All About Acne


There are around 17 million people in America who woke up this morning, shuffled into the bathroom, looked at themselves in the mirror and yelled, "Aw, come on!" Then, many of them started scrubbing, washing, peeling and picking at their faces in their attempts to rid themselves of their acne.

Most of these acne sufferers are teenagers and twentysomethings. However, the good times don't always end with the passing of adolescence -- adults get acne, too. In this cruel world, even babies get it. At some point in our lives, most of us will experience the unpleasantness of acne.


­Acne can take many forms, which we'll discuss in this article: whiteheads, blackheads, pimples and even large, cystlike masses. It's caused essentially by the blocking of one of the hair follicles in your skin. As infection deepens and pressure grows behind this clog, a pus-filled bump forms on top of your skin -- the dreaded pimple. In a moment, we'll take a more in-depth look at how your skin functions when things are running smoothly (and not-so-smoothly).

We know how acne forms -- and why some conditions, namely rosacea, cause acne -- but opinion varies on how to treat it. In this article, we'll learn what acne is, what causes it, how to prevent it from appearing in the first place and how to get rid of it after it shows up. In addition to some more traditional methods, such as washing with benzoyl peroxide or taking antibiotics, we'll look at the latest weapons in the war on acne, such as lasers and isotretinoin. So, if you're an acne sufferer, keep your chin up. And if you can't, we'll hopefully teach you some ways to get rid of that giant chin pimple that's weighing you down.


Your Epidermis is Showing

If you skinned an adult, you would have enough material to make a 4-by-5 foot (1.2-by-1.5 meter) area rug that weighed upward of 10 pounds (4.5 kilograms) [source: Chudler]. That skin rug is your body's largest organ, although it varies in thickness. The thinnest part of your skin, your eyelids, are only half a millimeter thick, while the thickest skin is found on the soles of your feet, which have pads that are about 1.5 millimeters thick [source: Amirlak, et al].

When you look at someone, you're looking at eyeballs, hair, teeth, clothes and millions and millions of skin cells that are dead. That's it. Every inch of skin you see is old, dead skin. This is the outermost layer of the skin's outermost layer, the epidermis. The new skin is being formed beneath it, in the innermost layer of the epidermis. As new skin cells are produced, they begin traveling outward toward the surface of your skin. Older, dying skin cells that exist between the new cells and the skin's surface are pushed up and out by these new cells. It can take as long as a month for a skin cell to make the journey from the inner layer of the epidermis to the outer layer. While this seems like a long time for one cell to travel such a short distance, anywhere from 40 million to 60 million of these cells are reaching their destination every day, where they then leap from your skin to freedom [source: KidsHealth]. While humans have fairly good vision, it is perhaps a blessing that we can't see the 40,000 dead skin cells a minute that fall off each of us.


Let's go beyond the surface.



Layers of Skin

2009 HowStuffWorks

Beneath the epidermis is a layer of skin called the dermis. This layer has sweat glands and sebum glands. Sebum is an oil that makes you waterproof. The sweat and sebum from the glands travel to the surface of the skin through narrow channels called pores. So, every second of the day, your body is outwardly radiating thousands of different cells through your pores, and your pores deserve a lot of credit for providing safe passage for these cellular nomads and enabling them to exit your body. All of these dead skin cells, oily sebum and sweat form a protective mix (along with other lipids, such as linoleic acid) on the skin's surface. This shield stops your skin from drying out and prevents harmful bacteria from infiltrating your skin. Males actually produce more sebum than females, but both genders crank up the sebum levels during puberty. This spike in sebum production is why puberty and acne form a­n evil alliance.

­The innermost layer of skin is called the subcutaneous layer. This is where your hair begins its growth, in the bottom of a porelike tube called a follicle. As hair grows out of this follicle, it makes its way through the other layers of skin and collects a coating of sebum in the process. This keeps it shiny and water-resistant. This is also why your hair gets oily and sticks out from your head in crazy directions if you go a few days without washing it.


­Just like a car crash in a tunnel will cause a major traffic blockage behind it, so too does a jam-up in a pore or follicle. We'll talk about these cellular crashes and oily wipeouts in the next section.

