What really causes acne?
Skin produces sebum, which is normally a good thing – it keeps your skin moisturised and helps maintain a healthy population of bacteria. But hormonal surges, which are particularly rife during adolescence but can happen later too, cause the skin to produce excess sebum, blocking pores.
If the blockage of dead skin cells and sebum stays below the skin you get a whitehead. If the blockage reaches the air, it turns dark and becomes a blackhead. When bacteria gets into the surrounding tissue, it can become inflamed, with small red bumps (papules), white or yellow pus-filled pimples (pustules) or large red bumps (inflamed nodules).
Some people are genetically predisposed to acne. Stress has also been linked to acne as have hormonal conditions such as polycystic ovary syndrome. Acne can be caused or aggravated by oil-based cosmetics, sunscreens or creams, hot and humid environments, working with oil and grease, and some medications, including steroids, certain contraceptive pills and some epilepsy treatments.
Acne myth 1: chocolate causes acne
You may have heard this one around the playground: stay away from chocolate bars if you want clear skin. At other times carbs are the culprit, while others still blame oily foods.
Reality: there's no link between chocolate and acne
Despite the myths, studies have found no direct connection between acne and chocolate, and dietary factors only affect a minority of acne sufferers.
"We grew up with stories about chocolate. But blaming chocolate for acne is also simplistic, it's based on anecdote rather than evidence. There have been studies in which chocolate was substituted with chocolate-like products to see if it led to acne, and it makes no difference," says Dr See.
"Some people will think 'I ate chocolate and now my acne is worse'. But they could be eating chocolate because they are looking for comfort food, so it could be due to emotional issues or stress, which we know can have an impact on acne."
However, researchers have found a possible link between acne and high glycaemic index (GI) foods, such as white bread. "It's really about the interaction between diet and hormones. A high GI diet stimulates insulin production, which then affects your hormones," Dr See says. There's also a potential that being overweight causes a change in metabolism and hormonal fluctuations, which stimulate the oil gland. But the link between diet and acne is full of controversy and is still being explored."
And having a good diet doesn't guarantee good skin. "I often see people with a fantastic diet, but they still have acne," says Dr See.
Acne myth 2: only teenagers get acne
There's nothing more frustrating for an acne sufferer than being told they'll grow out of it. Especially when said sufferer is well into their adulthood.
Reality: hormonal fluctuations can happen at any age
While it's true that almost all teenagers get acne to varying degrees, not everyone grows out of it. Both men and women can be affected by acne into adulthood.
Adult acne typically affects women after the age of 25 and may continue into the 40s – and it's becoming more common. "It's well documented that adult acne has increased compared to decades ago. We're not sure if it's to do with more stress or perhaps women having children later," says Dr See.
One of the causes of adult acne, particularly for women, is hormonal fluctuations.
"Typically, women will have a flare up of breakouts with their period or stress," says Dr See. "Sometimes this will be due to the fact that the woman's usual androgen levels are high, which stimulates the oil gland."
When it comes to acne in adult men, Dr See says their genes are likely to be the culprits. "Adult acne is more of an issue for women, but when we do see it in men in their 30s and 40s, they often have a family history of really bad acne."
Acne myth 3: vitamins and supplements cure acne
Remember that time Auntie Sue was convinced the path to clear skin was popping vitamin after vitamin every day?
Reality: don't waste money on treatments that don't work
Don't waste your money on supplements and vitamins that promise the world but don't deliver. "I recently had a patient who was offered a whole lot of supplements, and she was told to take them despite not having any results," says Dr See. "Now supplements and vitamins won't generally hurt you, but there's no scientific basis for using them to treat acne, and they can be very expensive. If you are given a treatment and you don't see results after eight to 12 weeks, you should seek an alternative."
Acne myth 4: acne is caused by bad hygiene
Another pernicious myth that can lead to stigma for acne suffers and can even make acne worse: some claim acne-prone skin is dirty skin.
Reality: acne isn't cured by scrubbing
"Too much scrubbing of your skin can further irritate the skin and trigger inflammation – you can't wash acne away. It's the worst myth in my opinion. Parents will tell their children 'you're not washing your face enough'. They see blackheads and think they're dirt. But they're not dirt," says Dr See. "They're open pores where the skin is oxidised. It's like when you cut a potato and it goes a bit brown where the air gets to it."
