What really causes acne? (and what to do about it)

↳ SPECIAL ANTI-ACNE EDITION! Less Awkard founders and best-selling authors Dr. Cara Natterson and Vanessa Kroll Bennett invited Dr. Angela to write a guest column all about zit management and prevention. Less Awkward and Bright Girl connected over a year ago, and Dr. Angela has relied upon the information-rich resource of the Less Awkard podcast for navigating her own parenting journey of her 3 teen/tween daughters. We were honored when Less Awkward invited Bright Girl to be sold in their OOMLA store. In this Q+A interview, Dr. Cara and Vanessa talk with Dr. Angela on all things acne! 

HERE WE GO WITH A SCIENCE Q+A!

Dr. Cara + Vanessa: At Less Awkward, we always start with the most important fundamentals. So what really causes acne?

Dr. Angela: There are 4 major players that are the root cause of acne. Here they are (in no particular order):

1. Cutibacterium acnes (aka C. acnes or the “acne bacteria”): this bacteria lives normally on our skin. In the presence of oil secreted from the oil glands in our skin, this bacteria THRIVES and then feeds on dead skin and other components that have broken down on the skin. This leads to proliferation of C. acnes which is one of the factors that leads to acne. The skin’s microbiome plays an important role in balancing C. acnes: when the “good and healthy” bacteria and other organisms in our skin microbiome are strong and abundant, this helps keep C. acnes levels in check.

• Treatments that target C. acnes include benzoyl peroxide and topical antibiotics such as clindamycin

2. Oil/sebum production: Oil production is primarily driven by hormones (mainly testosterone). Oil glands are present in our skin from birth, and during puberty, increasing testosterone levels – in both girls and boys – stimulates the oil glands to grow and produce more oil and sebum. As noted above: more oil = more fuel for the acne bacteria (C. acnes).

• Treatments include gentle surfactants, such as Decyl Glucoside and Disodium Coco-Glucoside, that help remove oil and gently cleanse the skin.

• Witch hazel is a botanical that helps balance oil production.

• Salicylic acid penetrates deep into the hair follicle, all the way down to the oil gland, dissolving oil and dead skin cells that clog pores and lead to acne.

3. Clogged pores: when the pore is blocked, skin cells are not able to shed normally and there is a buildup of dead skin cells, oil, and other byproducts that lead to acne.

• Clogged pores may be treated by gentle exfoliation and daily face washing. Certain ingredients can make a big difference here such as allantoin, a gentle keratolytic that helps exfoliate skin cells, and glycolic acid, an alpha hydroxy acid that helps remove dead skin cells.

• Topical retinoids such as adapalene, tretinoin, and tazarotene promote skin cell turnover, leading to clearer pores.

4. Inflammation: as one might imagine, inflammation is a big factor in acne – that’s why those acne lesions become red, irritated, painful, and juicy! To help fight inflammation, avoid pro-inflammatory foods (foods with high-glycemic index), minimize stress, and get adequate sleep.

• Anti-inflammatory skincare ingredients such as aloe, chamomile, rosehip, coconut oil, and turmeric may help reduce inflammation in the skin.

  
  

C+V: What’s the connection between diet and acne?

A: High-glycemic index foods (foods that spike your blood sugar quickly) are linked to acne. Examples include breads, pastas, soda, candy, milkshakes, pretzels, potato chips, cereals, etc. When we ingest foods that spike our blood sugar, this causes increased sebum/oil production in the skin as well as increased inflammation throughout the body, leading inflammation in skin. In summary, high glycemic index foods trigger 2 of the factors in acne formation: oil production and inflammation. Encourage your kids to consume low glycemic foods; a whole food-based diet is optimal (fruits, vegetables, nuts, meat, fish).

What about milk and acne? Milk is controversial; skim milk is more closely linked to acne compared to whole milk. But dairy products (yogurt, cheese, etc) are not necessarily linked to acne. It’s questionable as to whether hormones from cow’s milk may contribute to inflammation in the body and in the skin leading to acne. A 2005 clinical study involving 47,355 adult women who were asked to recall what they ate during their high school years. Women who drank 2 or more glasses of skim milk (cow milk) a day were 44% more likely to have acne than others.

