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What Causes Acne

Acne is caused by inflammation and clogged pores. Naturally occurring sebum, or oil, in the pores keeps skin healthy, moisturized, and clean by moving freely out of pores. But inflammation causes sebum to change from thin and watery to thick and sticky. This causes sebum to become clogged in pores.

Once the pore is clogged, dead skin cells, or keratinocytes, become stuck to the sebum making the problem worse. And when dead skin cells and sebum mix together, they attract acne-causing bacteria called Propionibacterium acnes (P. acnes) and Cutibacterium acnes (C. acnes).

Acne usually starts during puberty and can last until menopause or late adulthood.

These bacteria overgrow in the clogged pore causing more inflammation, infection, and acne lesions. These are commonly called pimples, zits, whiteheads, blackheads, breakouts, and bacne, when they occur on the back.

These red, inflamed, and often painful, lesions spread easily to surrounding areas when the wall of the clogged pore spills over into neighboring skin cells. This causes more inflammation as the body attempts to heal the area.

Acne most commonly occurs on the face, but can also be on the back, chest, arms, and shoulders. It is a common skin condition that affects 80% of individuals at some point in their lives.

Types of Acne

Acne Vulgaris is the medical name for the most common type of acne. It is a chronic condition of inflammation and clogged pores.

All types of acne, except fungal, are worsened or caused by hormone imbalances caused by inflammation.

Whiteheads(closed comedones) are clogged hair follicles that stay beneath the skin and produce a white top, or whitehead.

Blackheads (open comedones) are clogged follicles that reach the surface of the skin and open up. The contents oxidize at the surface and turn black or dark brown.

Papules are acne lesions that become inflamed. They look like small, pink bumps on the skin and are often painful. Papules are commonly called ‘sandpaper’ acne.

Pustules have a white or yellow pus-filled lesion. They are often red at the base.

Nodules are large, painful solid lesions that are lodged deep within the skin. This is a severe form of acne.

Severe nodular acne (cystic acne) are deep, painful, pus-filled lesions. It is a severe form of acne.


Blackheads, or open comedones, are a mild form of acne that happen when hair follicles become clogged and the pore opens up, exposing the contents to air. Oxidation turns the contents brown or black. Blackheads are similar to whiteheads, except whiteheads remain closed.

Oxidation of the pore’s contents gives blackheads their dark appearance. A blackhead may look like dirt stuck in pores, but it actually turned brown, or black, because of air exposure.

‘Comedone’ is just another word for your skin’s pore which is the opening in your skin that connects your oil-producing sebaceous gland to your hair follicle. Blackheads happen when the pore gets clogged with dead skin cells, dirt, oil, pollution, or debris and the pore opens.

According to the American Academy of Dermatology, acne affects nearly 50 million Americans and is the most common skin disorder in the United States.

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Whiteheads, or closed comedones, are a mild form of acne that happens when hair follicles become clogged and the pore stays closed.

Whiteheads are caused by clogged hair follicles which cause the pore to develop a pimple. This triggers inflammation and pimples become red, warm, and sometimes tender to touch. These are most commonly found on your face, especially in your T-zone (around your nose, chin and forehead) but are sometimes your cheeks or around your mouth. Whiteheads make up most of body acne, and can develop on your neck, back, chest and upper arms.

Whiteheads are similar to blackheads, except the contents of the clogged pore does not get exposed to air.

Whiteheads usually develop in teenagers and young adults during puberty because of hormonal changes going on in the body. But many adults have whiteheads, too. They are very common and affect nearly 100% of individuals at some point in their lives.

Fungal Acne

Fungal acne (Malassezia folliculitis or Pityrosporum folliculitis) is a common type of acne that occurs when pores become Infected with a fungus called Malassezia yeast.

Fungal acne causes small clusters of itchy red bumps, or pustules, to develop on your skin. They can develop into whiteheads and have white or yellow pus.

Unlike other forms of acne, fungal acne is characterized by being itchy.

Fungal acne and Acne Vulgaris may both be present on the skin at the same time. But fungal acne requires different treatment than Acne Vulgaris and the two are often confused with each other.

Cystic Acne

Cystic acne is a type of inflammatory acne that causes painful, pus-filled acne lesions deep under the skin. They develop when dead skin cells, bacteria, and oil clog hair follicles in the skin. A red, swollen infected acne cyst develops in the dermis.

This causes swelling and inflammation in the middle layer of the skin, called the dermis.

Cystic acne is characterized by swelling and inflammation. It is considered the most severe type of acne because the cysts can cause acne scars which are difficult to treat and can last for years after the acne has gone away.

Cystic acne and nodular acne are similar and sometimes develop at the same time. Cystic acne causes pus-filled cysts. Nodular acne causes hard, solid bumps that do not contain pus.