Acne myth 5: acne is caused by using cheap products
Acne suffers may put down their bad skin to using cheaper supermarket products rather than expensive lotions put out by the cosmetic power-houses.
"Many people think acne is caused by using cheap products. Some of my patients confess to using something cheap, thinking that this is the problem," says Dr See.
Reality: You don't always get what you paid for
CHOICE has found time and again that a high price tag is not necessarily a guarantee of quality. The same is true of personal care and cosmetic products. Just because a cleanser or moisturiser is made by one of the French beauty powerhouses, doesn't mean you'll get supermodel-like skin.
Dr See agrees. "An inexpensive product can be just as good as an expensive one," she says.
Acne myth 6: acne is linked to sexual activity
You might've heard this myth bandied about by a friend. Depending on the version, acne is either cleared up by sex or caused by it. And it's easy to see why the confusion may arise – acne is related to hormones, and there's nothing more hormonal than sex.
Reality: sex doesn't affect acne
Dr See says the sex and acne link just isn't borne out by the evidence. "It's amazing what people say! One of the funniest things I've come across is regarding acne being linked to sex – both too much and not enough. It's a silly myth, there is no correlation."
Acne myth 7: popping pimples is a good idea
It can be satisfying to pop a juicy whitehead or release a steadfast blackhead, and it may seem like you're releasing the pressure and doing the right thing.
Reality: pimple popping can lead to scarring
Dr See recommends against picking at acne. "Popping pimples feels fantastic, but what you're doing is rupturing the pilosebaceous duct. You're getting rid of the core of the pimple, but you create more inflammation, which contributes to scarring," she says.
"Squeezing pores also isn't really helpful as they just re-form – it's just a short term benefit. And you definitely shouldn't do it if it's very painful, because that could be rupturing the follicle."
How can acne be treated?
Mild to moderate acne
Mild acne can be treated with over-the-counter skin products that contain an antibacterial such as benzoyl peroxide (though don't overuse these, as you can irritate the skin further). Antibacterials stop the growth of bacteria and some, but not all, are designed to clean your skin right down into the pores. You don't need a prescription to buy these. Benzoyl peroxide is safe for adults and children and can be used during pregnancy. However, it can dry and irritate the skin so it is often useful to start with a low concentration.
Many acne treatments contain an antibacterial agent called triclosan. Although it's good at killing surface bacteria (you'll also find it in some toothpastes and soaps), it won't reach the bacteria in your pores. In fact, a recent review of medical research found no evidence that triclosan's an effective acne treatment.
Topical vitamin A, tea tree oil and zinc supplements may help relieve acne. There's no strong evidence that other claimed alternative remedies – such as echinacea, acupuncture, calendula or yoga – have any benefit.
Mild to moderate acne that doesn't respond to over-the-counter products can be treated with topical retinoids and topical antibiotics, which require a prescription.
Topical retinoids like tretinoin, isotretinoin and adapalene are widely used to treat whiteheads and blackheads and prevent the formation of new ones. They're derived from vitamin A and cause the skin to peel, unblocking your pores. But it's not all good news – they do have a range of side effects and should not be used by pregnant women. Retinoids can also irritate the skin and increase its sensitivity to the sun, so you should use plenty of sunscreen during the day, making sure it's not too thick, to avoid causing more pimples.
Topical antibiotics such as clindamycin and erythromycin work by reducing acne bacteria on the skin. They're useful for mild to moderate inflammatory acne but may not be so effective on blackheads. However, overuse of antibiotics in general has led to the rise of antibiotic-resistant bacteria, causing a rethink on their role in acne treatment. Topical antibiotics include clindamycin and erythromycin. They may cause dry or scaly skin and erythromycin may also give an itching, stinging or burning feeling, but there are no other notable side effects.
Moderate to severe acne
For those with moderate to severe acne, or in cases where the above treatments don't work, a GP may prescribe oral antibiotics or, for women, the oral contraceptive pill.
Teenagers tend to stick to oral antibiotic treatments more than to topical antibiotics, which can take a long time to apply. Typically, oral antibiotics are prescribed for between three and six months to help avoid antibiotic resistance. But due to their higher potential for serious side effects, they tend to be reserved for more serious acne cases.