C+V: Does stress cause zits?

A: Yes, primarily because stress is a major factor in driving inflammation throughout our bodies. Stress, whether acute or chronic, triggers a release of cortisol and adrenaline in our bodies. While this response is rooted in a protective mechanism to prepare us for “fight or flight”, it also stimulates inflammatory chemicals in our skin. Inflammation in our bodies translates to inflammation in our skin, a major factor in causing acne.

C+V: How does hydration affect skin health? And does this mean that drinking water is important?

A: Our skin is a living, breathing organ of our body. Our bodies, and all of the organs within them, require water as an essential nutrient. Ionic compounds and solutes dissolve in water, and this process allows for transportation of critical compounds to the cells and structures of the skin. Proper hydration helps maintain homeostasis throughout all of the organs in our body, including our skin. At a molecular level, proper hydration of our skin is thought to be necessary to maintain barrier function of the skin. Our skin barrier protects our internal selves from the environment around us and also prevents the evaporation of water from within our skin out into the external world. Contrary to some anecdotal claims (and social media trends,) there is no evidence that water consumption will improve wrinkles or skin laxity.

What if you don’t like drinking plain water? Seltzers or sparkling waters are nearly equivalent to standard waters in terms of hydration properties. Herbal teas and waters flavored with fruit to render flavor are likewise nearly equivalent to standard water given that these beverages are composed primarily of water. Coconut waters and electrolyte drinks are other effective options to supplement hydration for those who don't prefer the taste of plain water. Individuals should limit intake of electrolyte drinks as excess electrolytes can cause imbalances that lead to other medical issues. Try to avoid sugary drinks (i.e. frappuccinos, sodas, juices, etc.) There is a well-proven, direct correlation between foods and drinks with a high glycemic index (such as sodas, fruit juices, sugary coffee drinks) and acne.

Skincare products simply can't penetrate to the deeper layers of your skin and will therefore never be a substitute for proper internal hydration. Moisturizing your skin may improve the appearance of the skin but can't replace the functional benefits of adequate amounts of water in your skin cells and skin structures.

C+V: There are ads and influencer posts everywhere promising to fix acne… and the over-the-counter options at the local drugstore and online seem endless. Is there a best first approach here? Some active ingredients to look for that work?!

A: Abundant clinical evidence demonstrates the effectiveness of a proper, consistent skin care regimen being a cornerstone of healthy and clear skin. Skincare routines should be simple and streamlined: cleanser, moisturizer and mineral sunscreen in the morning; cleanser and moisturizer at night. If your skin tends to be oily, using a toner after cleansing your skin may help.

To optimize hydration, moisturizers should contain a mixture of humectants, emollients, and occlusives. Humectants such as hyaluronic acid, glycerin, and urea help draw water into the skin. Emollients such as ceramides and squalane oil support the "mortar" between skin cells and strengthen the skin barrier. Occlusives such as petrolatum, argan oil, and jojoba oil form a protective barrier on the surface of the skin, sealing water in.

My favorite botanical ingredients for treating acne prone skin include witch hazel, allantoin, aloe, chamomile, and marshmallow root.

If acne persists despite a consistent and effective skincare routine, my first step for patients is to add a topical retinoid such as adapalene (over the counter) or tretinoin (prescription) to address clogged pores. If the retinoid alone isn’t doing the trick after 2-3 months of consistent use, I’ll add a topical medication such as benzoyl peroxide or clindamycin (or a combination of both) to treat the C. Acnes acne bacteria.

C+V: And what about those breakouts that occur at the WORST time? 

A: Below are some tried and true remedies to address those “pimple emergencies”:

1. Pimple patches contain hydrocolloid, a gel-like substance made from gelatin or pectin; hydrocolloid dressings are often used for wound-healing in the medical world. Pimple patches help drain fluid caused by inflammation in the pimple; and they prevent you from picking at the pimples and driving further inflammation.

2. Topical treatments such as salicylic acid, benzoyl peroxide, or sulfur-containing products (gentler than BOP or sal acid) are well-proven acne remedies.

3. Clay-based mask with soothing anti-inflammatory ingredients such as rosehip or bilberry will settle redness and inflammation.

