Zits, pimples, blackheads, whiteheads...who doesn't dread them? Acne is the most common skin condition in the US, affecting 40-50 million people at any one time.

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Acne is unpleasant, but most cases can be treated.

Acne can range from mild pimples, through blackheads, whiteheads and papules, to deep, inflamed, pus-filled cysts and nodules. It is most visible on the face but can occur on the back, chest, neck, shoulders, upper arms and buttocks.

Acne affects boys and girls primarily during puberty but can occur at any age. Statistics show that 8 in 10 preteens have it, and a growing number of women are developing it in their 30s, 40s, 50s, and beyond. Even newborn babies can have it.

Common acne tends to emerge at 8-12 years, as the first sign of puberty. It is most common in girls aged 14-17 and boys aged 16-19. It normally disappears by age 25, though 12% of women and 3% of men will have acne until the age of 44. About 80% of people aged 11-30 will have it at some time. It is not uncommon for women to have a first outbreak when they are 20-35 years old.

Acne affects all races equally, and there is often a family history: if a parent had it, the child is likely to as well.

Despite its prevalence, conflicting and inaccurate information and myths can make acne difficult to deal with. In addition, what helps one person will not help another, and the success of readily available remedies depends on the severity of the condition.

Understanding what causes acne and ways of coping with it can help reduce and even eliminate the negative physical and psychological effects.

What causes acne?

Skin is covered with tiny holes called hair follicles, pilosebaceous follicles or pores. Follicles contain sebaceous oil glands, which produce sebum, the oil that prevents hair and skin from drying out.

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Acne forms when sebum and dead skin cells become trapped in a hair follicle.

Dead skin cells normally rise to the surface of pores, to be shed by the body.

During puberty, hormones can cause excess oil production, so that it clumps together with dead skin cells inside the pore and with dirt or oil from outside. The cells and oil become trapped inside the pore, creating a sticky plug: this is acne.

If the bacteria that live on the skin - Propionibacterium acnes - enter the clogged pore, they can multiply quickly, causing inflammation. If the inflammation goes deep into the skin, an acne cyst or nodule appears.

Acne is not infectious, and it is not caused by greasy foods or chocolate, makeup or stress.

Apart from hormonal factors, a link between high glycemic load and acne has been suggested. Oily makeup should be avoided as it can clog up the pores; environmental irritants - such as pollution and high humidity - and oil in the air are also factors. Adult acne may be made worse by smoking.

Dealing with acne

One of the many myths about acne is that it needs to "run its natural course." However, while not physically serious, it can have profound and lasting effects on the individual, which can be alleviated if medical attention is sought.

Acne's impact on self-esteem is well documented; it can lead to anxiety, loss of confidence, social withdrawal and absenteeism from school and work. Grades can suffer; bullying and isolation may occur. Teenage depression and suicidal thoughts have been linked with "bad" acne.

Physical consequences include dark spots on the skin that may take months or years to disappear; cysts and nodules can cause permanent scarring.

All these can be helped or prevented with appropriate treatment.

Types of acne

Dermatologists grade acne in four categories, according to the severity:

  • Grade 1 (mild): mostly confined to whiteheads and blackheads, with a few papules and pustules
  • Grade 2 (moderate, or pustular acne): multiple papules and pustules, mostly confined to the face
  • Grade 3 (moderately severe; nodulocystic acne): numerous papules and pustules; the occasional inflamed nodule; the back and the chest may also be affected
  • Grade 4 (severe nodulocystic acne): numerous large, painful pustules and nodules; inflammation.

The type of treatment will depend on the type of acne.

Dos and don'ts

To prevent oil buildup, the face should be washed morning and evening with warm or lukewarm water and a mild, gentle, non-abrasive cleanser. Washing is recommended after exercising, especially when using a helmet or hat, as sweat can cause clogging.

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Popping pimples can increase the chance of permanent acne scarring.

Use of a washcloth, mesh sponge or anything else that can irritate the skin should be avoided. Gentle, alcohol-free products are best; astringents, toners and exfoliants can irritate and dry the skin, making the acne look worse. Scrubbing is not helpful; it does not stop acne and can aggravate it.

People with acne should resist touching the face, as oils and dirt from the hands can aggravate breakouts. Equally, picking or popping pimples can make them take longer to clear and lead to scarring.

As oil from the hair can get onto the face, washing hair regularly will help. Oily hair may be washed daily.

Direct sun and tanning beds are not recommended. Tanning damages the skin and increases the long-term risk of melanoma skin cancer by 75%. Moreover, some acne medications make the skin very sensitive to ultraviolet (UV) light, which is increased by exposure to the sun and indoor tanning devices.

