What is acne?
Acne is the most common skin condition that affects young people between the ages of 10 to 19 years old. It is a skin condition that affects most people at some stage in their lives by causing oily skin, redness and different types of spots to develop on the face and body such as:
- Blackheads (small black or yellow bumps)
- Whiteheads (these look similar to blackheads but are more firm, and you cannot squeeze out the contents)
- Papules (small red bumps that might feel a little bit painful)
- Pustules (these spots look like papules but they have a white tip in the centre that is caused by a build-up of pus)
- Nodules (hard lumps under the skin that can also be painful)
- Cysts (the most severe type of acne spot. They are large spots filled with pus, and are the most likely type of acne spot to cause permanent scarring)
What are the different types of acne?
There are several different types of this skin condition:
This is the most common type of acne, and is sometimes called “common acne”. It is a chronic skin condition (meaning it lasts for 3 months or longer), and is caused by the inflammation of a small structure in the skin that is called the “pilosebaceous unit“. This unit contains:
- A hair shaft
- A hair follicle
- The arrector pili muscle (a small muscle that is attached to the hair follicle)
- The sebaceous gland (a gland that secretes an oily substance called sebum)
Acne vulgaris is commonly linked to puberty and adolescents (children and teenagers aged between 10 to 19 years old). Although it may first appear in adolescence, some people’s symptoms can persist into the early 30s. Acne vulgaris is more common in males than females during the period of adolescence, and it usually affects areas of skin that contain a high number of sebaceous glands (glands that secrete the oily substance sebum) such as the:
- Upper back
How do spots develop in people with acne vulgaris?
The glands that produce oily sebum (the sebaceous glands) can be particularly sensitive in people who get acne. Certain hormones can make these sensitive glands produce too much oil, which can then cause the following problems:
- The excess oil can mix together with some dead skin cells, and this build up of oil and dead skin can get trapped in the hair follicle and clog it up. This is what causes certain spots such as blackheads and whiteheads to develop.
- The excess oil also triggers certain bacteria on the skin to grow and become more active. This most commonly happens with a bacteria called Cuitbacterium acnes (which used to be called Propionibacterium acnes). This bacteria is normally found on everyone’s skin, and usually, it is completely harmless and does not cause any problems. However, when a lot of oil starts to build up in the skin, this bacteria begins to thrive and grow, and ends up causing inflammation and pus-filled spots to develop.
This is a rare and severe form of acne that usually causes large, painful, pus-filled cysts (called abscesses) to develop on the face, back and chest (although it can affect other parts of the body too). It affects deep skin tissue and is more common in males than in females. It is most commonly seen in young adults, and very rarely seen in children or elderly people.
The cysts in acne conglobata can become infected and filled with pus, turning them into abscesses (which is defined as a collection of pus within the body). The pus in these abscesses can often also have an unpleasant, foul smell. The severity of this skin condition can often make people feel embarrassed or shy, and lead to a number of different mental health problems.
One of the main problems with acne conglobata is that once the nodules and abscesses heal, they usually leave behind permanent scars called hypertrophic and atrophic scars.
- Hypertrophic scars – these are raised scars that are red or pink in colour and can feel itchy. They stay in their original place and do not spread to other parts of the skin.
- Atrophic scars – these scars appear as indentations in the skin. There are 3 types of atrophic scars: ice pick scars, boxcar scars and rolling scars. Usually, all three types of atrophic scars are seen in the same person, so it can be difficult to distinguish between them.
Acne conglobata can develop from an acute flare up of existing acne, or it can gradually develop years after someone’s acne has settled down. It is believed that the bacterium Cuitbacterium acnes plays an important role in the development of acne conglobata.
One of the recognised causes of acne conglobata is the use of anabolic steroids. For this reason, it is quite common to see this condition amongst bodybuilders, and many young adult males will go to see their skin doctor (dermatologist) complaining of severe acne and facial scars.