4. Apply ice to reduce redness and inflammation. 10-15 minutes every hour for 2-3 hours usually does the trick.

5. Cortisone injection (see your dermatologist!)

C+V: Does greasy sunscreen cause breakouts, undoing the benefits of all of these other steps?

A: Any skincare product may potentially cause a breakout, even those made for sensitive skin. Yes, products that are highly occlusive or contain certain ingredients like lanolin, cocoa butter, and carrageenan are more likely to clog pores; however, an individual may potentially react to any formulation, even the most hypoallergenic ones.

For acne prone individuals, I recommend seeking non-comedogenic (i.e. formulated to avoid clogging pores) sunscreens, but most importantly, be in tune with your skin and how it reacts to any particular sunscreen. On that note, I strongly prefer mineral sunscreen ingredients such as zinc oxide and titanium dioxide, to chemical ones (avobenzone, oxybenzone, octinoxate, etc) as I find (in my patients and myself) that across the board, chemical sunscreens are more likely to cause sensitivity and breakouts.

C+V: How about some basic rules about what time of day to use certain products?

Or a right order to go in if you are using more than one thing at a time?

A: Morning: Cleanser, toner, (serum), moisturizer, then sunscreen. Apply foundation/makeup after sunscreen

Evening: cleanser, toner, moisturizer, (then retinoid or other actives)

C+V: When is it time to move on from advice from friends or social media and see a doctor? And is this for a prescription regimen for acne, or just for advice?

A: When your skin is no longer responding to a consistent regimen, it may be time to see a professional. Aestheticians are a great option for individuals who aren’t having significant breakouts but are looking for guidance with their skincare regimens. When acne is worsening despite using products recommended by a skincare professional, it’s likely time to see your doctor or medical provider. Sometimes this visit may include guidance on your skincare regimen, over the counter product selection, and order of application. Or it may be time for topical prescriptions such as retinoids, topical antibiotics, or other medicated creams/gels to address acne. When topical regimens are no longer working, we consider an oral antibiotic or other medication to be taken by mouth until acne is under better control. I can’t stress enough the importance of lifestyle changes (proper diet, getting enough sleep, exercise, and stress management) in helping achieve clearer skin. Often, this is not discussed thoroughly in a quick visit to the doctor.

C+V: What’s the microbiome and how does it cause – or fix – acne?

A: Our skin has a specific microbiome, much like our gut has a microbiome. The microbiome is made up of over a trillion organisms–bacteria, viruses, and fungi–that live happily and normally on our skin! Nourishing and supporting all of the good bacteria/organisms in your skin, with proper skincare and hydration, is essential for keeping the pathogenic, or bad, bacteria in check. Think of your skin microbiome as a farm where all of the plants, crops, fertilizer, and animals work together. If a farm doesn’t have water, the plants and crops can’t grow and thrive. Weeds (i.e. bad bacteria and organisms) will grow and overcome all of the good guys. Similarly, the bacteria, viruses, and fungi that are beneficial to our skin require hydration and moisturization in order to flourish.

Moisturizing is extra important for our skin microbiome when using acne treatments  such as topical retinoids (adapalene, tretinoin), topical antimicrobials (BOP, Clindamycin), or hydroxy acids (salicylic acid or glycolic acid) because acne treatments can dry out and irritate the skin. Certain acne treatments may kill off some of the “good” microbiome organisms along with the “bad” acne-causing bacteria, so it’s important that we support our skin microbiome with pH-balanced, nourishing skincare products.

C+V: Is there any difference between the acne on the face and the acne on the chest (chestne), back (backne) or butt (buttne)?

A: It may all look the same, but there are often different processes occurring. Acne will present anywhere that oil glands are abundant. For most of us, that’s on the face/jawline, neck, chest, upper back/shoulders. On the butt (and sometimes the lower back, thighs, and groin), we more often see folliculitis, a common skin infection that develops within the hair follicles. Although folliculitis and acne are often treated with the same medications, fungal organisms may contribute to folliculitis and must be treated accordingly. Folliculitis is often exacerbated by shaving or tight fitting clothing as well as sweat, humidity and occlusion.