Over-the-counter treatments

Commercially available creams, washes and soaps may help by reducing oil or helping to break down blackheads or whiteheads.

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Readily available topical treatments help many people but still take time.

Over-the-counter (OTC) products containing benzoyl peroxide or salicylic acid help to clear the skin in cases of mild acne.

Despite commercial claims, there is no single magic treatment that works for everyone, and acne is unlikely to clear overnight. It normally takes 4-6 weeks to see an improvement with OTC treatments.

Any treatment should be continued after the acne clears to prevent further breakouts.

Prescription treatments

To treat more severe, widespread acne, involving cysts and nodules, when other products have not worked, a pediatrician, family doctor or dermatologist can provide more aggressive therapies.

Common clinical treatments are mostly topical - applied to the skin. These aim to kill the bacteria or reduce the amount of oil. They may contain a retinoid, prescription-strength benzoyl peroxide, antibiotic or salicylic acid.

Systemic treatments work through the body and are prescribed when acne does not respond to topical treatments alone or it is characterized by cysts and nodules and is red and swollen.

Fast facts about acne
  • Only 11% of people with acne visit a doctor, and 20% visit a skin care center
  • 30% purchase OTC treatments
  • 40% do nothing.

Learn more about acne

Common systemic treatments are antibiotics, hormonal treatments and isotretinoin.

Antibiotic pills, usually tetracycline, may be prescribed for 4-6 months alongside a topical treatment. They kill bacteria and reduce inflammation. An improvement should normally appear after 6 weeks. Side effects of tetracyclines include skin sensitivity to sunlight and UV light.

Hormonal therapies can help women, especially if the acne flares up around the time of menstruation. A combined oral contraceptive pill may be diagnosed even for those who are not sexually active. It may take up to a year to see the full benefits.

Co-cyprindiol is a hormonal treatment that reduces the production of sebum in people whose acne does not respond to antibiotics. It takes 2-6 months to see a significant improvement.

Side effects of co-cyprindiol include bleeding and spotting between menstruation, headaches, sore breasts, mood changes, loss of interest in sex and weight gain or loss. It has also been linked to breast cancer and blood clots.

Isotretinoin

Isotretinoin (previously marketed as Accutane) can counter most severe cases of acne. It helps to normalize and reduce sebum, prevents clogging of follicles, decreases the number of bacteria on the skin and reduces redness and swelling.

However, its side effects can be wide-ranging and serious, so it is only recommended for severe acne that has not responded to other treatments.

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Isotretinoin is successful against severe acne but must be used with caution.

Isotretinoin is taken orally for 4-6 months. The acne may worsen during the first 7-10 days of treatment, before settling. In 85% of cases, one course is sufficient for permanent clearing.

However, the side effects can be so dramatic that extreme caution is needed. Patients must sign an iPLEDGE, where they agree to strict terms of usage, and are monitored with visits and medical tests throughout the treatment.

Common side effects include: inflammation, dryness and cracking of the skin, lips and nostrils; changes in blood sugar levels; inflammation of the eyelids; conjunctivitis; and blood in the urine. More rarely, it can cause hepatitis, pancreatitis and kidney disease.

Isotretinoin will damage an unborn baby and must not be taken if there is any chance of pregnancy. At least one method of contraception must be used by women who could become pregnant, and a pregnancy test must be carried out before and after treatment. Mood changes such as depression, anxiety, aggression and suicidal thoughts have been reported, although a link is not confirmed.

Isotretinoin is similar to vitamin A; therefore vitamin A supplements are strictly contraindicated. Some antibiotics must be avoided to prevent interactions.

Researchers recently found that dermatologists are prescribing antibiotics for an average of up to 11 months before moving patients on to isotretinoin, raising concerns about the risk of antibiotic resistance.

Clinical guidelines recommend antibiotic therapy for a maximum of 6 months, but fears about the side effects of isotretinoin can cause delays in starting it.

Surgical options

Other procedures to treat acne include:

  • Lasers and other light therapies, which reduce the P. acnes bacteria
  • Chemical peels administered by a dermatologist to treat blackheads and papules
  • Drainage and extraction to remove a large acne cyst that does not respond to medicine
  • Injecting a cyst with medicine can remove it quickly, but this is only done if absolutely necessary.

More recently, scientists have been investigating acne as an immune-mediated chronic inflammatory skin disease, involving an innate immune response that is not able to control P. acnes. It may be that this will lead to new solutions in future.

Medical News Today's Knowledge Center explains more about cystic acne.