Acne fulminans, which is also known as acne maligna, is a rare form of acne that is often confused with acne conglobata as they can have very similar symptoms. Because this condition is so rare, it is not fully understood what causes it, but it is currently thought that acne fulminans may be triggered by the following:
- Using high doses of a medication called isotretinoin (which is used to treat severe acne)
- Having high levels of testosterone in the body
- Using anabolic steroids
- An autoimmune response (this is when the body’s immune system gets confused and starts to attack the body itself)
This type of acne usually affects young males (mainly Caucasian) between the ages of 13 to 22, although it can occur in females too. Similar to acne conglobata, bodybuilders who use anabolic steroids can also develop acne fulminans. Most people who develop acne fulminans have had acne in the past too.
This type of acne can cause cysts and painful nodules to develop on the skin. These nodules may develop ulcers and bleeding, and may be covered with crusts. Patients suffering with acne fulminans may also complain of a fever or pain in their joints.
Due to the severe symptoms, many people with this condition can also become withdrawn and isolated. This in turn can have a large negative effect on their mental health and wellbeing.
This type of acne is also called “neonatal acne” or “baby acne“. It develops in babies that are younger than 6 weeks old, and can be quite common.
Baby acne develops in response to a fungi called Malassezia that is naturally found on the skin’s surface. A baby affected by this tends to develop inflamed papules and pustules on their skin.
Baby acne is more commonly seen in boys, and treatment is not usually needed as the symptoms usually go away by themselves by the time the baby is 4 months old.
Another type of acne seen in babies is called “infantile acne“. It usually develops in older babies that are between 3 to 16 months old. This type of acne is much less common than neonatal acne, and can cause blackheads, whiteheads, nodules and cysts to develop on the baby’s skin. Infantile acne takes longer to clear up and it can affect babies for up to 1 to 2 years.
Babies who have had infantile acne are also more likely to develop acne later on in life. Infantile acne is also more likely to cause scarring than neonatal acne.
This type of acne is also known as hidradenitis suppurativa, and is still poorly understood. It is a rare form of acne that usually develops after puberty, and is seen more commonly in females than in males.
Acne inversa causes painful nodules and abscesses to develop. The abscesses can burst, which leads to scarring of the skin. It is considered a difficult condition to treat, and can cause a significant negative impact on a patient’s quality of life.
Although there has not been research done to verify this, there seems to be a strong link between smoking and the development of acne inversa.
Acne mechanica is a type of acne that is caused by repetitive rubbing, friction, squeezing or stretching of the skin. These repetitive movements on the skin’s surface cause inflamed papules and pustules to develop in the affected areas.
Most of the research that has been done on acne mechanica is related to skin conditions found in athletes, or in people who have had repeated physical trauma to the skin. This trauma can include things such as:
- certain clothing (e.g. tight straps, belts, headbands)
- sportswear (e.g. football shoulder pads)
- repeated skin friction at a place of work (e.g. rubbing of back in truck drivers)
This type of acne causes papules, pustules, nodules and plaques to develop most commonly on the back of the head and neck. Acne keloidalis nuchae is almost always seen in young, dark-skinned males, and rarely in females.
This type of acne mainly affects young women, and is considered to be an emotional or psychological condition. It is caused when people “pick” and “scratch” their acne spots, therefore making the acne become worse.
Who usually gets acne?
Acne is one of the most common skin conditions in the world, and it can affect a very wide range of people with different ages, ethnicities and genders. The most common type (which is also known as acne vulgaris) usually develops in young people going through puberty and who are aged between 10 to 19 years old. The symptoms can however, start at any age. There are also certain types of acne (such as neonatal or “baby” acne) that can commonly develop in new born babies.
Which types of acne are more commonly seen in women?
The types that are more commonly seen in women include:
- Acne inversa
- Acne excoriée
- Adult acne caused by hormonal changes (e.g. during pregnancy, the menstrual cycle and menopause)
Which types of acne are more commonly seen in men?
