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The Complete Guide to Everything You Need to Know About Acne

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Zits. Spots. Breakouts. Whatever you call yours, it could be a skin condition called acne

But before you notice one spot on your face and immediately call it acne, you might want to read our complete guide first. Because whilst one or two hormonal zits are really, really annoying, they don’t necessarily signal that you actually have severe acne. 

Confused? I don’t blame you. So here is a breakdown of what acne actually is, who typically gets it and how to identify whether you have it or not. With help from skincare experts Dr Nowell Solish, Dr Ahmed El Muntasar, Akis Ntonos, Ila Dayananda, Dr Sonia Khorana, Dr Jodi LoGerfo, Anna De La Cruz and Stephanie Criscione, we also discuss what causes acne, the (many) different types and, most importantly, the best ways to treat them. 

 


What actually is acne?

Acne occurs when oil (sebum) and skin cells mix together and essentially create a ‘plug’ over the opening of the hair follicle,” explains De La Cruz. “This plug creates an environment where bacteria can thrive and the end result is a lesion, i.e. breakout.”

Criscione continues, “those plugs can lead to the formation of microcomedones, comedones, pustules, papules, cysts and nodules [more on those later]. Although there is no cure for acne, there are many effective treatments available to help heal and clear the skin.”

Acne doesn’t always occur on the face, it can also present itself on the back (known as ‘bacne’), chest and even shoulders too as these areas have the most oil glands. 

 

Image – Easy2shoot/Stocksy

 


Who generally gets it?

Contrary to what you might think, acne isn’t just a problem in teenagers. “While it is certainly true that the onset of puberty (hormones) and oil production can play a major role in many young adults experiencing breakouts, they’re not the only ones,” says De La Cruz

“Individuals can continue to experience, or even experience for the first time, breakouts in their 40s. Adult females often experience breakouts due to the combination of stress and hormones.”

“Unfortunately we’ve seen a significant rise in adult-onset acne in the US, likely due to many factors that contribute to breakouts such as stress, hormonal fluctuations, lifestyle implications and an impaired microbiome,” adds Criscione.

 


How do you know if you have it?

Criscione says the signs of acne differ, depending on the seriousness of the condition. “The first signs are usually oiliness and congestion, especially in the centro-facial region,” she says. 

“In biological males, acne can often begin manifesting during puberty in areas where facial hair starts to grow. When left untreated, acne skin will become more severe, resulting in red, inflamed lesions.”

A doctor or dermatologist can diagnose acne and determine what level you have – grade 1, 2, 3 or 4 (4 being the most severe). 

“To properly diagnose acne, a provider must take a deep dive into family history, hormonal factors, symptom severity, how long the condition has been present, and followed with a thorough skin examination to determine the type and severity of the condition,” explains Criscione

 

Image – Ohlamourstudio/Stocksy

 


The different causes of acne

There are a few things that could be causing your acne. The first, and most common is when pores and/or follicles get clogged and blocked up with oil or dead skin. “Acne vulgaris is a disease of the pilosebaceous follicle (the pore),” explains Dr LoGerfo

“It is composed of a hair follicle, hair shaft and sebaceous gland. Acne develops through a complex mechanism which involves the cells of the follicle sticking together which prevents them from shedding normally onto the skin’s surface,” she continues.

“There is also excess sebum (oil) production and bacteria. This plugs the follicle, causing a comedone, a dome-shaped, smooth, skin coloured papule. This series of events cause inflammation and subsequent formation of an acne lesion. There could also be an imbalance of the microbiome within the follicle.”

So, avoid touching your face with dirty hands as much as possible and practice a consistent cleansing routine.

“Genetics can also play a role in the formation of acne,” she adds. “If you have a close family member with acne, you are at an increased risk to develop it.”

Hormonal changes can have a lot to do with extra oil production too, causing breakouts. “Male hormones (androgens) are involved as well, promoting sebum production,” Dr LoGerfo adds. 

And diet could also play a part in causing acne. For example, eating and drinking things like sugar and fat free milk are advised against. “The role of diet is an evolving concept with dairy and foods with high glycemic index being proposed as possible causes, but there needs to be more study,” says Dr LoGerfo.

 


The different types of acne

Image – Susanaramirez/Stocksy

Bacterial acne

The cause is in the name. “Bacterial acne is considered an inflammatory condition (papules, pustules, nodules and cysts) caused by an overabundance of acne-causing bacteria P. acnes on the skin,” says De La Cruz

“Now, keep in mind our skin’s number one job is protection (from fighting off infection and healing wounds) and it naturally hosts many bacteria and other organisms, including viruses and fungi to accomplish this.

But issues arise when there is an imbalance in this, our skin’s microbiota, which can lead to inflammation and (bacterial) acne. This is typically treated with an anti-biotic.”

