Acne is one of the most prevalent skin conditions in the modern day and age. The American Academy of Dermatology Association reports that it affects about 85% of people between 12 and 24, with cases of adult acne increasing and affecting mostly women. Common it may be, but depending on the severity it may lead to scarring. It can also have impacts on psychological health: self-image and self-esteem, confidence, and in some cases even depression. Acne takes on several forms and has several causes. Understanding these is key to finding appropriate treatment and potentially making lifestyle changes that can prevent and treat symptoms.

What is acne?

Acne, in essence, is the result of a buildup of matter (sebum, microorganisms, etc.) in the pores. This is caused by and/or results in inflammation. Let’s take a look at the symptoms associated with acne…

Comedones

Comedones are relatively mild forms of buildup resulting in clogged pores. There are two types of comedones: open and closed. Open comedones, often referred to as “blackheads” are clogged pores that are exposed to air. The excess sebum oxidises, resulting in the dark appearance. Closed comedones are functionally the same, only they are covered by a layer of dead skin, fully trapping the buildup beneath. The lack of oxidation means it stays white, leading to its alternative name: “whiteheads“.

Comedonal acne is often thought of as a “mild” forms of acne as they lack the visible inflammatory response (redness, itchiness, feeling of heat) we associate with the following forms of acne.

Papules, Pustules

We often refer to acne as “moderate” if there are more than a few papules and/or pustules in addition to comedones. Papules are essentially comedones that have become noticeably inflamed, and may be sensitive. Pustules present similarly to whiteheads, but the “head” will often be somewhat larger and filled with pus: dead white blood cells that have come to fight a bacterial infection.

Nodes and Cysts

Acne is considered “severe” when in addition to many papules/pustules, there are nodes and/or cysts. “Cystic acne”, while less common, remains widely experienced and can be quite painful, and are prone to recurring (the sac remains in the skin, and can often only be surgically fully removed). Nodes/nodules are similarly painful and are prone to scarring, like cysts. You might consider consulting with a dermatologist for treatment, though it may potentially be managed through regular treatments with an experienced aesthetician.

What is causing my acne?

Though people often think of acne as a singular condition/concern, there are different types of skin conditions that we associate with “acne”, each requiring their own method of prevention and treatment.

Acne Vulgaris

Also commonly known as “teen acne”, this is the most common type of acne and is caused by several factors. Underlying each form is a strain of bacteria known as Propionibacterium acnes (P. acnes) which colonises the duct of the sebaceous follicle. Acne vulgaris is also associated with a disbalance in sebum production and keratinocyte proliferation (read: oil and skin cell production). Acne vulgaris can present in all areas of the face as well as on the body, and affects men and women of various ages, though most commonly in teens and up to early adulthood.

There are a number of underlying factors that can trigger other types of acne, such as certain steroids and other drugs. Other, more severe forms of acne include acne fulminans and acne conglobata, often accompanied by fever. For these, please see a dermatologist directly.

Hairline Acne

Hairline acne is acne that presents along the hairline, often as small comedones or papules. It is typically among the easiest to treat, as it is caused by one or both of two things. 1. A buildup of sebum along the hairline alone. In this case you might not be washing your entire face, e.g. when removing makeup or rinsing off sweat. If you don’t cleanse up into the hairline, bacteria, dead skin, etc. can accumulate, resulting in clogged pores). Or, if you are noticing papules occurring deeper into the scalp as well as the hairline, it might be time to check the ingredients list in your hair care products: pore-clogging ingredients are often to blame! Try a switch to a sulfate-free hair care routine.

Acne Mechanica (sports-induced acne)

As heat and sweat increase through intense exercise, conditions for pathogenic microbial growth likewise increase. Acne mechanica is the term for acne specifically related to the use of sports equipment. Like hairline acne, it is one of the more straightforward and easy forms of acne to treat. Precautions include using a buffer between the skin and the equipment that reduces friction and wicks moisture. Consider using looser-fitting clothes for affected areas. Products with salicylic acid also tend to help with this form of acne, unclogging pores and calming inflammation. To ensure harmful bacterial growth is reduced, shower regularly after exercising. To rebalance your microbiome, ensure you are using a toner after every shower to restore your skin’s healthy pH levels. For on-the-go, our favourite is Hydrinity’s Hyacyn Active Purifying Mist (beloved of frequent flyers, athletes, and more). We also love the BioCalm and BioAcne Toners by Nelly De Vuyst. For a travel-friendly quick exfoliation and salicylic treatment, we love Glowbiotics’ Triple Action Clarifying Pads.

Hormonal Acne

Hormonal acne refers to acne caused by a dysregulation of hormones. While commonly associated with puberty and menstrual cycles, it also affects adults (mostly but not exclusively women) and is often correlated with pregnancy and menopause, and results from excess sebum and keratinocyte buildup. Underlying factors for hormonal acne may also be conditions such as PCOS and other hormone-related conditions, as acne may be triggered by elevated androgen levels (primarily testosterone). While there is no cure for hormonal acne, holistic therapies (as provided through naturopathic doctors and practitioners of Traditional Chinese Medicine, for example) are recommended to help balance hormones overall, and can assist in making lifestyle adjustments feasible and appropriate to you. We have also curated a collection of pregnancy-safe, and hormonal-acne-specific skincare products to safely and effectively manage hormonal acne.

