Acne: What Causes It and What to Do About It

According to dermatologist Dr. Nicholas Perricone’s The Clear Skin Prescription, there are seven phases of acne from its onset to its most severe form, the cyst.

What are the seven stages of acne formation?

Stage 1: Retention Hyperkeratosis

In normal skin, there is exfoliation of the skin follicle. In retention hyperkeratosis, there is no exfoliation of the follicle, and so keratin (skin protein) and sebum clogs the follicle. Sebum production is triggered by several factors, including stress hormone (cortisol), certain neuropeptides, and dihydroxytestosterone (a breakdown product of testosterone). The degree to which each of these factors plays a role in your skin partially depends on your genetics.
What can be done at this stage: Increase exfoliation with Retin-A, salicyclic acid or glycolic acid peels. According to Perricone, Retin-A was found by Dr. Sydney Hurwitz to be effective against acne. Retin-A, salicylic acid and glycolic acid work to exfoliate as they increase the rate of cell turnover in the skin. Also, one may treat this stage of acne by decreasing sebum production with oral contraceptives, stress management, and, according to some, certain dietary restrictions. Oral contraceptives, such as Ortho Tri-Cyclen, contain hormones that bind to testosterone, decreasing its activity, including the increase in sebum production. Stress triggers the release of the hormone cortisol, which increases the activity of the sebaceous glands. Finally, some patients report improvements in acne when adopting a diet low in sugars, dairy products, and glutens. However, these claims are largely unproven and unsubstantiated by the scientific community, as reported in the Journal of the American Academy of Dermatology in 2005. As such, these diets may be helpful to some individuals, but the majority of people do not exhibit results from them.

Stage 2: Bacteria accumulation

In this phase, bacteria accumulate and multiply in the follicle. A species of bacteria called Propionibacterium acnes are most commonly found in the follicle, and multiply quickly.
What can be done at this stage: Benzoyl peroxide is often applied topically to the skin to kill P. acnes. Benzoyl peroxide has been found by Nacht et. al. to kill bacteria by generating reactive oxygen species in the sebaceous follicle; because it triggers free radical formation, its use should be limited to the spot of the comedone. Topical antibiotics such as clindamycin, ATS solution, or Benzamycin and oral antibiotics are often administered as antibacterial agents. However, according to Dr. Leslie Baumann, as many as 60 percent of acne patients exhibit antibiotic-resistant strains of P.acnes, so antibacterial agents may not always be the answer. In addition, light injections administered by a dermatologist have been proven effective against this stage of acne. Light of wavelength 410-420 nm focuses on porphyrin, the pigment that is produced by P.acnes, and effectively kills the bacteria. In addition, techniques from stage 1 are often employed to prevent new acne formation.

Stage 3: Microcomedo/microcomedone/comedone formation

The bacteria continues to propagate in the follicle, forming a microcomedo. As the microcomedo grows, it may adopt one of two forms: closed, which is called a whitehead; or open, in which case it is oxidized by air and characterized by melanin production, and known as a blackhead. This is known as grade 1 acne.
What can be done at this stage: Anti-bacterial agents and light treatments (see stage 2).

Stages 4-5: Papule and Pustule Formation

In these stages, an inflammatory, undrained lesion called a papule is formed. This is known to dermatologists as grade 2 acne. If the papule continues to grow, it forms a more visible inflammatory lesion, called a pustule (grade 3 acne).
What can be done at this stage: Anti-bacterial agents and light treatments (see stage 2).

Stages 6-7: Nodule and Cyst Formation

Most acne sufferers do not reach these stages. However, in some cases, nodules and, later, cysts form.
What can be done at this stage: Dermatologists will sometimes prescribe the orally administered Accutane for patients with stage 6-7 acne. Unfortunately, Accutane has been associated with numerous detrimental side effects, including vision loss, increased blood triglyceride (fatty acid) levels, severe dry skin and mouth, the inability to see at night, and severe birth defects in pregnant women. For these reasons, Accutane is often considered a last resort for patients highly resistant acne.

What is a good skin care régimé for someone with acne?

Patients with acne benefit greatly from seeing a dermatologist. Another excellent source is Dr. Leslie Baumann’s The Skin Type Solution ($9.60, Amazon.com). The book provides a 61-question quiz that identifies your specific skin type, and which makes specific product recommendations. This is particularly helpful for acne patients, who may suffer from other skin conditions in addition to their acne, such as hyperpigmentation, dry or sensitive skin, etc.

In general, the following skin care régimé should be helpful for those with acne; however, for more specific recommendations, consult Dr. Leslie Baumann’s The Skin Type Solution. All products listed below are recommended by Baumann for acne for varied skin types.

Morning

1. Cleanser, such as Aveeno Clear Complexion Cleansing Bar ($6.75, Amazon.com). The Aveeno Clear Complexion Cleansing Bar contains salicyclic acid, which is used to unclog the pores. According to Baumann, salicyclic acid is more effective than alpha hydroxy acids (such as glycolic acid or lactic acid) in reducing the number of comedones (pimples). In addition, salicyclic acid products are preferrable over those containing benzoyl peroxide because benzoyl peroxide increases free radical production in the skin.