Oral antibiotics include doxycycline, tetracycline and erythromycin. All oral antibiotics can cause stomach upsets, and some aren't suitable for pregnant women. Doxycycline can make people more sensitive to sunlight and easily sunburnt. Minocycline is also widely used, but it can have side effects including dizziness, light-headedness and vertigo.
The oral contraceptive pill decreases androgen levels in the body, which can decrease the production of sebum. Effective for reducing acne are Diane-35 and Brenda-35, both of which contain cyproterone acetate and oestrogen, but some brands of the pill can actually aggravate acne. If you're considering oral contraceptives to treat acne, your doctor should explain the risk of potential side effects such as blood clots – cyproterone acetate may increase the risk more than some other contraceptive pills.
Sometimes a combination of treatments works best. Some studies suggest that combining a topical antiseptic like benzoyl peroxide with an oral antibiotic can give better results than either used alone. Talk to your doctor. Stubborn acne may require specialist intervention from a dermatologist, which will require a referral from your GP.
Pills containing isotretinoin (a retinoid sold by prescription under brand names including Roaccutane, Oratane, Isohexal and Accure) have been shown to be very effective at treating acne by attacking all the contributing causes of acne. It reduces the amount of sebum made by the glands in your skin, reduces acne bacteria and inflammation and opens clogged pores. However, there are potential links to some worrying side effects, including depression and birth defects, so it's not suitable for women who are planning to have a baby or are pregnant.
Women who take the drug during pregnancy have a very high risk (30–40%) of serious birth defects in their baby. The main effects are on the heart, brain and ears. For this reason, doctors will want to rule out any possibility of pregnancy before treatment begins. Effective contraception should be used diligently during treatment and for one month before and after. Breastfeeding is also not advised while taking this drug.
Isotretinoin has been linked to serious depression and even suicide. The US Food and Drug Authority (FDA) revealed in 2000 it was receiving a growing number of reports of psychiatric side effects, including suicides, in patients taking the drug Accutane (the US version of Roaccutane).
However, while it does happen, reported mood change associated with isotretinoin is relatively uncommon. Current medical estimates put it at 1–2% of patients. Doctors point out that it's difficult to determine whether the drug really is the cause because people with severe acne are more prone to depression, as are teenagers.
Generally only dermatologists can prescribe isotretinoin. Although for some people it's the only solution to a debilitating medical and psychological problem, there's concern overseas that it's too often prescribed for mild and moderate acne that could be treated some other way.
"Usage of this medication is controversial, but it has been prescribed for over 25 years. Prescribing it comes down to patient selection and monitoring," says Dr See. "It is well known that effective acne treatment increases patient wellbeing and quality of life, however some patients may develop mood changes and even depression. All patients need to be monitored for this, but it is not a common event."
The way in which isotretinoin is prescribed has changed over the years with the development of variable dose regimens. Patients are usually prescribed a low starting dose that is then slowly escalated over a few months to minimise side effects.
Retinoids can irritate the skin and increase its sensitivity to the sun, so you're usually advised to apply them at night. A sunscreen is also recommended – at least SPF 15+ and containing a physical blocker, such as titanium dioxide – to reduce the risk of UV damage and skin cancer.
The blackhead removal tool
Don't squeeze or pop pimples – it can damage the skin and cause infection and scarring when sebum, bacteria and shed skin cells are pushed into the surrounding tissue. Blackheads and pimples can be dealt with using a blackhead removal tool available from the pharmacy. Usually made from medical-grade stainless steel, the tool should feature a needle on one end and a thin loop of metal on the other. Follow the directions included with the device to ensure proper use.
Better skin routine
- Wash your face twice a day with water and a mild soap or cleanser, and pat it dry.
- Use oil-free or 'non-comedogenic' skin-care products and make-up.
- Use heavier cleanser and moisturiser in winter and lighter products in summer.
- Gel-based sunscreens are probably best for people with acne, as creams might aggravate it. Also, keep out of the midday sun and avoid sunlamps and tanning beds.
- If you're using an acne treatment and it hasn't worked after three months, ask your GP for an alternative.