Acne is a common dermatologic condition that affects millions of people worldwide. It costs billions of dollars a year to treat.

Acne was once thought only to affect teenagers, but in reality, it can affect any age group and any skin type.

It can range from mild cases to very severe ones, requiring help from a dermatologist. Also, acne can present on the face, scalp, chest, arms, and back.

Acne can afflict patients with not only physical findings but psychological ones as well.

To get it under control, you need to build a skin care routine for acne that is personalized to your specific needs.

In this article, we will help you do exactly that by covering the common questions and talking points.

Acne background

How does acne form?

A common myth is that acne is an infection, so you can take antibiotics for a few days, and it is gone forever.

That is not the case at all.

Acne is, in many cases, a lifelong inflammatory condition that requires patience and long term treatment to keep it under control and prevent scarring.

There is no quick fix to get rid of it overnight.

Multiple factors cause acne to form. We have pores or openings in our skin. Hairs emerge from these pores. The pores have oil glands attached to them, which produce and expel oil, also called sebum.

When dead skin cells and oil do not get expelled but rather get trapped in the pores, this leads to a type of acne called comedonal acne or noninflammatory acne.

Comedonal acne consists of blackheads, which have open pores, and whiteheads, which have closed pores.

When bacteria get trapped along with the dead skin cells and oil, this results in the form of acne called inflammatory acne.

This type consists of papules (small pink-red bumps), pustules (pink-red bumps with pus on top), nodules (bigger medium-sized red bumps), and cysts (deep large red bumps).

Nodules and cysts can be much more difficult to treat and painful and can lead to permanent scarring and discoloration of the skin.

Is there a grading system for acne?

While there is no universally accepted grading system for acne, most dermatologists can group patients into mild, moderate, or severe acne categories (1).

Mild acne usually consists of a few blackheads and whiteheads.

Moderate acne has more blackheads and whiteheads as well as papules and pustules.

Finally, severe acne has a lot of blackheads, whiteheads, papules, and pustules, plus nodules and cysts. Severe cases usually have extensive scarring and discoloration of the skin.

Does acne run in families?

Genetics can play a part in acne development.

Acne can run in families. If both your parents had acne, you are more prone to getting a severe case of acne at a younger age (3).

Certain genetic conditions, such as polycystic ovary syndrome (PCOS), can run in families and make these patients more prone to acne.

Acne factors

Are hormones linked to acne?

Excess male hormones, or androgens, can increase oil production and lead to acne. This can happen in male puberty, female menopause, or medical conditions, such as PCOS.

Can stress cause acne?

When you experience stress, your body produces a hormone called cortisol. This hormone cortisol is a steroid that worsens acne by causing your oil glands to secrete more oil.

Does diet play a role in acne?

If you suffer from acne, you should avoid foods that are high in carbs and sugars, such as cookies, cake, pasta, and white bread, as these can make acne worse (2).

Foods, like these, with a high glycemic index, lead to an increase in the production of androgens, which leads to more acne.

Even dairy has been implicated in worsening acne.

You should stick to high vitamin A and C and zinc foods, such as fruits and vegetables.

Also, stay well hydrated by drinking 8 – 8oz glasses of water a day. Dehydration can lead to more oil production.

Can medications worsen acne?

Certain medications can worsen acne.

These medications include hormones, such as some oral contraceptives, anabolic steroids, and testosterone. These cause excess oil production.

Other medications include topical and oral steroids (like prednisone), antiepileptics, antidepressants, immunosuppressants, and certain chemotherapy drugs.

Lifestyle habits and acne

Does poor hygiene lead to acne?

Acne is definitely worsened by not caring for your skin properly.

Every good daily acne routine requires washing your face twice a day. It is important to wash your face in the morning, to get rid of dead skin cells and oil that was produced overnight, and at night, to get rid of dead skin cells, oil, bacteria, makeup, and dirt that accumulated throughout the day.

You should never go to bed without washing your face. Also, if you sweat during the day, either from sports, gym, or work, you should wash your face immediately after these activities.

You do not need to use harsh soaps or scrub vigorously at your skin to get it clean. This can irritate your skin and make acne worse.

Be sure to wash with lukewarm or cool water because hot water can irritate patients with dry and sensitive skin. If you have oily skin, stick to gel cleansers, such as Neutrogena Hydroboost Cleansing Gel.

If you have sensitive skin, avoid cleansers with sulfates, which can irritate your skin. The ZELEN Life Cleanser is sulfate-free.

If you have dry skin, a cream cleanser like Cetaphil Gentle Cleanser is a good choice.

Is smoking bad for my acne?

Smoking cigarettes and marijuana can lead to worsening of your acne. It increases hormones such as cortisol and androgens, which will lead to excess oil production and subsequent acne formation.