2. Spot treatment, such as ZAPZYT Acne Treatment Gel ($4.99, Amazon.com), or, for more sensitive skin, Neutrogena On the Spot Vanishing Formula ($16.69 for three, Amazon.com). Both contain benzoyl peroxide, which is effective against most pimples. The ZAPZYT contains 10% benzoyl peroxide; however, if you have sensitive skin or experience redness or irritation from the product, the Neutrogena product would be preferrable. In either case, because benzoyl peroxide triggers free radical production, take care to only apply the product in the area of the comedone (pimple).

3. Oil-Control Treatment, such as Philosophy On a Clear Day Blemish Serum ($30.00, Amazon.com). This product contains ultra-effective salicyclic acid as the first ingredient, and glycolic acid, which increases cell turnover. Although it is a bit pricier than drugstore formulations, the use of glycolic acid as the first ingredient should make this one worth it for those with non-chronic acne.

3b. Moisturizer (optional; use only if your skin is dry), such as Aveeno Ultra Calming Moisturizing Cream ($13.95, Amazon.com). This product contains feverfew extract. Because Johnson and Johnson extracts parthenolide from feverfew extract, the feverfew in this product is anti-inflammatory (which may help a bit with acne) and a potent antioxidant (which helps against aging). However, if your skin is oily, you may wish to skip this step, especially because, according to New York City dermatologist Jody Levine, “you want the active ingredients, like salicyclic acid, to soak in without interference.”
4. Oil free foundation or powder with SPF, such as Neutrogena Healthy Defense Powder with SPF 30 ($19.98 for two, Amazon.com). The product does not contain any ingredients that should provoke acne, and provides oil coverage and SPF protection, which is often hard for women with oily or acne-prone skin to find. One word of caution: any powder product requires about 14 times the amount of normal powder application to receive the SPF listed on the package, so a powder with an SPF of 30 is really providing an SPF of about 2 with normal use. As such, be especially careful to stay out of the sun between 10 A.M. and 4 P.M. (when the sun’s rays are the strongest), wear a hat, and use an oil-free sunscreen when you can.

Night

1. Cleanser, such as Aveeno Clear Complexion Cleansing Bar ($6.75, Amazon.com). (see morning for description)

2. Spot treatment WITHOUT benzoyl peroxide, such as Clean and Clear Advantage On-The-Spot Acne Treatment ($6.75, Amazon.com). This product contains 2% salicyclic acid. The benzoyl peroxide spot treatment from the morning is not recommended for night because benzoyl peroxide can denature the tretinoin found in Retin-A (used in step 3 at night, see below), and thereby decrease its efficacy. However, if benzoyl peroxide is used on the spot in the morning to kill bacteria, and salicyclic acid increases cell turnover and unclogs pores at night, the pimple should be gone soon!
3. Retinoid treatment (if not pregnant or nursing). Ideally, see a dermatologist for a prescription for Retin-A, which has twenty times the potency of retinol sold over-the-counter. Retinoids are helpful against acne because they increase the rate of cell turnover, exfoliating the skin. If Retin-A is not an option, RoC Anti-Wrinkle Treatment for All Skin Types ($14.79, Amazon.com) contains retinol fairly high on the ingredients list and anti-aging antioxidant vitamin E. If your skin is not sensitive, Neutrogena Advanced Solutions Nightly Renewal Cream ($21.05, Amazon.com) contains retinol, alpha hydroxy acids, and anti-aging antioxidant green tea, which has a higher ORAC score (measure of antioxidant capacity) than vitamin E. Because retinoids are sometimes irritating, you may wish to start using the product every other night for the two weeks or so, and then gradually work up to every night. Retinoids also increase photosensitivity, which is why the product should only be used at night.
4. Moisturizer (optional; use only if your skin is dry), such as Aveeno Ultra Calming Moisturizing Cream ($13.95, Amazon.com). Sometimes retinoids are irritating or drying to the skin, so you may wish to use a soothing, anti-inflammatory moisturizer like this one at night, even if you choose not to during the day.

Are there any ingredients patients with acne should avoid?

Yes. All of the following were not recommended for at least one acne-prone skin type in Dr. Leslie Baumann’s The Skin Type Solution:
-butyl stearate
-cinnamon oil
-cocoa butter
-coconut oil
-decyl oleate
-isopropyl isostearate
-isopropyl myristrate
-lanolin
-mystristyl myristrate
-neopentanoate
-neopalmitate
-octyl palmitate
-octyl stearate
-peppermint oil
-propionate
-propylene glycol
-sodium lauryl sulfate
However, it should be noted these ingredients do not provoke acne in all patients. Consult your dermatologist or The Skin Type Solution if you have a question about a certain ingredient and your skin type.

Overall, what should I do if I have acne?

Acne is one of the hardest conditions for dermatologists to treat, because there can be so many different causes at work simultaneously. Although many different diets, supplements, and treatments have been proposed to get rid of acne, a careful skin care régimé (see above) should alleviate symptoms for patients with non-chronic acne. If over-the-counter products do not seem to help your condition, see a qualified dermatologist in your area, who can prescribe patient-specific treatments.