Breaking Down Acne

by Joshua Goldman, MD, MBA

Acne sucks.  Period.  We can’t think of a single beneficial aspect of the stupid thing.  It ruins prom pictures, makes inherently self-conscious teens more self-conscious, and causes your co-workers stare you chin as if Charlie Sheen we’re doing a drug-induced rain dance on it.  As such, it’s time we make it go away.

Now about that.  American capitalism loves acne.  You can’t get through an episode of The Bachelorette without a Clearasil commercial proffering a one-cream cure.   If you walk the Health & Beauty section at Target, you’ll find an entire aisle dedicated to acne treatment.  They’ve designed fancy motorized scrubby brushes, magic creams, and multi-step tonics to treat it.  I’ll let you in on a little secret: you don’t need any of that stuff.  A $80 bottle of crème de Provence is no better at treating acne than a generic bottle of 10% benzoyl peroxide.  In fact, the French “crème” is probably making your acne worse.  Don’t believe us?  A little walk through the underlying cause of acne may turn you into a believer.

What is it?

Acne is what we doctors call a multi-hit condition.  In order for acne to occur, a number of things must simultaneously take place, creating the perfect storm for a juicy pimple.  Additionally, not all acne is the same.  It comes in all sorts of shapes and sizes, each of which have a unique name and underlying cause.  We all know that acne is a problem of the pores on our skin.  With acne, three key components centered around these pores contribute to the pimples we’ve all grown to hate.

1. Hyperkeratosis: Our skin is constantly growing and then shedding.  Dust is made primarily of shed skin cells as a result of this process.  On normal, flat skin, this process works flawlessly.  When this process takes place at the opening of a skin pore, it can cause problems.  In certain people, a small amount of normal skin bends down into the pore.  When that skin sloughs off, rather than simply falling away form your body, it builds up at the opening of the pore.  This continues over time until the pore begins to clog at the top.  This is step number one in acne’s master plan: clog the pore.  If the process stops here, you end up with an “open commedone” or black head.

2. Increased Sebum Production:  Specific types of pores (called sebaceous glands) produce oil (called sebum), which your bodies needs to keep your skin moist.  People will often describe themselves as having “oily skin.”  These individuals likely produce more sebum than average.  This isn’t a problem until step number one (see above) occurs.   When a pore is clogged with skin cells…and then your fill that gland with oily sebum, you get a pore filled with gooey skin cells.  We call this a “closed commedone” or white head.

3. Proprioni acne: If you’re a microscopic bacteria that lives on human skin, the pore described above filled with dead skin cells and oil is like Time Square on New Year’s Eve.  It doesn’t get better than that.  These little guys, a specific type of bacteria called Proprioni acne (the namesake of acne), work their way into the pore and multiple like crazy.  Their invasion stimulates a reaction from your immune system transforming the pore from an idyllic NYE Las Vegas into a gunfight scene from a Quinton Terantino movie.   The end result of the immune system vs. bacteria battle: a big, red, inflamed, painful pimple.

Starting to see why French crème probably isn’t the solution?

How can I fix it?

Once you understand the key facial malfunctions that lead to acne, the treatment options become a lot more obvious.  No rocket scientists were needed.

1. Stop the Hyperkeratosis: While your first instinct is to scrub your face to death with one of those whirling dervish facial brushes you’ve seen on TV, this won’t do the trick.  Remember that the hyperkeratosis is happening at the point where your skin curves into the pore.  Physical scrubbing won’t get this hard-to-reach spot unless you grind your skin all the way down to the dermis…which we advise against.  Enter a class of topical creams called “keratolytics.”  These creams are function like a gentle daily facial peel.  They are able to slide down into your pores and knock off those stubborn cells clogging them.  There are a number of different chemicals and brands to chose from, the most commonly used of which is tretinoin (Retin-A).   They also come in various strengths.  The higher the chemical percentage, the more aggressive the peel.  As you can imagine, the most common side effects are irritation, redness, and dryness of your skin (you’re peeling off a few layers from the entire surface of your skin where the cream is applied).   If this happens, simply decrease the strength of the cream or use it less often.  For those gentle-faced individuals that can’t tolerate a retinoid cream, salicylic acid in over-the-counter face washes works as a more gentle keratolytic (1).

2. Decrease the Sebum Production: Now that we’ve opened up your pores, we need to do something about all that oil.  For all the ladies out there, we have options.  For the gents, the pickings are slim on this front.  Oral contraceptives that contain estrogen have been proven effective in reducing oil production, especially in women with acne that is related to their menstrual cycle, and thus improving acne.  There are two specific brands of oral contraception that are FDA-approved for acne treatment, Ortho Tri-cyclen and Estrostep, but any birth control that contains estrogen will do the trick (1).  Estrogen is only for the ladies so this isn’t an option for men.  Everyone, however, can take oral isotretinoin (a.k.a. Accutane).  Accutane literally shrinks the size, and the thus oil production, of all oil glands in your body, head to toe (2).  You can imagine the laundry list of side effects that occur when you do this.  As such, we save it for the most severe cases of acne.   The side effects are so severe that a negative pregnancy test and regular blood work must be performed while taking the medication and for a period of time afterward.

3. Kill the Proprioni acne:  The last piece of the puzzle is the pesky bacteria that naturally inhabit our faces.   Antibiotics are the weapon of choice here.  We have two options: oral and topical.  Topical antibiotics, specifically topical formulations of erythromycin or clindamycin, are preferred as they have fewer side effects and are better tolerated.   When it comes to moderate to severe acne, however, you’re gonna need to switch to the big guns and use oral antibiotics.  Studies show that the most effective oral antibiotics are: minocycline, doxycyline, and tetracycline (in that order).  If you’re pregnant or younger than 8, you’ll have to use a second tier antibiotic so you don’t cause permanent damage to developing bones and teeth.  Also, you need to meet with your doc before you start any of these wonder drugs.

A couple key things to keep in mind when it comes to acne treatment:

  • You have to use your medications daily.  The key to acne is prevention.  You don’t want to wait until you have a breakout to start treatment.  Using your medication every day, even when the promised land of clear skin has arrived, will prevent future breakouts and keep your skin looking great.
  • The medication doesn’t work overnight.  It will take approximately 4 to 6 weeks to begin to see an improvement in your acne with daily use of your new regimen.  Don’t give up on the regimen because it didn’t work after 2 days.
  • Titration is key.  The topical creams come in varying strengths.  You want to start at a lower strength to prevent your skin from lighting up like a Christmas tree.  If the lower strength doesn’t get the job done, you can increase the strength steadily until you find the right strength.

Take Home Message

Acne sucks.  The solution, however, is not expensive designer creams.  Remember the three types of treatments you can use in your anti-pimple arsenal designed to target the three pathologic processes of acne: hyperkeratosis, oil production, and bacteria called Proprioni acne.  Keratolyitcs remove the dead skin cells clogging your pores.  Oral contraceptive pills can reduce oil production in women.  Topical and oral antibiotics kill the Proprioni acne that naturally inhabit your skin.  Varying combinations of these medications, used on a daily basis, will provide you with significantly clearer skin in 4 to 6 weeks.   If the first regimen you try doesn’t work, keep in mind that there are a multitude of other regimens involving different types and strengths of medication in each class that you can try.

Questions? E-mail the Author:


1. Strauss J, Krowchuk D, Leyden J. Guidelines of care for acne vulgaris management. American Academy of Dermatology Clinical Guidelines. April 2007.

2. FDA Drug Safety Guidelines: Accutane. Food & Drug Administration. Published 2000.


11 2012

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