 

Fungal acne

“Unlike bacterial acne, fungal acne is caused by an overgrowth of yeast (which is a type of fungus) on our skin,” explains De La Cruz. “The result is inflamed acne-type lesions on the skin as well as itchiness.”

You can study the lesion size too, to determine whether it is fungal acne. “Often, fungal acne lesions are very similar in size and they may be quite small and appear in patches or clusters,” she adds. “To bring balance back to the skin, your dermatologist may recommend several different options from a medicated body wash to an antifungal cream or medication.” 

 

Cystic acne

Cystic acne, “is considered a severe form of acne and it can take months to resolve,” warns De La Cruz

“The lesions are usually over 5 millimeters in diameter and can be found on an individual’s face, chest and back. These deep, painful lesions can result in inflammation and scarring so it is imperative to seek the advice of a medical professional early on.”

 

Hormonal acne

“Hormonal acne is characterized by breakouts triggered by hormonal fluctuations, generally during puberty, menstruation, pregnancy, or menopause,” explains Dayananda

“It often manifests as inflamed pimples, cysts, and nodules, mainly around the chin, jawline, and cheeks.” So why particularly during hormonal changes? “They stimulate the production of excess sebum, an oily substance that clogs pores and dead skin cells, which leads to acne,” she says.

“Androgens, including testosterone, are pivotal in this process because they stimulate the sebaceous glands. These hormonal imbalances can cause increased inflammation and bacterial overgrowth in the skin, exacerbating acne symptoms.”

 

Nodular acne

This is, “a severe form of acne affecting the face and upper trunk,” according to Dr Khorana. “It is characterised by nodules and cysts that typically resolve with scarring”.
Factors like increased sebum production, inflammation, bacteria, medications, and genetics can cause nodular acne.
“You may see solitary or multiple inflammatory nodules and pseudocysts which may be firm or tender,” explains Dr Khorana.

 

Acne conglobata

“This is a rare but serious form of inflamed acne,” says Criscione. “It often presents with tender, disfiguring, double or triple connected comedones, inflammatory nodules and deep burrowing abscesses. This is a chronic inflammatory condition that if left untreated can lead to scar formation and disfigurement.”

 

Acne mechanica

This is a form of acne which usually appears on the body, but it can also be found on the face. “It’s a type of acne caused when there is excessive heat or friction on the skin,” Criscione explains. 

“It’s often called ‘sports acne’ as it’s common in young athletes due to helmets, sweat, sweat bands and mechanical friction. Anything that traps heat and rubs against the skin can trigger acne mechanica.”

 

Acne rosacea

“This is a type of acne that affects adults, usually after the age of 30,” Criscione says.  “It tends to be more common in women however men get more severe forms. Acne rosacea only appears on the face primarily in the central facial region. 

You may experience some bumpiness and microcomedones, and the skin will be flushed, red, and tiny blood vessels may appear on the nose and cheeks. Stress exposure, product usage, and lifestyle factors can make acne rosacea symptoms worse.”

 

Acne cosmetica

“This is common and relatively easy to treat, caused from using hair or skin products that clog the follicles,” Criscione explains. “Comedogenic ingredients along with excess sebum, debris and bacteria accumulate within the follicle, blocking pores and resulting in skin blemishes.”

 

Acne tropocalis 

Presumably taking its name from the ‘tropics’, “this is an unusually severe type of acne occurring in climates where the weather is very hot and humid,” Criscione says. “This skin condition is seen with more frequency in hot/humid climates where bacterial and fungal infections are more common.”

 


The different types of acne blemishes

Acne can present itself in many ways. Here is a description of each type of blemish and how to identify them.

 

Young Pacific Islander female with long hair and acne looking at camera while standing against green cottage wall in Sonoma County, California

Image – Bylorena/Stocksy

Comedones

You may have seen this word many times when reading about the topic of acne. But what exactly are they? “The main characteristic of acne is comedones, which are caused by a hair follicle getting blocked with oil, dead skin cells and dirt,” explains Ntonos.

It might be easier to identify them as blackheads or whiteheads. “Comedones can either be open or closed. When they are open on the skin’s surface, they are called blackheads. They look dark due to the debris inside oxidizing.” And when they are closed? “They appear as whiteheads, which are bumps that match the skin tone.”

 

Blackheads

A type of comedone, that looks dark “mainly on the face and nose,” Ntonos says. “Their darkness comes from sebum and dead cells oxidizing in the pores, not from dirt. Slightly raised blackheads do not cause pain like pimples because there is no inflammation.”

These types of blemishes, “frequently appear in groups,” according to Dr Khorana.