The types that are more commonly seen in men include:
- Acne vulgaris (common acne)
- Acne conglobata
- Acne fulminans
- Acne keloidalis nuchae
- Neonatal acne (babies younger than 6 weeks old)
- Infantile acne (babies aged between 3 to 16 months old)
What causes acne?
Acne does tend to run in families. This means that if either of your parents had it in the past, you are more likely to get it too. There are however, other reasons why some people may get it.
Many people develop symptoms when their bodies are going through hormonal changes. During puberty, the body increases its production of a hormone called testosterone. It is currently believed that testosterone increases the amount of oily sebum that our skin makes, therefore making it more likely to develop acne during this time.
Natural changes in the body that involve changing hormone levels and therefore trigger hormonal acne can include the following:
- Menstrual cycle (the period)
- Pregnancy (especially in the first 3 months)
There are also specific types of contraception that can make some women develop acne (or make any existing symptoms worse) such as:
- Progestogen-only pill (the mini pill)
- Depot injection
- Hormonal coil (IUS)
Other triggers that may cause it to develop include:
- A disease that develops in women called polycystic ovary syndrome (PCOS)
- Using anabolic steroids
- Taking certain medications (e.g. steroids, lithium and some medications used to treat epilepsy)
- Regular friction or rubbing on the skin (e.g. through wearing certain clothing such as belts and headbands)
- Wearing certain cosmetic products
What are the symptoms of acne?
Acne spots can look different on different people and are sometimes called “blemishes” or “pimples”. The skin can also appear to be red and greasy.
The types of spots someone gets also depends on the type of acne that they have. The different types of spots you can get are shown below:
The severity of acne can be described as follows:
- Mild – this is when there are mainly blackheads and whiteheads, and only a few papules and pustules.
- Moderate – this is when there are more inflamed spots such as papules and pustules present, and there may also be some mild scarring.
- Severe – this is when there are many inflamed and painful spots such as papules, pustules, nodules and cysts. There may also be some scarring present.
Although the different types of spots are the main symptoms, acne can cause other complications too that can have a negative impact on quality of life, such as:
- Scars (both temporary and permanent)
- Becoming socially withdrawn
- Low self-esteem
- Hyperpigmentation and discolouration of the skin causing dark marks or patches
Where can you get acne?
Acne most commonly develops on the face, and almost every person with this skin condition gets spots on their face. It can however, also develop on the body. Different areas of the face and body can be affected depending on which type of acne you have. These areas include:
- Around the mouth
- Buttocks & groin
Which other conditions have similar symptoms to acne?
There are some other skin conditions that may have symptoms that are similar to acne. These include:
- Rosacea – a common skin condition that causes redness, visible blood vessels and sometimes little red bumps to develop on the face.
- Folliculitis – inflammation of the hair follicles.
- Peri-oral dermatitis – a red rash that develops around the mouth.
- Milia – small, round bumps that are usually white or yellow that develop underneath the skin.
If you have some symptoms that you are worried about and cannot be sure what is causing them, you should speak to your family doctor, or you can go directly to a skin doctor (dermatologist) if possible.
The information in this article is written for general information purposes only, and is not a substitute for professional medical advice, treatment or care. It is incredibly important that you do not make decisions regarding any symptoms based on this information alone. If you are worried about any symptoms you may be having, or have any further questions about this condition, please speak to a qualified and trustworthy medical professional.
How do you treat acne?
Although acne cannot be cured, there are a variety of treatment options that can help control it.
Things you can do at home
There are some things you can do at home to help control your symptoms, for example:
- Washing: Try not to wash areas with acne more than twice a day as it can irritate the skin and make your symptoms worse.
- Water: Try to use lukewarm water to wash your face. Very hot or very cold water can sometimes make symptoms worse.
- Squeezing spots: Try not to squeeze your spots as this can worsen symptoms and can also leave behind permanent scars.
