Acne

What are the different types of acne?

Non-inflammatory acne is more mild. It causes whiteheads (closed blocked pores) and blackheads (open blocked pores), but not redness or swelling.

Inflammatory acne occurs, as the name implies, when there is some degree of inflammation. It can be further broken down into two categories: mild-to-moderate and moderate-to-severe.

What is considered severe acne?

Cystic acne is a severe type of inflammatory acne resulting in the formation of often-painful cysts. This type of acne can result in more long-term issues with scarring and post-inflammatory hyperpigmentation.

Does it matter what type of acne people have in terms of prognosis or treatment selection?

Virtually all cases of acne are treatable. Non-inflammatory acne responds well to over-the-counter treatments and retinoids, which work by preventing the formation of lesions. Retinoids also have some anti-inflammatory properties, so they function well when combined with other medications for inflammatory acne.

Mild-to-moderate types of acne also typically respond well to retinoids, as well as to benzoyl peroxide and topical antibiotics. Moderate-to-severe and severe acne cases may require oral antibiotics and other treatments.

Diagnosis

What causes acne?

Hormone surges lead to enlarged sebaceous glands and increased sebum production in the hair follicle, which can block the follicle with a combination of skin cells and sebum. This, in turn, leads to increased growth of a bacteria called C. acnes (formerly referred to as P. acnes), which is accompanied by inflammation.

Are there different causes for the different types?

Non-inflammatory acne typically results from a more superficial blockage, so there is not a lot of inflammation.

Inflammatory acne occurs when the blockage takes place deeper in the follicle and/or when bacteria is introduced to the area.

Why does acne flare in certain ages?

Acne can occur throughout a person’s lifespan, beginning in infancy. But adolescents tend to have more acne-prone skin, as hormonal changes stimulate production of excess oil and lead to enlarged pores, resulting in acne and inflammation. This is why teenagers are particularly susceptible to the condition.

Why are some people more prone to acne than others? Is acne genetic?

There does appear to be a correlation between certain factors and acne-prone skin. Males are more likely to experience acne in adolescence, whereas females are more affected by post-adolescent acne.

There also appears to be a genetic link, especially with more severe forms of acne. Additionally, there are greater rates of acne in people who have insulin resistance, which is thought to be linked to a higher production of androgens (male hormones).  

Treatment

How is acne treated over-the-counter?

There are numerous effective over-the-counter acne treatments available. It’s important to wait at least eight weeks before declaring a treatment ineffective.

• Benzoyl peroxide has antimicrobial properties, similar to those of antibiotics. However, it has the benefit of not leading to antibiotic resistance, as can occur with topical and oral antibiotics alone. Combining benzoyl peroxide with topical or oral antibiotics is effective and shown to reduce this risk of antibiotic resistance. There are both over-the-counter and prescription strengths of benzoyl peroxide available.

• Salicylic acid works by penetrating the hair follicle and inhibiting the formation of acne lesions. It also has an antiinflammatory effect.

• Tea tree oil has antimicrobial and anti-inflammatory properties, thereby reducing the formation of lesions and decreasing the redness associated with inflammatory acne. Undiluted tea tree oil can cause damage to skin and do more harm than good; therefore, we don’t recommend using it in full strength. A 5% strength tea tree oil has been associated with good outcomes.

• Alpha hydroxy acids, such as glycolic acid and lactic acid, are used for a variety of skin issues, and work by helping to exfoliate (shed) the top layer of skin cells and helping to prevent buildup around the hair follicle.

How is acne treated by topical prescription medicine?

Topical prescription medications are sometimes necessary when over-the-counter options are not effective.

• Topical retinoids get inside the DNA of the cells and work to change that DNA to reduce the blockage of the follicle and formation of the comedone, or clogged pore. Retinoids are also known to reduce inflammation, and can improve the absorption of other medications. Once available only by prescription, some topical retinoids are now available over-the-counter.

• Topical antibiotics, such as clindamycin and erythromycin, work by reducing the C. acnesbacteria on the skin. They also lower inflammation, which is why they are often used in inflammatory acne.

Does laser acne treatment work? What about light therapy?

While light therapy and lasers have become more popular recently, they generally require combination with other medications, a series of treatments, and often result in a reduction of symptoms (but not complete resolution).

There are several types of light therapy available depending on the type of acne being treated.

• Visible light therapy–including red, blue and blue+red light devices–is used for treatment of pimples. It works by killing the C. acnes bacteria.

• Infrared lasers work by causing damage to the sebaceous glands, thereby decreasing the production of sebum.

• Photodynamic light therapy involves the application of a solution that makes the skin more sensitive to the light before the application of laser or light treatment. This therapy appears to work well for more severe forms of acne. It’s important to note that this treatment sometimes causes undesirable side effects such as swelling, crusting, pain, and discoloration of the skin.

What are recommended oral prescription medications? When should people take these instead of using a topical treatment?

