Who doesn’t know the horror of waking up to an inflamed red pimple? Not only does it cause physical discomfort but the psychological toll and sheer embarrassment over the “damned spot” can weigh on us for days. If this has happened to you then you know first hand how hard it is to face down acne.
Of course, Internet blogs, health, and beauty magazines are brimming with cure-all antidotes, recommended spot treatments, and do-it-yourself remedies for the condition. But how much of what you read is based on science? In this article, we are going to explore what science says about acne and about what is truly effective as opposed to a myth?
Here is what will be covered:
- What is acne?
- Who gets acne?
- What does acne look like?
- Acne treatments
- Dermatologic consultation
- Debunking acne myths
Acne is a multifactorial chronic inflammatory condition of the hair follicle and its associated oil glands (pilosebaceous unit). Due to abnormal shedding of cells that line the hair follicle and an increase in the production of oil from the sebaceous glands, often initiated by androgens with the onset of puberty, a micro-plug (a clogged pore) is created.
These events lead to an environment within the hair follicle that favors the colonization of a commensal bacteria Propionibacterium acnes. These bacteria secrete inflammatory molecules and chemotactic factors that initiate and stimulate the inflammatory response.
Acne most commonly occurs on the face, chest, back and shoulders, the areas with the largest number of oil glands.
Acne is the most common skin condition in the United States. It affects up to 50 million Americans annually. According to the Global Burden of Disease study, acne affects approximately 85% of young adults between 12 to 25 years of age. And amongst all adult women, 12%-22% suffer from acne at some point in their lifetime.
Acne can take several forms:
- Inflammatory acne
Noninflammatory acne lesions are called comedones. Comedones form when hair follicles become clogged and blocked by oil and dead skin cells. When the clog is at the surface of the skin, the comedone appears black and “blackheads’ are formed. When the clog is not at the very surface of the skin, the clog appears white or skin color and “whiteheads” are formed.
–Inflammatory acne lesions
Inflammatory acne lesions include red raised bumps that are often tender. The tips of some of these lesions often contain white pus. Larger more painful bumps can develop beneath the skin surface. And the most inflamed cystic lesions, ones that are red, painful, and pus-filled may result in scarring of the skin.
Effective acne treatments reduce bacterial infection and the production of oil from the hair follicle, reduce inflammation, and, attempt to normalize cell turnover within the hair follicle.
–Basic skincare routine.
There is no consensus amongst the dermatological community on how often an individual with healthy skin should wash their face with a cleanser. There is no medical evidence that proves washing a healthy face with a cleanser is necessary or beneficial. There is, however, adequate research that shows that acne sufferers fare better when they cleanse the face with a mild soap-free cleanser twice daily.
Some people resort to “popping” pimples, particularly if they pop up before a big event. However, squeezing or “popping” pimples doesn’t necessarily get rid of the problem. In fact, it may extend the inflammatory reaction deeper making the acne lesion more noticeable or more painful. Further, popping an acne pimple may lead to a skin infection and/or increased scarring. If you have acne, you should see a dermatologist!
— Over-the-counter (OTC) products can be effective for mild acne.
People who have mild acne, especially those with whiteheads and blackheads, may find OTC products that contain salicylic acid effective. This chemical is keratolytic. That means that it causes the peeling (or desquamation) of thickened skin cells by disrupting the space between skin cells. Salicylic acid is beneficial when used in concentrations of 3%-6%. It may become destructive to the skin at concentrations above 6%.
Mild acne sufferers may also benefit from OTC products containing benzoyl peroxide. Benzoyl peroxide is metabolized on the surface of the skin to benzoic acid and free oxygen. Yes, it is a free radical but it has never been shown to cause skin aging! (That is a topic for another article.).
As a result of both a lower skin pH and the presence of free radicals, benzoyl peroxide has broad-spectrum antimicrobial activity. Benzoyl peroxide has also shown to decrease the metabolism of the glands associated with the hair follicle but whether the oil production is actually decreased is controversial.
Adapalene, a type of retinoid, is now available OTC. It may be effective for treating mild acne. Retinoids bind to specific receptors within cells that affect the actual growth of cells and decrease inflammation. This product, however, may cause skin redness, dryness, itching, and burning. And some people may experience an initial worsening of acne during the first several weeks of use.
Individuals with moderate or severe acne or for those patients where OTC products have been ineffective, dermatologic consultation is recommended. Topical products including topical retinoids that normalize cell turnover and decrease oil production and topical antibiotic creams may be prescribed. Systemic antibiotics and combination topical anti-acne preparations are also available for those with more resistant and severe breakouts. For the most severe cases, where scarring is an issue, systemic retinoid therapy may be considered.