- Make up: Try not to use too much make-up or other cosmetic products on areas with acne. If you do want to use these products, try to find ones that are labelled as “non-comedogenic”. This means that they will be less likely to clog up your pores.
- Sleeping: You should always remove your makeup completely before you go to sleep.
- Dry skin: If you are having trouble with dry skin, you should use a fragrance-free water based lotion, spray, cream or ointment.
Acne treatments can either come in a “topical” form (meaning that you apply it to your skin directly) or they can come in the form of pills and tablets. The treatment choice depends on how severe the symptoms are, and which type of acne you have. If you only have mild symptoms, you can visit your pharmacist and ask them for advice, they should be able to recommend some over-the-counter products such as gels and creams that can help treat mild symptoms.
For some people with more severe symptoms, the gels and creams available at the pharmacy may not work. Instead they may need to see their family doctor or a skin doctor (dermatologist) who can prescribe stronger medications for their symptoms. It’s important however, to be patient when you start taking acne medication because it can take around 2 to 3 months before it starts to work.
Topical acne treatments (gels, creams & lotions)
Topical medications are ones that can be applied directly on the skin (for example a gel, cream or lotion). Your doctor may recommend that you use a combination of topical treatments. Examples of topical acne medications include:
Benzoyl peroxide is available as a gel or a cream and can often be bought at a pharmacy without needing a prescription. It comes in different strengths (2.5%, 4%, 5%, 10%). Your pharmacist will be able to help you decide which strength is best for you to use. It is important that you follow the instructions that your pharmacist gives you for how to use the medication.
How does benzoyl peroxide work?
Benzoyl peroxide works as an antiseptic. An antiseptic is a substance that stops or slows down the growth of microorganisms such as bacteria. When you use benzoyl peroxide products, it can help reduce the amount of bacteria that are present on the surface of your skin, reduce some inflammation, and also reduce some of the blackheads and whiteheads on your skin. You will usually be recommended to use the benzoyl peroxide for around 6 weeks.
Does benzoyl peroxide have any side effects?
Benzoyl peroxide can irritate your skin (especially in high concentrations), so it is important to use it as instructed to avoid too much skin irritation. It can produce the following side effects:
- dry skin
- tense skin
- burning, itching or stinging
- peeling of the skin
It can also bleach clothing, bedding and hair, so you should be careful to avoid getting it on these areas. Benzoyl peroxide can also increase your skin’s sensitivity to sunlight, so you should do your best to avoid the sun and sources of UV light (e.g. sunbeds) when you’re using this product. If you cannot avoid them, you should wear sunscreen.
Medical-grade skincare products (sometimes called cosmeceuticals) are products such as cleansers, moisturisers and toners that contain specific medications that can be used to treat acne.
These products can either be used alone, or alongside some other prescribed medications, and they should always be purchased from a medical professional.
How do medical-grade skincare products work?
Medical-grade skincare products are usually stronger than the products you can get over the counter at the pharmacy. They contain certain medications that can help reduce the amount of oil that is produced by the skin, which helps improve the symptoms of acne.
Do medical-grade skincare products have side effects?
The side effects of medical skin care products can vary depending on which product is being used. Some side effects include (but are not limited to):
- Burning sensation on the skin
- Skin irritation
You will need a prescription from your doctor before using topical retinoids.
WARNING: Women who are pregnant or breastfeeding should NOT use topical retinoids as there is a risk of causing birth defects.
Topical retinoids are usually available as gels, creams and liquids. Examples of topical retinoids include:
- Retinoic Acid
Your doctor will be able to recommend a specific topical retinoid for you. It is very important to speak to your doctor first before trying any of these medications.
- redness, peeling or flaking of the skin (this is very common)
- skin irritation
- an initial acne “flare up” (this goes away when you continue to use the product)
It is important to use topical retinoids as directed, and if possible to avoid too much exposure to sunlight and UV light (e.g. sunbeds). If you cannot avoid sunlight or UV light, you should wear high factor sunscreen which has an SPF level of 30 or above.