Acne Causes: When Skin Attacks

Where there is lots of sebum, there is a fertile home for acne vulgaris, the most common form of acne. Your face, upper back, shoulder and upper chest have more sebaceous follicles than other parts of your body, making these areas targets for acne. More than eight out of 10 people will become acquainted in their lifetimes with acne vulgaris [source: Harper].

There's not one single factor that can take all the blame for acne vulgaris. The following all se­em to play a part:


  • Excessive cell division in the follicles. Researchers point to this as the first trigger of acne, but they aren't entirely sure what causes the skin cells to go bonkers and multiply. Androgen hormones likely play a part. When you get too­ many cells all trying to exit through the same narrow follicle, it mea­ns only one thing: a breakout.
  • Too m­uch sebum. When we hit puberty, our bodies crank up the hormone production, as well as the sensitivity to those hormones. This in turn kicks sebum production into overdrive.
  • Bacteria­. Specifically, bacteria known as Propionibacterium acnes, or P. acnes for short. This bacteria can often be found in acne lesions (there are different types of lesions, which we'll discuss in a moment). This bacteria leads to our fourth cause of acne vulgaris: inflammation.­
  • ­Inflammation. When skin cells and sebum jam up a follicle, bacteria shows up and then you get inflammation. Talk about making a bad scene even worse. Now, instead of just having a follicle backed up, the blockage is flaring outward, sensitive or even painful to the touch and unsightly. ­

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Whiteheads, Blackheads and Other Acne Lesions

2009 HowStuffWorks

­Depending on the exact course of events, blockage, infection and inflammation can result in different types of lesions on your ski­n. The two most common are whiteheads and ­blackheads.

­Whiteheads may seem like they appear overnight, but they can actually take up to two months to form before they're visible. Whiteheads form when the pore is totally blocked, and the growing matter has forced the comedo (blockage) to just beneath the surface of the skin.


If there is a plug of cells in the pore and the pore opening expands, so that it's not entirely blocked off, then a blackhead appears. The portion of the comedo­ that is nearest the surface has a concentration of melanin, giving it its appearance and appropriate name.­

If a pore becomes blocked and the wall of the pore collapses and releases the bacteria-ridden clog of skin cells and sebum into the dermis layer of the skin, it leads to other, more severe forms of acne lesions. Among these:

  • Papules. Papules are small (less than half an inch across) bumps that are round and feel somewhat firm to the touch. Papules can get infected if you pick at them or roughly scratch them and open them up.
  • Pustules­. Less-scientific circles commonly refer to pustules as "zits." These are the pus-filled pimples that form in your follicles and sweat glands.
  • Nodules. Nodules are large and hard, existing just beneath the skin. If you set your mind to squeezing or agitating them, they can leave behind elements that may cause the big bump to come back again and again.
  • Suppurative nodules­. Many people call these cysts or boils, and though they resemble and feel like cysts, they're not (cysts have other traits -- such as the ability to contain trapped gases -- and have different causes, like genetics or tumors). These should be examined and treated by a dermatologist.

Now that we know about acne vulgaris in all its forms, we'll learn about other kinds of acne in the next section.


Baby Acne, Prepubertal Acne and Rosacea, Oh My!

It's possible to be afflicted with acne in one form or another from the cradle to the grave. Fortunately, most of us only suffer from it for a period of several years in our lives, and then move on. Others, however, have to deal with it before, during and long after puberty.

Babies (as well as kids and grown-ups) can develop a form of acne called milia. This appears in the form of little white bumps across the face, usually on the nose or around the eyes. This is extremely common, occurring in about half of all babies. If your infant has milia, it's nothing to freak out about -- in fact, if your pediatrician confirms it is just milia, the doctor's orders will be to do absolutely nothing about the condition. It will clear up in its own good time. Researchers believe milia in infants is the result of undeveloped sebaceous glands, which causes these little cysts to develop in the pores and hair follicles.