Nodular Acne

Nodular acne is caused by clogged pores deep under the skin.

Cutibacterium acnes (C. acnes), a naturally occurring bacteria in the skin, becomes trapped and overgrows.
This causes infection and inflammation.

The clogged pores develop into hard lumps called nodules. The nodules themselves are deep under the skin in the dermis, but on the surface of skin you may have red, very painful bumps. They do not develop into a whitehead or blackhead.

Nodular acne is a severe type of acne that can last for weeks or months. It can leave acne scars which are difficult to treat and can last for years after the acne lesions have healed. Getting nodular acne under control requires treatment from a Dermatologist and often prescription medications.

Acne Diet

An acne diet is a healthy plant-based low glycemic diet. Some acne diets focus on foods with probiotics to improve your microbiome, vitamins, Omega 3 fatty acids, and other nutrients that are known to be good for skin health.

An acne diet is a way to balance hormones and the inflammation that causes acne. It can help reduce all types of acne. Focusing on eating a plant-based, low glycemic diet can help reduce inflammation, pimples, and acne lesions.

The typical Western diet is full of foods that cause inflammation in the body. Sugar, cow’s milk (especially skin milk), whey protein, alcohol, certain fatty acids, and other commonly found foods in the Western diet are known inflammatory agents.

Acne develops when inflammation in the body triggers hormones to overproduce. The main hormones are androgens, like testosterone, but progesterone and estrogen also play a role in acne development. When the body overproduces these hormones, it changes the consistency of sebum from thin and watery to thick and sticky. Thick and sticky sebum clogs pores.

All types of acne can benefit from an acne diet. Eating fruits and vegetables and lean proteins while avoiding foods that cause acne will improve overall health, too.

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Acne Treatment

Acne treatments depend on the type of acne you have. When in doubt, or if over the counter treatments don’t work after 6-8 weeks, be sure to see a Dermatologist.

Comedones Dermatologists recommend using a retinoid for whiteheads and blackheads to unclog pores. Adapalene is an affordable over-the-counter topical treatment that can help whiteheads and blackheads. Prescription retinoids, like tretinoin, are also effective.

Cleansers and skin care products with benzoyl peroxide will help reduce excess P. acnes bacteria. Using topicals with salicylic acid will help unclog pores deep into the hair follicle. Azelaic acid and glycolic acid may also help reduce pimples.

After 6-8 weeks, if these treatments are ineffective, a facial with extractions may be helpful.

Papules Using a cleanser and other skin care products with benzoyl peroxide or salicylic acid will help unclog pores. Azelaic acid and glycolic acid may also help reduce pimples

Pustules Use skin care products with benzoyl peroxide or salicylic acid to unclog pores. Azelaic acid and glycolic acid may also help reduce pimples Even though it’s tempting, don’t pop them. This can cause acne scars.

Nodular and Cystic Acne These severe types of acne often need prescription anti inflammatory antibiotics, medications, and topical skin care products.

Anti-inflammatory antibiotics commonly used for severe acne are doxycycline, minocycline, and tetracycline. These can help reduce the overgrowth of P. acnes and C. acnes and get acne under control.

Using antibiotics long term is not recommended because it increases the risk of antibiotic resistance. Antibiotics kill off the overgrowth of acne-causing bacteria, but also kill the good bacteria that is helping to keep your skin clear. Probiotics can help replace good bacteria while taking antibiotics.

Commonly prescribed topical antibiotics are Clindamycin and erythromycin. Other medications for severe acne include Accutane, retinoids (vitamin A), Spironolacetone, Dapsone, oral contraceptives, and Clascoterone (Winlevi).

Acne treatment for nodular and cystic acne should be assessed by a Dermatologist to reduce the risk of acne scars.

Acne Scars

Acne scars can develop from the inflammation of acne lesions. Of those with acne, 1 in 5 will have acne scars. Severe acne, like nodular and cystic acne, have a higher risk of acne scarring.

Acne scars develop when the inflamed pore swells. This causes the cell wall to break down and the contents of the pimple to spill into surrounding tissue. This damages surrounding areas and spreads acne. As the skin heals, it produces new collagen fibers which causes scars. Acne scars are either indentations or raised depending on how your body produces collagen fibers.

Acne scars can be treated aggressively with surgical procedures like dermabrasion, lasers, chemical peeling, microneedling, subcision, excision, steroid injections, punch grafting, cryosurgery, or dermal fillers.

Some adults carry scars from acne. Some relatively aggressive surgical procedures can improve scars. Procedures include dermabrasion, several types of lasers, and chemical peeling. These procedures remove the scarred surface and expose unblemished skin layers.

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