Daily behaviors and acne

Can I pop my pimples?

Popping pimples can irritate them and inflame the pimples, causing your acne to get worse.

It can also lead to a skin infection that may require oral antibiotics to cure and could cause permanent scarring.

Therefore, you should not ever pop pimples.

Do I need to wash my hats?

Proper hygiene extends to how your care for the things that come in contact with your skin, not just what products you use on your skin.

Athletic headgear should be cleaned with a disinfectant after every use to remove bacteria, dirt, and oil. Headbands, hats, and caps would be washed after every use for the same reasons.

It is best to wash in hot water to kill the bacteria. The same applies to pillowcases, towels, and washcloths.

This type of acne, which is caused by friction forcing bacteria into your pores, is called acne mechanica.

Can my phone cause acne?

As with anything that comes in contact with your face, your cell phone harbors makeup, dirt and bacteria’s so it can worsen your acne.

Every time you put your phone up to your face, you can implant the dirt and bacteria into your pores. You should clean your phone daily.

Can masks worsen acne?

With the threat of COVID, people are wearing masks now.

Proper hygiene is essential to avoid worsening of your acne. You should use a clean mask every day.

If you sweat in your mask during the day, you need to change your mask and immediately wash your face. You must wash your mask in hot water to kill the bacteria or use disposable ones.

Should I clean my makeup brushes?

Makeup brushes and sponges can worsen acne if they are not cleaned after every use. They can harbor bacteria and dirt, which you can implant in your pores if they are not cleaned.

It is also recommended to clean them with soap or brush cleanser and hot water to kill the bacteria.

Skin care and acne

Can my skincare products be causing acne?

Acne patients should stick to products that are labeled non-comedogenic (will not clog pores) or oil-free or safe for acne.

This includes cleansers, moisturizers, makeup, concealers, sunscreen, or any other products you put on your skin or that come in contact with your skin.

You must also read labels for your hair care products as well, as some can contain oils that can clog your pores. If your hair is oily, you can transfer that oil to your face and clog your pores.

If I have oily skin, do I need to moisturize?

Every skin type, even oily skin, needs to moisturize twice a day.

If you rob your body of moisture it needs to protect itself, it will cause your skin to go into overdrive and produce excess oil, which leads to acne.

So, to keep your skin from producing excess oil, you need to moisturize. There are many good gel or lotion moisturizers for oily skin types, which are not as heavy as creams, such as Neutrogena Hydroboost Gel Moisturizer.

If you have dry or sensitive skin, Cetaphil Cream works well.

Do I need to wear sunscreen if I have acne?

Daily sunscreen use is important for everyone, but especially for acne patients. It is a required step in any acne routine.

Most of the acne meds will remove some of your protective barrier against the sun’s harmful rays, making it easier for the sun to penetrate to the deeper layers of your skin. This will lead to more wrinkles and an elevated risk of skin cancers in the future.

You should wear SPF 50, broad-spectrum sunscreen every day, and remember to reapply every 1-2 hours throughout the day. If you have oily skin, you can choose a gel sunscreen or one that dries quickly, such as La Roche Posay Melt In Sunscreen Milk SPF 60.

If you have dry skin, you can select a cream-based sunscreen that dries quickly but will not dry out your skin, such as La Roche Posay Melt In Sunscreen Milk SPF 60.

People with sensitive skin can use a mineral-based or physical sunscreen without chemicals, like La Roche Posay Anthelios Mineral Sunscreen SPF 50.

Do I have to use a toner?

Toners help reduce the amount of oil on the face. If you have dry or sensitive skin, the use of toner is not necessary and might be irritating.

Also, even oily skin can get irritated with the combination of acne treatments and toners together.

Listen to your skin. It will let you know what it needs. If you remove too much oil, it may lead to your skin overproducing oil and worsening your acne.

If I have acne, should I exfoliate every day?

Over exfoliating of the skin can lead to a worsening of your acne and even scar your skin. You should only exfoliate 1-2 times a week, depending on what your skin will tolerate.

More than this and you can irritate your skin and worsen/inflame your acne. It can also lead to abrasions and subsequent infections, and scarring of your skin.

There are 2 types of exfoliators: chemical and physical.

Chemical exfoliators that use chemicals such as glycolic acid are usually safer than physical exfoliators that can use abrasive beads.

A skin care routine for acne

What is the best skin care routine for acne prone skin?

There are so many products on the market for acne, and it can be overwhelming to create an acne routine.

While every acne patient is different and should be treated differently, there are a few basic things that every acne patients should do to care for their skin.

It is also important to use products in a particular order so they are properly absorbed. You should wait a few minutes between each step to make sure the product is absorbed before putting on another.