A considerably more rare form of acne is prepubertal acne. This is nonmilial acne that forms in children before the first physical signs of puberty, such as the growth of pubic hair. Prepubertal acne may be caused by an imbalance in androgens, which are sex hormones such as testerone. While these hormones greatly increase at puberty and signal the body to initiate its growth changes, a premature release of androgens may cause sebum levels to also increase before puberty. Children who show signs of prepubertal acne should be checked out by a doctor.

Persistent and returning bouts of acne are sometimes caused by a condition called rosacea. Rosacea tends to show up and disappear on its own time table, and months can pass between flare-ups. When it does become active, it passes through several stages. As these stages progress, the condition worsens and will usually continue to worsen until medical treatment is sought.

­A person experiencing prerosacea will notice an increased amount of what appears to be blushing, or getting flushed easily. This is because blood vessels in the face are dilating more than they should. Worse, this redness tends to center itself in the face, so that, come December, your nose may very well be guiding the sleigh. Rosacea ultimately caus­es outbreaks that look a lot like acne vulgaris: pimples, bumps and a rashy redness. However, it can cause dilation of blood vessels in the nose (so that it looks like you've been drinking heavily) and even swelling of the nose.


Acne Myths

Knowing as we do that acne is caused by too many skin cells, too much sebum, bacteria and inflammation, let's take a look at what doesn't cause it. These acne myths have been circulating throughout high schools for decades:

  • Diet. While it may give us stomach aches, plump us up and make the idea of wearing fashionable jeans a comical notion, our skin isn't really affected by greasy pizza, fried chicken skin or chocolate-covered anything. (Just wash your hands after you put down that deep-fried Twinkie.) While a few studies have shown possible links between diet and acne, there's not enough research to support the conclusion.
  • Our parents. There may be a connection between your genes and sebum overproduction, but, overall, your acne is uniquely yours, so you can't throw all the blame on mom and dad for this one.
  • Dirt. Although it seems to fly in the face of logic, having a dirty mug won't cause acne. No, the problem comes from the inside out. In fact, if you try too hard to clean your face, you may actually irritate your skin and make matters worse.
  • Most makeup products­. It's unlikely your makeup products are resulting in blemishes, especially if they're labeled "oil-free" or "noncomedogenic." However, some people have skin that gets more irritated than that of others, so if you think your makeup is contributing to your outbreaks, stop wearing it or change products. Also, in general, be sure to thoroughly but gently remove all makeup from your face at the end of each day.

So if avoiding pizza doesn't prevent it, what does? On the next page, we'll take a look at some acne prevention strategies. Here's a hint -- take a yoga class, or at least a deep breath.


Preventing Acne

A little benzoyl preoxide or salicylic acid might work some small miracles for you. Some people swear by herbal alternatives like tea tree oil.

The easiest thing you can do is start cleaning your face (gently!) with warm water and soap. Twice a day should do the trick -- more than that, and you might just agitate your skin into a breakout. This will help clear the pores of dead skin cells and excess sebum.

If you break a sweat, be sure to shower as soon as possible afterward to prevent excessive oil buildup on your skin.


Loosen up -- with your attitude and your clothing. Nobody is insisting you turn into a laid-back hep cat, but tight clothing, straps, bandages and the like can all irritate the skin. Stress -- while not a primary culprit -- does seem to contribute to acne breakouts, perhaps by disrupting your hormone levels.

Try using some over-the-counter acne medications. These often come in creams, gel tubes or medicated pads and often contain either benzoyl peroxide or salicylic acid. These two substances help prevent acne in different ways:

  • Benzoyl peroxide kills P. acnes bacteria and also dries out the face (even leading to mild peeling), which many believe helps prevent acne.
  • Salicylic acid works to help the follicles clear themselves of dead and dying skin cells.

Both of these substances are available in varying strengths. You should start out with just a little bit of the weakest kind available, and see how your skin reacts. Many people find that one or the other works miracles, but of course all of us are different and react in different ways to medications.

With any luck, these measures will prevent you from having an acne breakout. If not, head on over to the next section to learn how to get rid of acne once it's crashed the party.


Treating Acne

If you have acne, don't pick at your face! Clean it, get a facial, go see a dermatologist (who can pop those pesky pimples for you), just don't take matters into your own hands. A zit that sticks around for a week or more is far better than a scar that sticks around forever.

