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Uncracking The Code Behind Your Acne

Uncracking the code behind your acne can be frustrating for many. Finding the underlying cause of your acne and the different types of breakouts is helpful in the treatment of acne and prevention of acne scarring.

(1) Comedonal acne— black heads and white heads—is caused by occlusion or blockage of hair follicles (pores) by the keratinized lining of the upper portion of the hair follicle. Keratin (i.e. skin debris) is normally shed through the follicular opening. However, when this debris is retained and trapped by excess oils on the skin this creates a whitehead. When the blocked pore opens, it appears grayish-black to the naked eye creating a blackhead.

Treatment: The best topical treatment for comedonal acne is prescription nighttime topical retin-a, specifically Tretinoin and Tazorac in conjunction with a morning Salicylic acid wash—a keratolytic (destroying the excess keratin, opening up clogged pores). Tretinoin skillfully speeds up the skin’s ability to turnover, opening up blocked pores and evening out dyspigmentation as well as promoting collagen synthesis. In addition to acne treatment, topical retin-a is a noninvasive way to help soften fine lines and wrinkles overtime. When using topical retin-a products, both over-the-counter and prescription, I recommend to all my patients with both oily and dry, sensitive skin to start 2-3 times a week and then increase to nightly as it is very dry and can be irritating.

Microdermabrasion is a technique used to help with both comedonal acne and acne scars. A dermatologist will use a small handheld device containing micro needles that penetrate your skin (1-3mm deep) creating small micropunctures in the skin, promoting collagen and elastin synthesis and unclogging pores.

(2) Pustules, commonly referred to as pimples, are a result of an inflammatory response to excess oil, bacteria (specifically Propionibacterium acnes bacteria) and debris (dead skin cells) on the top layer of the skin. Our body recognizes all of the above as foreign, stimulating an inflammatory response causing redness and swelling. Hormonal effects on the production of sebum by our sebaceous glands may also contribute to pustular acne, specifically around the jawline, chin and neck.

Treatment: Evaluation by a dermatologist is essential in the treatment of pustular acne as if left untreated can result of cosmetically displeasing scarring and dyspigmentation. We find a combination of oral antibiotics in addition to topical retinoids, and topical antibiotic creams and gels is helpful for mild-to-moderate pustular acne. However, if resistant or less than desirable results, oral isotretinoin (Accutane) may help in the treatment of both pustular, cystic and comedonal acne. Oral isotretinoin, a vitamin A derivative, is prescribed by dermatologists and requires blood work monitoring and monthly pregnancy tests.

(3) Deep cystic acne can be frustrating for many as they typically do not have a head. Cysts are caused by occlusion or blockage of a hair follicle resulting in formation of a small balloon or “sac” underneath the skin. The sac continues to be filled with debris making the cyst larger in size and increasingly painful and red. Similarly to pustular acne, a short course of a combination of oral antibiotics and topical retinoids may be helpful for mild-moderate acne. However, oral isotretinoin is often the best approach to patients with cystic acne as this powerful medicine attacks acne in 3 main ways, including unclogging pores, reducing oil production, decreasing inflammation (redness and swelling). If cystic acne is around the jawline, chin and extends to the neck, consultation with both a gynecologist and dermatologist is recommended to explore hormonal influences on your acne.

Does your acne flare around your menstrual period? Do you have increased facial hair growth? Are you experiencing unexplained weight gain or hair loss? If yes to any of the above, consultation with a physician is essential to test for polycystic ovarian syndrome (PCOS) and consider a combination of an oral contraceptive and spironolactone. Spironolactone, an oral medication, used at higher doses for high blood pressure, can be helpful at lower doses for hormonal acne (check out our podcast episode: Season 2, Episode 2 "Pimples in the Prime Years").

(4) Nodules: When there is increased inflammation surrounding a blocked pore, a deep nodule (firm, hard bump) forms. Differing from cysts which are often more superficial, softer containing pus, nodular acne reside deeper in the skin, increasingly painful and firm with palpation. Nodular acne is considered more severe acne and can be more persistent than comedonal and pustular acne. For transient relief, a 2-3 month course of oral antibiotics may be helpful in reducing discomfort and inflammation (redness, swelling) as well as intralesional steroid injections to that 1-2 stubborn deeper nodular acne.

Treatment: Consultation with your dermatologist is essential to discuss treatment options of nodular acne as well as subsequent management of acne scarring. If you experience fever, chills, bone pain and joint discomfort, as well as, severe nodular and/or nodulocystic acne, it is important to schedule an appointment with your dermatologist for further evaluation, imaging and treatment with oral steroids.


Finally, the key to successful acne treatment:

  1. Do not be discouraged, it takes time to see results. A majority of topical and oral acne treatments often take at least 6-8 weeks to notice improvement in your acne. So don’t jump ship to a new medication or give up on your current treatment if you aren’t seeing rapid results. There are numerous treatments available for acne (invasive and noninvasive), so if you aren’t pleased with your results, consult with your dermatologist the next step up the ladder.

  2. Compliance is key! Remembering to take the pills or using the topicals can be tough at times. I recommend setting an alarm on the phone as well as putting your nighttime creams by your toothbrush (brush your teeth, apply your retin-a!).

  3. Invest in gentle, noncomedogenic facial cleansers and moisturizers. Make sure your moisturizer and cleanser states “facial”, “noncomedogenic” and/or safe for dry, sensitive acne-prone skin. Use of safe ingredients and fragrance-free products is essential in maintaining hydration with minimal irritation.

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