If you don’t layer them properly or wait enough time to be absorbed, you are wasting your money.

The best skin care regimen for acne depends on your skin type. It doesn’t have to be expensive.

Here is a basic body and face routine for acne that anyone can start out using. It can be altered later depending on how severe your acne is and how you respond to the products.

Morning:

• Cleanse
• Toner or acne product
• Moisturize
• Sunscreen
• Makeup

Evening:

• Remove makeup
• Cleanse
• Acne treatment
• Moisturize

1-2 times a week:

• Exfoliate

Acne treatments

Are there over the counter (OTC) acne treatment options?

These skincare products are usually reserved for mild and some moderate cases of acne. They can be combined or used as stand-alone treatments.

If these treatments are not helping your acne, do not delay in seeing a dermatologist.

The longer you wait, the more chance of permanent scarring. If you are pregnant, planning to become pregnant, or nursing, you must consult with a physician before starting any regimen.

1. Benzoyl peroxide

Benzoyl peroxide (BP) is a great product for treating acne.

It helps by removing dead skin cells, reducing oil production, unclogging pores, and killing bacteria, especially Propionibacterium acnes (P. acnes), which is the main bacterial culprit that contributes to the formation of pimples.

It is one of the most popular products in every acne skin care routine. BP is found in topical creams and face/body washes, such as Panoxyl Wash.

Care should be exercised with its use as it can bleach skin and clothing, so it inapt preferred for darker skin types.

Sometimes BP can be irritating when you first start using it. You can start by using a low percentage product (2%) and only using it a couple of times a week.

Gradually you can increase its frequency of use and strength as your skin tolerates it. Some products can be used twice a day if necessary and if tolerated.

2. Salicylic acid

Salicylic acid (SA) is another good product to treat acne. It works by removing dead skin cells, reducing oil production, unclogging pores, and reducing inflammation.

It is gentler than BP, so it is a good alternative or start point for patients with sensitive skin. It is found in topical creams and face/body washes, such as Neutrogena Acne Wash or Oxy Pads.

SA is usually well-tolerated, but if it is not, you can use the same protocol as described with BP by starting out using it infrequently and increase, as tolerated, up to twice a day.

3. Retinoids/retinol

Retinoids help acne in several important ways. First, they get rid of dead skin cells, control oil production, and unclog pores to treat acne.

Also, they help to fade the discolorations left behind by acne and even smooth some acne scars. It is found in topical creams or gels, such as Differin Gel.

When starting with retinoids/retinol, use it a couple of times a week for 2 weeks, then if well tolerated, use it 3 times a week for 2 weeks.

If it is still well tolerated, you can use it every night. Use it only once a day at night.

You should wait 30-60 minutes after washing your face before applying the retinoid.

You may need to use a moisturizer before or after, depending on what your skin will tolerate. Daily sunscreen use is essential when using this product.

4. Niacinamide

Niacinamide is a form of vitamin B3. It has anti-inflammatory properties, which help with acne, as well as decrease oil production. It is found in topical creams.

5. Sulfur

Sulfur helps treat acne by decreasing oil production and unclogging pores. It can be found in topical creams and face washes.

6. Topical tea tree oil

The use of topical tea tree oil (TTO) has shown promise in small studies for the treatment of mild to moderate acne patients. It was comparable to BP in efficacy and ceaseless irritation, but TTO took longer to work (4-6).

What are some prescription/medical acne treatment options?

Prescription products and treatments can be used to treat any type of acne, from mild to moderate to severe.

For moderate and severe cases, these treatments are usually used in combination for the best results. Since many different factors lead to acne formation, the combination of different treatments allows us to attack acne from different causes.

These treatments are prescribed or performed by dermatologists who specialize in the treatment of the skin.

If you are looking for a board-certified dermatologist, you can look at the American Academy of Dermatology’s website (www.AAD.org) to help you find one close to you.

1. Topical antibiotics

Topical antibiotics, such as erythromycin and clindamycin, work well at killing the bacteria that cause acne, P. acnes.

Usually, they are combined with BP, which leads to better results and prevents bacterial resistance to the antibiotic agents when used alone.

2. Oral antibiotics

Oral antibiotics, such as doxycycline and minocycline, work by not only killing bacteria causing acne but also by reducing the inflammation associated with certain types of acne.

They are relatively safe but can lead to yeast infections, stomach upset, and sensitivity to the sun in some patients.

If they cannot be tolerated, oral erythromycin or azithromycin has been used with some success, but they are not the preferred choice.

3. Topical retinoids

Prescription retinoids include adapalene, tretinoin, and tazarotene, which are stronger than their OTC counterparts.