Here are some other things that might help:


  • Oral antibiotics that kill the P. acnes bacterium. Tetracycline is a common antibiotic used for this purpose, and it works by taking away the bacteria's ability to produce proteins.
  • Topical antibiotics. A note of warning -- as is the case with oral antibiotics, it's possible for the P. acnes bacteria to become increasingly resistant to the antibiotics.
  • Retinol, a substance produced from vitamin A that causes your skin to dry out and peel.
  • Chemical peels using glycolic acid, an exfoliating agent that will loosen up and separate dead skin cells in your pores.
  • Birth control pills. Some women have had success treating your acne with oral contraceptives, which reduce sebum production in women.
  • Isotretinoin. This medication, which comes in drugs like Accutane, can often treat acne that's resistant to other types of treatment. The use of isotretinoin must occur under strict medical supervision due to its serious side effects.
  • Microdermabrasion. Way cooler than just washing your own face, microdermabrasion is a process whereby a small device blows crystals onto your skin, which are then vacuumed up.
  • Laser. Diode lasers lay waste to your sebaceous glands without harming the surface of your skin. (Topical painkillers are often used in treatment, which can hurt.)
  • Light and heat treatments. Various forms of low-intensity light (blue, red, green-yellow or a combination) seem to be effective in killing the P. acnes bacteria. The use of heat shrinks the size of the sebaceous glands.
  • Treatment of acne scars. There are several ways to help make acne scars less noticeable, such as injecting them with fat or collagen or treating them with lasers. Surgery can also help fill out especially severe scarring, as can skin exfoliation treatments like microdermabrasion.

­Nobody likes acne, and fortunately there are a lot of good resources out there to help you deal with yours. Talk to your doctor or dermatologist to find the best solution, and with a little luck and effort, you may just find the solution that's right for you.

For more articles on acne, skin care and hormones in general, see the links on the next page.


Lots More Information

Related HowStuffWorks Articles

More Great Links

  • American Academy of Dermatology. "What is Acne?" (Feb. 20, 2009)
  • American Acne & Rosacea Society.
  • Amirlak, Bardia, MD, et al. "Skin, Anatomy." Sep. 5, 2008. (Feb. 18, 2009)
  • Chudler, Eric, Ph.D. "The Skin." University of Washington Engineered Biomaterials. (Feb. 18, 2009)
  • De Raeve, L; et al. "Prepubertal acne: a cutaneous marker of androgen excess?" Journal of the American Academy of Dermatology. Feb. 1995.
  • Encyclopedia Britannica. "Linoleic acid." (Feb. 19, 2009)
  • Gibson, Lawrence, MD. "Acne scars: What's the best treatment?" May 22, 2008.
  • Harper, Julie C, MD.; Fulton Jr., James, MD, PH.D. "Acne Vulgaris." July 15, 2008. (Feb. 18, 2009)
  • HealthScout. "Acne." (Feb. 20, 2009)
  • KidsHealth. "Your Skin." March 2007. (Feb. 19, 2009)
  • Kupiec-Banasikowska, Agnieszka, MD, et al. "Rosacea." Feb. 22, 2007. (Feb. 20, 2009)
  • Lee, Delphine J.; Shellow, William V.R. "Management of Acne." Primary Care Medicine: Office Evaluation and Management of the Adult Patient (5th edition). Lippincott Williams & Wilkins, 2006. ISBN 078177456X, 9780781774567.
  • Mayo Foundation for Medical Education and Research. "Rosacea." Nov. 15, 2008. (Feb. 18, 2009)
  • MedicineNet. "Definition of Propionibacterium acnes." July 29, 2004. (Feb. 20, 2009)
  • National Institute of Arthritis and Musculoskeletal and Skin Diseases. "Acne." Aug. 2006. (Feb. 18, 2009)
  • Ogbru, Omudhome, Pharm.D. "Tetracycline." Dec. 19, 2008. (Feb. 20, 2009)
  • WebMD. "Skin Problems & Treatments Health Center: Rosacea." July 24, 2007. (Feb. 18, 2009)