Acne Rosacea

Entirely distinct from acne vulgaris, though in some cases both may occur for an individual at the same time. Acne rosacea is a form of rosacea, an inflammatory disorder, often hereditary, associated with symptoms such as redness, skin sensitivity, telangiectasias (small, visible blood vessels), and most commonly presents as papules, with the distinctive symptom (not always present, but characteristic) of itchiness at night (when the demodex mites are most active).

With acne rosacea, it is important to rebalance the microbiome, as acne rosacea symptoms result from hyperproliferation of the Demodex folliculorum mite (present on all skins but due to the dysfunction in immune response associated with rosacea, becomes overwhelming). In the case of acne rosacea, it is important to both minimise rosacea triggers as well as minimising skin sensitivity and rebalancing the microbiome. Our personal favourite treatment is Nelly De Vuyst’s BioCalm Sensitive Skin Essential Concentrate and BioRosacea Anti-Redness Serum, whose powerful blend of anti-inflammatory and targeted anti-demodex formulation eliminates the demodex overpopulation in just 10 days.

Fungal Acne

Fungal acne occurs when yeasts overpopulate, clogging pores and causing inflammation. It is important to distinguish fungal acne from acne vulgaris, caused by P. acnes bacteria, as bacterial antibiotics will have no (or potentially a worsening) effect on fungal acne (overuse of antibiotics is a topic for another time, but a course of antibiotics may also negatively affect the healthy bacteria of the skin, contributing to further overpopulation of the yeasts). Risk factors include living in humid climates, hyperhidrosis (excessive sweating), immune conditions or use of immune suppressants, and use of antibiotics.

Fungal acne, like acne rosacea, presents primarily (though not exclusively) as papules, commonly with itchiness, and is highly contagious. When choosing a skincare product to treat fungal acne, you must ensure that it is anti-microbial (not just anti-bacterial), and microbiome-enhancing (pre/pro/postbiotic) products are also recommended. Our personal favourites are Nelly De Vuyst’s Pure Hygia Oil and BioAcne Serum. Ways to prevent and reduce fungal acne breakouts are avoiding conditions the yeast enjoy: heat, humidity, friction, and opening follicles (e.g. by waxing and plucking hairs) – so avoid the saunas and hot tubs, wear some loose clothes (if it’s affecting the body)

How to manage acne

recommendations

Depending on the degree and type of acne, treatment may differ. Different ingredients will target different types and forms of acne (eg. azelaic acid for acne rosacea, mandelic acid for sensitive skin presenting with acne, etc.); as an inflammatory condition, anti-inflammatory ingredients are key.

For those who enjoy wearing makeup and are prone to acne, being conscientious about ingredients is important. Many common ingredients in conventional makeup products are known to be comedogenic (acne-causing): silicones, alcohols, artificial fragrances, certain pigments, emollients, etc. Furthermore, some ingredients such as pthalates (fragrance stabilisers) and parabens (preservatives) act as endocrine disruptors, which may trigger hormonal acne as well as other aspects of health affected by the endocrine system. Try to curate a skincare and makeup routine that is endocrine-disruptor-free.

We also recommend in all cases of acne to adopt regular use of a toner, as pH toners help rebalance the skin’s pH to support a healthy microbiome – this is of even higher importance for those with an active lifestyle that shower and/or swim/bathe more frequently or have an active outdoors lifestyle, as water and soaps can elevate the skin’s pH, encouraging bacterial growth and resulting in a disbalanced skin microbiome.

Lifestyle choices that may help prevent and manage acne symptoms include stress reduction (cortisol levels impact sebaceous gland activity), adopting an anti-inflammatory and low-glycemic diet (blood sugar spikes lead to inflammation and elevated sebaceous gland activity), as well as good sleep habits and regular hydration – both through topical hydrators and drinking water (I know you must be sick of hearing it by now: “drink more water”, “get better sleep”, “eat healthy”… but it’s true!).

managing the healing process

It is also important to refrain from picking, “popping”, and/or squeezing acne lesions, as this can spread the infection deep within the skin and worsen the severity of the lesions, potentially leading to (further) scarring and more stubborn/recurring and painful lesions.

We know how difficult this can be, easier said than done, and we know that the struggle to stop these behaviours can also bring their own feelings of shame, stress, anxiety, and low self-esteem already provoked by acne lesions. I’m sure you’ve heard it all before but for whoever needs to hear it again: no skin is perfect and perfection is not a sustainable or helpful goal for personal health; it is not in line with the complexity of reality. Our nature is that we are imperfect beings that face challenges but are able to grow and heal, and this process is almost never linear. We encourage you to hold compassion for yourself, and encourage you to seek professional guidance in finding alternative/replacement behaviours to ease away from skin picking for sustainable solutions.

In conclusion…

Acne is a complex pathology with a variety of causes, manifestations, and treatments – there is no one size-fits-all approach, making it of the highest importance to seek tailored solutions with your skincare professional. Feel free to reach out to us with any questions and we wish you the best of luck on your skin health journey!

written by Kira Ptak on behalf of ARTEBELLA Skin Health (2024)