If you are taking retinoid pills or tablets by mouth, then your doctor may tell you to avoid using a topical retinoid alongside it.
You will need a prescription from your doctor before using topical antibiotics.
Topical antibiotics are available as a lotion or a gel. They are often used in combination with a topical retinoid or benzoyl peroxide. Your doctor will usually recommend using the topical antibiotic for no more than 6 to 8 weeks. This is to help prevent the bacteria on your face becoming resistant to the antibiotic. Examples of topical antibiotics include:
It is incredibly important to speak to your doctor first before using any of these topical antibiotics.
How do topical antibiotics work?
Topical antibiotics help kill the bacteria that is on the surface of the skin. This helps stop the bacteria from infecting the acne spots and making them worse. They can also help reduce inflammation around the spots.
Do topical antibiotics have any side effects?
Although they are uncommon, topical antibiotics may cause the following side effects:
- minor skin irritation
- a burning sensation
- peeling of the skin
If you are taking antibiotic pills or tablets by mouth, then your doctor may tell you to avoid using a topical antibiotic alongside it.
Azelaic acid is usually used as an alternative topical acne treatment if the side effects and irritation from topical retinoids or benzoyl peroxide can not be tolerated. It is available as a cream or a gel.
How does azelaic acid work?
Azelaic acid works by removing dead skin cells on the surface of the skin, and by killing bacteria on the skin. It can also help reduce inflammation. You usually need to use it for around 4 weeks before it starts to work.
Does azelaic acid have any side effects?
Azelaic acid side effects are usually mild. They can include:
- burning sensation on the skin
- stinging sensation on the skin
- discoloration of dark skin
You should speak to your doctor before using azelaic acid.
Salicylic acid is a medication that you can buy at the pharmacy without needing a prescription from your doctor. It is sometimes used by patients who cannot handle the side effects of other medications they have tried.
How does salicylic acid work?
It works by removing dead skin cells on the surface of the skin (which is called exfoliating). Removing dead skin cells stops them from being able to clog up hair follicles. This in turn, helps stop new acne spots like blackheads and whiteheads from developing.
Your pharmacist will be able to help you decide if you should try salicylic acid products.
Systemic acne treatments (tablets & pills)
Systemic medications are ones that work throughout the entire body. These medications are usually only used for people with moderate or severe acne. Examples of systemic acne medications include the following:
You will need a prescription from your doctor before you can take any antibiotic tablets. Please do not take this medication without consulting a doctor first especially if you are pregnant or breastfeeding.
Antibiotic tablets (which are called oral antibiotics) are usually used to treat more severe forms of acne. If your doctor gives you a prescription for antibiotics, it is very important that you follow the instructions of how to take them properly. Examples of the type of antibiotic tablets your doctor may prescribe for acne include the following:
*Doxycycline, minocycline, lymecycline and tetracycline all belong to a group of antibiotics called “tetracyclines”. These medications should NOT be taken by pregnant women or children as they can cause tooth discolouration.
How do antibiotic tablets work?
Just like the topical antibiotics, the antibiotic tablets work by killing bacteria and helping to reduce inflammation. It will usually take 6 weeks before you start to notice any improvements in your acne.
Do antibiotic tablets have side effects?
Each antibiotic tablet can have certain side effects which you should familiarise yourself with before taking them. Your doctor will be able to tell you about the side effects of the antibiotic they have prescribed.
Tetracycline antibiotics can make your skin more sensitive to sunlight and UV light, so you should try to limit your skin’s exposure to the sunlight and if you cannot, you should make sure to wear high-factor sunscreen. They can also make the oral contraceptive pill less effective during the first weeks of treatment. If you are sexually active during this time, you should consider use another method of contraception such as condoms.
You will need a prescription from your doctor before taking hormonal medications.