There is a plethora of advice from “skincare experts” regarding acne on social media, blogs and in health and beauty magazines. But there is usually no science to prove such claims. Some of these “experts” are well-intentioned but simply misinformed. Others, financially benefit from their claims although they may still believe such claims to be true.
Myth #1. Change your pillowcase once a week
Yes, in our culture we all prefer a clean pillowcase. Unfortunately, there are no scientific studies that correlate pillowcase or sheet changes or washes with acne breakouts.
Myth #2. Use a silk pillowcase
This is a popular claim, especially from those that sell silk pillowcases. Silk pillowcases are beautiful and they feel lovely on the skin. Unfortunately, there is no science that proves a silk pillowcase improves or prevents acne compared to any other pillowcase material.
Myth #3. Makeup causes acne
In 1972, Dr. Albert Kligman coined the term ‘acne cosmetica.’ A mild form of persistent acne seen primarily in adult women triggered by the use of cosmetics. Yes, some individuals breakout after applying certain cosmetics. And for others, cosmetic usage improves their acne.
The cause of acne cosmetica isn’t the product itself but particular pore clogging or “comedogenic“ ingredients in the cosmetic. Although major manufacturers do perform some testing on their products in an attempt to minimize breakouts from their “non-comedogenic” products, there is no federal guideline or standard to guarantee that any particular product won’t cause or exacerbate acne in any given individual.
Choose makeup and other facial products carefully. Opt for oil-free products. Yes, select “non-comedogenic” products from reputable manufacturers, not because it guarantees a breakout won’t occur, but because the product has likely had some level of testing. And that’s better than nothing.
Myth #4. Chocolate causes acne
There is little, if any, evidence that proves chocolate causes or worsens acne. Further, the relationship between diet and acne is highly controversial. That being said, patients who find an association between ingesting a particular food and their acne breakouts should avoid or limit the intake of that food.
As far as particular foods that cause or worsen acne, there is some weak scientific evidence that suggests a heavy consumption of dairy products may exacerbate acne. Further research is certainly warranted regarding this relationship.
More convincing evidence exists linking acne breakouts to high glycemic index diets. The glycemic index is a system that ranks carbohydrate-containing food based on its effect on blood-sugar levels. High glycemic index foods, like white rice, white bread, and potatoes increase blood insulin levels. Elevated insulin levels stimulate hormones that increase oil production, which plays a fundamental role in acne formation.
It was once believed that no relationship existed between diet and acne. Although much research needs to be done, the once common dogma that concluded no association exists between acne and diet should no longer be accepted.
Myth #5. Toothpaste on acne is beneficial
No double-blinded study found that proves toothpaste is an effective treatment for acne. But there are plenty of patients seen in dermatology offices for irritating inflammatory reactions due to toothpaste application on the face.
Myth #6. Home remedies.
Honey, tea tree oil, egg whites, and colloidal oatmeal, are just a few home remedies that are often touted as effective acne treatments. The problem is, there is no scientific evidence that supports the beneficial claims of these treatments. And many home remedies, especially plant-based products like tea tree oil, oregano oil, and lemon juice can cause allergic reactions.
Consult with your dermatologist before using home remedies and then proceed with caution.
The bottom line
Acne is a common condition that affects millions of people around the world. Although there are many myths about what causes and what effectively treats acne, most have been debunked. We know that acne is a chronic inflammatory condition that affects hair follicles and associated oil glands. And, we know that mild acne can often be effectively treated with OTC products, such as salicylic acid or benzoyl peroxide. But severe acne or acne that doesn’t respond to OTC products should be treated by a dermatologist. Prescription medications such as antibiotics and retinoids may be prescribed.
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Fayne Frey, MD
Fayne Frey, M.D., is a board-certified clinical and surgical dermatologist practicing in West Nyack, New York, where she specializes in the diagnosis and treatment of skin cancer. She is a nationally recognized expert in the effectiveness and formulation of over-the-counter skincare products.
She is a frequent speaker in many venues where she captivates audiences with her wry observations regarding the skincare industry. She has consulted for numerous media outlets, including NBC, USA Today, and, the Huffington Post. and has also shared her expertise on both cable and major TV outlets.
Dr. Frey is the Founder of FryFace.com, an educational skincare information and product selection service website that clarifies and simplifies the overwhelming choice of effective, safe and affordable products encountered in the skincare aisles.
Dr. Frey is a graduate of the Weill Cornell Medical College and is a fellow of both the American Academy of Dermatology and the American Society for Dermatologic Surgery.