While cases of mild-to-moderate acne may respond well to topical therapy, moderate-to-severe acne often respond best to oral antibiotics (among them doxycycline and erythromycin). These are typically used along with topical retinoids, which help to reduce the risk of resistance.

Once well-controlled, oral antibiotics can be discontinued and the patient can continue with a regimen that includes retinoids. Ideally, the use of oral antibiotics should be limited to the shortest duration possible, in order to prevent resistance, typically three-to-four months.

Other oral treatment options include birth control pills. They work well for adult-onset acne, and to treat the hormonal acne that tends to surge with changes associated with the menstrual cycle. By helping to control some of these hormonal changes, they decrease the acne associated with these surges.

Spironolactone, which works by blocking androgens, is sometimes used as a third-or-fourth line treatment in women, though there is unclear evidence for effectiveness in treating acne. This medication is also used for conditions such as hypertension, and it has a diuretic effect, so it may lead to increased urination.

What is the strongest treatment for acne?

In severe cases that don’t respond well to other treatment, isotretinoin (also known as Accutane) is an option. This medication is classified as a retinoid and it works by shrinking sebaceous glands, thereby decreasing the production of sebum and production of the bacteria associated with acne.

Isotertinoin can have serious side effects, and it is extremely important that women taking it do not become pregnant, as it carries significant risks in pregnancy. Patients on isotretinoin are required to be monitored carefully and participate in the iPledge program.

Is there a risk to long-term oral prescription treatment?

Generally, it’s best not to stay on any medication for longer than necessary, and in the treatment of acne, patients taking oral prescriptions can generally be transitioned onto a topical maintenance program once adequate control is achieved.

Taking antibiotics for longer than necessary can create issues with resistance and the changes to the normal flora in the gut they can cause can sometimes leads to diarrhea.

As for isotretinoin, given the strict monitoring and serious side effects associated with it, it is usually only used for a limited period of time, typically up to around three-to-four months, along with benzoyl peroxide to reduce the risk of resistance.

When should I see a provider, versus trying an over-the-counter treatment?

In general, mild to moderate cases of acne can often be treated effectively without a prescription. It’s fine to try some over the counter products containing benzoyl peroxide, salicylic acid, or tea tree oil (as long as it’s no more than 5% strength).

The trick is that it’s important to give these products time to work. Allow them at least three weeks before declaring a treatment ineffective and then either add something else, or stop it and start a new treatment if you’ve experienced irritation or side effects.

If you think you may have more of a moderate-to-severe case of acne, with lots of comedones or deep, cystic acne, it’s probably best to consult a provider, as a prescription will likely be needed to treat these cases effectively.

Can acne be cured?

The short answer is no, but it can be treated very effectively. While virtually all cases of acne will respond to treatment, it is a condition that tends to be recurrent for years. Most people tend to “outgrow” adolescent acne and the incidence of cases significantly decreases with age. Maintenance therapy is an important aspect of keeping acne at bay following treatment.

How can hyperpigmentation and scarring due to acne be addressed?

Postinflammatory hyperpigmentation and scarring can be a concern for patients following treatment and resolution of acne. People with darker skin can be predisposed to developing the hyperpigmentation, or dark spots, which may take months longer than the acne to clear up.

There are several options for treatment including topical retinoids, azelaic acid and hydroquinone. Treatment options for scarring include laser therapy, chemical peels, injectable soft tissue fillers, as well as minor surgical procedures.

Prevention & Maintenance

What causes acne?

Hormone surges lead to enlarged sebaceous glands and increased sebum production in the hair follicle, which can block the follicle with a combination of skin cells and sebum. This, in turn, leads to increased growth of a bacteria called C. acnes (formerly referred to as P. acnes), which is accompanied by inflammation.

Are there different causes for the different types?

Non-inflammatory acne typically results from a more superficial blockage, so there is not a lot of inflammation.

Inflammatory acne occurs when the blockage takes place deeper in the follicle and/or when bacteria is introduced to the area.

Why does acne flare in certain ages?

Acne can occur throughout a person’s lifespan, beginning in infancy. But adolescents tend to have more acne-prone skin, as hormonal changes stimulate production of excess oil and lead to enlarged pores, resulting in acne and inflammation. This is why teenagers are particularly susceptible to the condition.

Why are some people more prone to acne than others? Is acne genetic?

There does appear to be a correlation between certain factors and acne-prone skin. Males are more likely to experience acne in adolescence, whereas females are more affected by post-adolescent acne.

There also appears to be a genetic link, especially with more severe forms of acne. Additionally, there are greater rates of acne in people who have insulin resistance, which is thought to be linked to a higher production of androgens (male hormones).  

Useful Links

Overview of Acne (American Association of Dermatologists)

Diagnosing and Treating Acne (American Family Physician)

Treatment of Acne (American Family Physician)

Complementary Treatments for Acne (Cochrane)

Acne Clinical Guidelines (American Association of Dermatologists)

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