Hormonal medications can help certain women who suffer from acne, especially if their acne develops around the time of their period, or if they a hormonal condition such as PCOS (polycystic ovary syndrome). Examples of hormonal medications that may be prescribed to women with acne include:
- The combined oral contraceptive pill
- Medications called “anti-androgens” e.g. cyproterone acetate, spironolactone and flutamide
It is very important that you speak to your doctor first before trying any of these hormonal medications.
How do hormonal medications for acne work?
These medications work by reducing the production of a certain group of hormones called androgens. Androgens usually cause a lot of oily sebum to be secreted, so medications that reduce the levels of androgens in the blood can help reduce the amount of oily sebum that is produced in the skin.
You will need a prescription from a specialist skin doctor (dermatologist) before using isotretinoin. Please do not take this medication without consulting a specialist doctor first.
WARNING: It is extremely important that women who think they are pregnant, know they are pregnant, or who are breastfeeding do NOT take isotretinoin. This medication is likely to harm the unborn baby and also increases the risk of having a miscarriage. It is extremely important that women do NOT become pregnant whilst they are taking isotretinoin, and for at least 1 month after they stop.
Isotretinoin is a treatment that is used to treat severe acne. It comes in the form of capsules, and is more commonly known under its brand names Accutane®, Roaccutane® and Rizuderm®.
How does isotretinoin work?
Isotretinoin helps reduce acne symptoms by doing the following:
- Reducing the amount of oily sebum produced in the skin
- Prevents hair follicles from getting clogged up
- Reduces the amount of bacteria on the skin
- Reduces swelling and redness around acne spots
The following people should NOT take isotretinoin:
- Women who are pregnant or breastfeeding
- Women who think they might be pregnant
- Children under the age of 12
- Children who have not yet hit puberty
- People who have an allergic reaction to isotretinoin in the past
- People who are allergic to soya (the capsules contain soya)
- Those who have fructose intolerance (the capsules contain sorbitol)
Does isotretinoin have any side effects?
This medication can cause a wide range of serious side effects. That is why it is only used for severe cases of acne under the supervision of a specialist skin doctor (dermatologist), and is only used after all other treatments have failed.
Because of the various side effects, people taking isotretinoin usually need to have blood tests done before and during their treatment. It is also very important to tell your doctor if you are taking any other medications for acne, as they may not work well with isotretinoin and may make your symptoms worse.
Below are examples of side effects, but not all side effects are listed below. For a full list of side effects you should speak to your skin doctor who should be able to provide them for you.
Some common isotretinoin side effects include:
- very dry skin and lips
- skin that is sensitive to sunlight
- dry eyes
- dry throat
- dry nose
- general aches and pains
- Emotional or psychological symptoms: anxiety, depression, aggression, violence, changes in mood, suicidal thoughts
- Stomach and bowel symptoms: severe stomach pain, nausea, vomiting, bloody diarrhoea
- Skin symptoms: skin rash that bleeds or blisters, and can come alongside eye infections, fever, ulcers and headaches
- Muscle weakness symptoms: trouble moving arms and legs, painful, swollen or bruised areas of the body, dark pee
- Liver or kidney disease symptoms: yellow skin or if the whites of the eyes turn yellow, trouble peeing, feeling very tired
- Eye symptoms: sudden changes in your vision, or not being able to see as well in the dark
WARNING: If you become depressed or think about ending your life whilst you are taking this medication, you must STOP taking the medication and speak to your doctor straight away.
Most of the side effects experienced when taking isotretinoin usually go away once you stop taking the medication.
There are also some non-medical treatment options for acne. However, these treatments may not work and cannot always be recommended by your doctor. They include the following:
This is a small instrument that is shaped like a pen, and that can help “clean out” blackheads and whiteheads.
This is a procedure where certain chemicals are applied to the face, and after some time the skin starts to peel. This peeling reveals a new layer of skin underneath the old, dead skin.
This treatment is also called photodynamic therapy. It is when a specific kind of light is shone on the skin to try and improve the symptoms of acne. Using blue light in particular can help decrease bacteria levels and reduce the amount of oily sebum produced by the skin.
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