 

Whiteheads

As we’ve just learned, these are the closed comedones “where the pores are totally clogged with sebum, bacteria and dead skin cells,” Ntonos explains. “They present as bumps on the skin’s surface and feel firmer to touch than blackheads since their pores are shut off from the skin’s surface.”

 

Papules

Ntonos says these are raised bumps that develop as part of acne outbreaks. “Papules are usually less than 1cm in size and can appear pink, red or match your skin tone,” he explains. “They form when the walls of your pores break due to inflammation, resulting in firm, blocked pores that feel sensitive when touched.”

 

Pustules

Not to be confused with papules, these are more pus-based. “Pustules are inflamed, pus-filled lesions that surface on the skin, resembling an aggravated version of whiteheads,” explains Ntonos

“They stand out due to their noticeably larger size and the pus that fills them, giving them a white or yellowish centre capped with a white head, encircled by a reddened area.” In other words, they’re the ones that look really tempting to squeeze!

“These bumps are sensitive and can appear on any part of the body, making them a noticeable and often uncomfortable feature of acne.” So as tempting as they look, it’s best not to squeeze them.

 

Nodules

“Nodules present as substantial, tough lumps deep under the skin’s surface,” Ntonos says. “Due to their depth and severity, they are often the source of considerable discomfort.”

Ntonos warns that this is the more persistent type and can last for weeks or even months. “Visibly, they are large and flesh-coloured, with a density that makes them distinctly palpable and often quite painful to touch.”

 

Acne cysts

Bigger than pustules or nodules, these can cause pain and scarring. “Acne cysts are the most intense form of acne lesions, presenting as large, tender, pus-filled pockets skin to boils,” explains Ntonos

“These cysts form deep within the skin and are soft to the touch, suggesting a fluid-like content. They can sometimes combine with neighbouring cysts, creating extensive areas of inflammation beneath the skin’s surface.”

 


The different grades of acne

Grade 1 acne

“Grade 1 acne includes non-inflamed lesions on the face,” says De La Cruz. At Face Reality they refer to them as stages. “Stage one refers to mild breakouts, which can include some blackheads and bumpiness, and occasional inflamed lesions,” Criscione explains. “But in general, the blemishes are not widespread.”

 

Grade 2 acne

“Grade 2 includes non-inflamed lesions as well as papules and limited pustules mostly on the face,” De La Cruz says. “Stage two is defined as moderate acne,” adds Criscione.

 

Grade 3 acne

“This designates an inflamed acne condition that can include breakouts on the face, chest and back,” De La Cruz says. “Blemishes are large, red and inflamed and scarring is likely at this stage,” adds Criscione

 

Grade 4 acne

“Grade 4 is the most severe form of acne and includes deeper level lesions such as nodules and cysts,” explains De La Cruz

 


How to know which type of acne you’re experiencing

“The type of acne you have is based on the types of acne lesions you have,” explains Dr LoGerfo

“Comedonal acne is acne consisting of clogged pores, inflammatory acne consists of papules and pustules. Nodular or cystic acne is more severe, and the lesions associated with them can be deep, painful and very infected.”

 


The best over-the-counter treatments for acne

Dr LoGerfo recommends a number of treatments, including benzoyl peroxide, adapalene (aka differin), alpha hydroxy acids (AHAs), azelaic acid and salicylic acid. 

 

skincare lotion and gels textures

  • Benzoyl peroxide

“Benzoyl peroxide destroys the bacteria that causes acne and helps to decrease the amount of oil on the skin,” she explains. “It also has comedolytic properties, which means it unclogs pores and can help prevent them from being blocked again.”

  • Adapalene

Adapalene is a retinoid. “This means it helps unclog pores and can thwart breaking out further,” Dr LoGerfo says. “It is available over the counter at a 0.1% strength.”

  • AHAs

You may have heard of alpha hydroxy acids before. “These include lactic acid and glycolic acid,” she explains. “AHAs exfoliate and can help remove dead skin cells. They also help unplug pores and help clear blackheads and if you have any pigmentation from previous acne lesions, AHAs can help decrease skin discolouration.”

  • Azelaic acid

From personal experience, azelaic acid worked wonders on my pustules which persistently appeared around my mouth, on my chin, along my jawline and sometimes cheeks. Since using a course of anti-biotics and azelaic acid for around six months, my acne has completely gone, apart from the odd hormonal cluster. 

“This ingredient can help unplug pores and prevent new breakouts, usually available over the counter from 0.5% -2%” says Dr LoGerfo.

 


The best acne medications

Roaccutane is a front runner. “It is the main medication for acne,” says Dr El Muntasar. I would advise doing thorough research on Accutane, as it has a history of causing mental health problems as well as other side effects like nosebleeds and joint pain.

Dr El Muntasar says there are alternatives if you don’t want to go down the Accutane route. “Antibiotics like Minocyline and Doxyxycline work just as well,” he says. “Medical creams such as Differin and Tretinoin are also great to use.”

