whiteheads. Whiteheads are closed comedones and blackheads are open comedones, but they are both basically plugged hair follicles that result from:
Too much keratin (a protein in your skin) shedding at the top of the follicle
Increased sebum production (from genetics or hormonal changes)
You can image that when these two things happen simultaneously, the hair follicle is going to get plugged and swell as it is filled with keratin and sebum. From the macroscopic level, whiteheads are comedones that are completely plugged and not exposed to air and blackheads are ones that have an open top that are exposed to air. Blackheads are black because the oxygen in the air oxidizes the keratin and melanin giving them the black color. Furthermore, because of the excess sebum, P. acnes is also going to grow out of control because of all the extra food that’s available. Although P. acnes does not normally cause any major problems for most people, under these circumstances, it can cause a lot of local inflammation. If this is severe enough, you can get pus accumulation, redness, and swelling. Because these lesions can be quite itchy and cosmetically concerning, people might be tempted to pick at them. The combination of picking and inflammation (if severe enough) is usually what leads to scarring in acne.
In summary, acne formation is a combination of 4 processes:
Excess keratin proliferation
Too much sebum production
Clogging of pores
P. acnes overgrowth
Most people with acne will probably tell you that they have tried numerous ways to fix their acne, and let’s be honest, there is a ton of treatments available for acne, from homemade remedies to prescription medications. For our purposes today, we will only focus on explaining treatment types that have been repeatedly shown to be effective in clinical trials.
Acne treatments almost always target one of the four aforementioned processes (see above). We will briefly outline examples of well known treatments and which one of these pathways they target. Keep in mind that we are not recommending (nor are we sponsored by) any specific treatment or brands, because the best and most appropriate treatment for you needs to be determined clinically by your doctor.
Excess keratin production
To combat this pathway, you would need to shut down or reduce keratin shedding by your skin cells and hope that this will prevent accumulation and plugging of the follicle. This can be done by using vitamin A derivatives such as Retin-A (tretinoin) and Differin (adapalene).
Too much sebum production
To reduce sebum production, you need to either shut down sebaceous glands or damage them. You can damage them through the use of lasers, and there is some evidence that this works, or you can shut them down using an oral version of the vitamin A derivative (isotretinoin), and there is A LOT of evidence that this work. In fact, isotretinoin (Accutane being the most well known brand name) is known as pretty much the end-of-the-line treatment for acne (not to be confused with treatment for acne scars). This is because isotretinoin also effectively targets the other 3 pathways as well. However, like most other drugs, isotretinoin is not free of potential side effects so it certainly isn’t for everyone.
Clogging of pores
You can prevent or remove clogged pores by making sure that the hair follicle is not blocked. This can be done by removing the blockage using benzoyl peroxides. These products can be bought over-the-counter or be in prescription strength but in either case there are far too many brands to list. These products also kill bacteria on the surface of your skin. While surface bacteria does not contribute to acne formation in the same way as P. acnes, it can cause secondary infection and inflammation to skin that is damaged by acne.
P. acnes overgrowth
While it doesn’t truly cause a skin infection in acne, P. acnes plays an important role in triggering the inflammation. Thus, getting rid of P. acnes should improve the inflammatory component of acne. Naturally, given that P. acnes is a bacteria, antibiotics are known to work well, especially the tetracycline class of antibiotics because they also have the additional effect of reducing inflammation.
Okay, now that we have established how acne works, let’s use this information to dissect some common myths about acne.
Myth 1: Acne only affects teenagers.
Fact: Acne certainly does predominantly affect teenagers due to hormonal changes in puberty and development, but acne can affect people of almost any age. This is because hormonal disturbances can happen outside of puberty, such as with medications and medical conditions like polycystic ovarian syndrome.
Myth 2: Acne improves with sun exposure.
Fact: There is no strong evidence supporting that acne improves with sun exposure. In fact, ultraviolet radiation can cause skin damage, inflammation, and long term cosmetic changes that may be just as aesthetically concerning as acne.
Myth 3: People with acne should not wear sunscreen.
Fact: You may have gathered the answer from what’s already been said, but this is generally speaking a bad idea. Sure, there are so many sunscreen products out there that some are bound to have the potential to aggravate your acne, but this doesn’t mean you should avoid this effective method of sun protection all together. If your current sunscreen aggravates your acne, consider checking out other brands or speak to your dermatologist for some recommendations.
Myth 4: Having acne outbreaks means that you are not washing your face frequently or vigorously enough.
Fact: This is just not true. During our explanation of how acne arises, there was no component involving dirt on your face. In fact, vigorous scrubbing or frequent use of harsh cleansing products can irritate your acne and your normal skin. Let’s be honest, if scrubbing your face with soap and water were sufficient to treat acne, there wouldn’t be so many websites, products, and medications out there for acne treatment.
Myth 5: Blackheads are pores clogged with dirt.
Fact: Blackheads are filled with oxidized keratin, melanin, and sebum, and not dirt.
Myth 6: You should pop your acne pimples.
Fact: While you might be very tempted to do this, in most cases, popping your pimples is a bad idea. This is because penetrating your skin with a sharp tool can cause scarring damage and can open your skin to a secondary infections. Most of the time, it probably wouldn’t even change the amount of time needed for the acne to heal.
Myth 7: Acne is related to your diet.
Fact: Okay, this is not completely a myth, but we lack strong evidence to link acne to diet. There is some evidence that acne is linked to food with a high glycemic index. You might not realize this, but the label ‘high glycemic index’ includes a lot of foods that people tend to eat, including most breads, pastas, pretty much anything you can buy at a coffee shop, most desserts/snacks, pizza, potatoes, and many more! Remember, there is only SOME evidence that high glycemic index foods are linked to acne and unanimously avoiding all of these foods is both impractical and unlikely for most people, and avoiding these foods might not even improve your acne. You are better off relying on treatments that are known to work and continue to eat a healthy balanced diet.
This is a definitely a lot of information but we hope you found it helpful. Acne is one of those things that affect a large portion of the population but fortunately, we have a great understanding of how it works and there are numerous effective therapeutic measures that are readily available for acne patients.
That’s all for today folks and we hope you found this information useful!