As with the OTC retinoids, these also work by getting rid of dead skin cells, controlling oil production, and unclogging pores to treat acne.

Also, they help to fade the discolorations left behind by acne and even smooth acne scars.

4. Topical dapsone

Topical dapsone works to resolve acne by acting as an anti-inflammatory agent (7). It should not be combined with BP since it can turn the skin orange.

5. Topical azelaic acid

Topical azelaic acid helps get rid of dead skin cells and unclog pores. It also has anti-bacterial and anti-inflammatory effects to aid in the resolution of acne (8). It should not be used in darker skin types as it can bleach the skin.

6. Isotretinoin

Isotretinoin is an oral form of retinoid, which is reserved for only the most severe acne cases because of its long list of side effects, such as dry skin/lips/eyes, depression, and joint pain.

It is very effective at treating acne but could cause significant long term problems, such as inflammatory bowel disease, and can lead to birth defects if taken while pregnant.

It works the same way as topical retinoids to treat acne, but it is just more effective.

7. Anti-androgens

Certain oral medications, such as spironolactone, work to decrease androgen production and are very effective at reducing hormonal acne.

8. Birth control pills

Certain birth control pills have also been used to treat acne since they decrease androgens.

9. Laser

There are certain lasers and light therapies that can help with acne by reducing inflammation and killing bacteria, causing acne.

It usually takes several treatments to see the effects and may require maintenance treatments to keep it under control.

10. Chemical peels

Chemical peels that contain products such as retinoids, SA, and glycolic acids help with acne (9). It usually takes several treatments as well as maintenance treatments to keep it under control.

11. Intralesional steroid injections

Steroids, mainly triamcinolone, can be injected into larger acne nodules to offer rapid relief of pain and decrease the size of the lesion (10).

Sometimes steroid-induced atrophy of the skin can occur in the area injected even in low concentrations. This atrophy may be permanent.

How long does it take for treatments to work?

Unfortunately, there is no magic cure for acne that works overnight.

You must be consistent and patient with whatever treatment you are using. It can take 4-8 weeks to start seeing improvement.

As long as your skin is tolerating the treatment, continue using it. If you have side effects from the treatment, such as redness, peeling, burning, or pain, stop the treatment and call your dermatologist.

Conclusion

Acne is a common and sometimes difficult to treat skin condition.

It can appear in any age group or race. Different factors contribute to acne formation and worsening of acne. These include genetics, hygiene, diet, hormones, medications, stress, smoking, skin, and hair products.

Patients can experience mild to severe cases. Skin conditions, since they are visible, often cause significant psychological damage.

It is important to start treatment immediately, before scarring occurs.

All acne patients need a good basic skin care routine for acne. If OTC products don’t improve your acne, you need to seek prescription treatments from a board-certified dermatologist.

There are many good treatments, both topical and oral, available and can be combined for better results.

Whatever treatment you are on, you need to be patient. It takes several weeks to start to see improvement. The treatments only work if you use them, so be consistent as well.

References

1. Zaenglein AL, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016; 74: 945-73.

2. Smith RN, Mann NJ, Braue A, Makelainen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol. 2007;57:247-256.

3. American Academy of Dermatology website https://www.aad.org/

4. Bassett IB, Pannowitz DL, Barnetson RS. A comparative study of tea tree oil versus benzoyl peroxide in the treatment of acne. Med J Aust. 1990; 153(8): 455-8.

5. Enshaieh S, Joey A, Siadat AH, Iraji F. The efficacy of 5% topical tea tree oil gel in mild to moderate acne vulgaris: a randomized, double-blind placebo-controlled study. lndian J Dermatol Venereol Leprol. 2007; 73(1): 22-5.

6. Lubtikulthum P, Kamanamool N, Udompataikui M. A comparative study on the effectiveness of herbal extracts vs 2/5% benzoyl peroxide in the treatment of mild to moderate acne vulgarism. J Cosmet Dermatol. 2019; 18(6): 1767-75.

7. Draelos ZD, Carter E, Maloney JM, et al. Two randomized studies demonstrate the efficacy and safety of dapsone gel, 5% for the treatment of acne vulgaris. J Am Acad Dermatol. 2007;56:439.e1-439.e10.

8. Cunliffe WJ, Holland KT. Clinical and laboratory studies on treatment with 20% azelaic acid cream for acne. Acta Derm Venereol Suppl (Stockh). 1989;143:31-34.

9. Grover C, Reddu BS. The therapeutic value of glycolic acid peels in dermatology. Indian J Dermatol Venereol Leprol. 2003;69:148-150.

10. Levine RM, Rasmussen JE. Intralesional corticosteroids in the treatment of nodulocystic acne. Arch Dermatol. 1983;119: 480-481.