 

Skincare products gels and lotions isolated over a white surface

Image – Ohlamourstudio/Stocksy

 


The best in-office treatments for acne

There are multiple options available in-office, according to Dr El Muntasar. “Number one is a skin peel such as a deep salicylic acid peel, azelaic peel or retinoid peel and these work really well,” he says. 

He also advises considering laser treatment. “There are new lasers to target oil glands in the skin to help reduce the amount of oil produced. Medical grade skincare is fantastic to also help reduce oil production and soothe acne.”

Dr Solish also recommends microdermabrasion, laser and PDT (photodynamic therapy). “It can be very effective and newer treatments, including laser therapy with devices like Aviclear have been approved,” he says. 

 


How long does it take to get rid of acne

One of the most common question experts are asked when it comes to acne is, how long will it take to clear up? Of course, it all depends on the severity of your acne and no one’s skin is the same. However, Dr El Muntasar explains that in normal cases, “generally, time with the skin is measured in months rather than days or weeks. So, it can take three months onwards for the acne to fully clear.”

 


How to treat your acne scars

There are plenty of ingredients available over the counter that help with acne scarring, for example niacinamide, azelaic acid and vitamin C. If nothing is working for you though, a dermatologist can help you find other solutions that may include topical or oral medication, hormonal therapies, LED light therapy or chemical peels. 

 

Close-up portrait of young woman with problem skin and freckles on face in studio

Image – Asyamolochkova/Stocksy

 


How to build your acne skincare routine

The products acne-sufferers most need in their kit is a cleanser for acne-prone skin, a decent exfoliator and some form of treatment product. 

Choose a cleanser containing ingredients like salicylic acid which helps to clear up and prevent breakouts.

Using a physical scrub once or twice a week will help give your pores a good clean out as the grains can dig deeper than your cleanser can. I would advise anyone with very painful acne though to use it once a week as it could be too abrasive on raw breakouts and you also don’t want to overdo it with the acids. I add a few sprinkles of it to my cleanser every so often or I use it on its own, depending on how sensitive my skin is feeling. 

Other good products to have in your acne kit are a skin balancing moisturiser and spot-fighting serum.

 


The takeaway

Just when you thought having acne just meant a few spots, whatever the size, at a certain time of the month, you then read this article. Who knew there were so many different types?

And it’s not just the types of acne that can be confusing, it’s all the different shapes and sizes of the blemishes themselves too. 

However, hopefully now you can now identify yours a bit easier and know which course of action to take. For example, if you’re a teen or young adult who struggles with blackheads you’ll now know that you’re likely to have grade 1 acne and that things like regular exfoliation will help keep your skin cleaner and clearer. 

If you suffer from painful nodules or cysts that take weeks to clear up and scar easily however, it might be time to visit a doctor or dermatologist for further advice.

 

Meet the experts

Dr. Nowell Solish is Indeed Labs Dermatologist. He is a world-renowned expert in cosmetic dermatology with 20+ years of experience, co-director of Dermatologic surgery at The University of Toronto, and advisor for skincare brands including Indeed Labs. He continues to work with patients in his Toronto practice.

 

Dr Ahmed El Muntasar GP and Award-Winning Aesthetician.

 

Akis Ntonos is a dermatology nurse practitioner, injectable specialist, and co-founder of Aion Aesthetics, a premier New York aesthetic and injectable clinic. 

 

Ila Dayananda MD, MPH is a board-certified OB/GYN and chief medical officer OB/GYN at Oula Health.

 

Dr Sonia Khorana is a GP with a special interest in dermatology, working as an aesthetic doctor, laser specialist and wellness & menopause lead. She is also the Dermatology Expert for Olay UK and Hero Cosmetics UK and a judge for this year‘s Glamour Beauty Power List Awards and Get The Gloss Beauty Awards.

 

Dr Jodi LoGerfo is a skincare expert, Doctor of Nursing Practice and a Family Nurse Practitioner certified in Family Medicine and Dermatology.

 

Anna De La Cruz is VP of product development and master esthetician at Glo Skin Beauty.

 

Stephanie Criscione is medical aesthetician and director of education and acne clinic at Face Reality Skincare.

 

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Beauty Editor

The former Beauty Editor of Glamour UK, Philippa has been a beauty and lifestyle journalist for over 16 years, picking up countless tips and tricks from makeup artists, hair stylists, dermatologists and celebrities. In that time she’s written for names like Cosmopolitan, The Sunday Times Style, The Telegraph, Grazia, Refinery 29 and Byrdie. Philippa lives in the UK with her husband, two children and their hyperactive cockapoo, Paddy.

Expertise: Makeup, hair care
Education: Oxford Brookes University
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