Skin 101: Acne, How it Starts, How to Treat It

Acne 101
In writing a post recently, I realized that I didn't have a good post that explained the basics of pimples, how they start and how the typical over the counter ingredients work to treat it. There's a reason you see the same active ingredients over and over in over the counter treatment products. There are many ways to target acne, but only a few key ingredients to do that.

Acne Pathophysiology
First, a brief look at how acne forms. There are obviously many more things involved in this process (and really, no one really understands the entire process. If we did we'd have a magic treatment to prevent all acne). But, to understand how treatments work on acne, you first need to understand the basics of how those blemishes are formed.

1. First, when you have a typical hair follicle, you'll find a small oil gland off of it. The normal cell cycle is for skin cells to slough off (aka- just basically fall off), and for new cells to be created underneath to replace them.

2. For some reason, within the hair follicle some of these cells will start to accumulate and clump together, rather than just going out as they usually do. As this happens, the oil production will increase some, the cells will clump together more, and the sides of the hair follicle will start to have inflammation. The inflammation contributes to more skin cells sloughing, clumping, more oil, etc. It basically becomes a downward spiral. The hair follicle starts to get clogged with oil and clumped skin cells.

3. As the hair follicle gets clogged with debris, you'll notice that rather than just having the walls of the hair follicle with inflammation, some of those cells will start to move into the debris as well. These are various types of white blood cells, and when they accumulate together you probably know them better as pus. Around this time you'll also have bacteria entering the mix. Typically this is p. acnes, which is usually just found around on your skin and such. It loves to eat oil, so this environment is perfect for it to thrive.

4. As the process spirals more and more out of control that hair shaft just fills up with everything. It will get big and swollen as it fills with sloughed skin cells, inflammation, bacteria and more sebum. You may even have the shaft rupture, allowing everything to infiltrate into the surrounding skin. That's not so bueno. If it is severe enough you might even see scarring later on down the road.

The first way to treat acne is to start up at the very beginning of that acne circle of death. The skin cells that are sloughed off have 2 reasons they are sticky and clog things up. The first is that they have slightly different charges on their cell surface, think of them as a bunch of little magnets. Little positive and negative areas line up and keep the cells close together. Once this has happened, an enzyme (transglutaminase) creates little cross bridge connections holding the cells together.

Retinoids will actually treat both of those issues. First, they help to normalize the rate at which the skin cells slough off. The cells that do slough off (at their newly improved rate) will have reduced charges and overall the levels of transglutaminase (and therefore cross bridges) are reduced as well. Blemishes under retinoid treatment are less cohesive and looser. You're less likely to have the whole follicle plug up and create the blemish, and then when it does the decrease in compactness means that other treatments will be able to penetrate into the blemish more easily. It's a win-win all around.

Antibiotics in Acne Treatment
So, remember back in Step 3 when I said that bacteria will infiltrate into the whole sebum-white cell-sloughed skin cell mess? It only makes sense that getting rid of the bacteria will help to stop the downward spiral of a pimple. Less bacteria=less inflammation=less pus, etc.

There are 2 main ways to treat the bacteria. The first is with Benzoyl Peroxide. Benzoyl Peroxide will create free radicals (read more about that in my antioxidants in skin care post), and those will directly attack and kill the bacteria. Keep in mind that due to the free radicals you'll see damage also to the area's skin cells, so there is a potential for speeding up aging.

The second way to treat the bacteria is obviously with antibiotics! Usually Clindamycin or Erythromycin are used. Both work equally well, though there's more risk of bacteria becoming resistant with Erythromycin. When used in combination with Benzoyl Peroxide the risk of resistance is lower. Both of these anti-biotics also work as anti-inflammatories. Both of these antibiotics need to be prescribed.

Finally, you'll sometimes see Sulfur (or Sodium sulfacetamide) used as the anti-biotic in over the counter meds. Sulfur can also work on the rate of skin cell sloughing, though it won't affect the charges and enzyme levels like a retinoid.

So, obviously cleaning the junk out of the pimple is a good thing. You should not do this by popping the pimple. That follicle won't only push everything out the pore, but it will likely also rupture back into the skin, spreading the inflammation and bacteria, resulting in an even bigger mess. Extractions can be performed by those trained to do it properly (such as an esthetician), or you could remove things from your pores using a mask like the Gelatin Mask to pull everything out. I'm also a big fan of a mud mask.

Alpha and Beta Hydroxy Acids are also great for helping to clear out the hair follicle. BHAs like Salicylic Acid are more effective because they are lipid soluble, so can penetrate into the sebum clogging the follicle much more easily. Note that Salicylic Acid is also anti-inflammatory.

I'm sure we've all seen in magazines the recommendations to head to your dermatologist for a steroid injection if you get a big blemish the day of an event. It really does work. Bringing down the inflammation makes the swelling go away, the redness is gone, and while that little plug of sebum and sloughed cells is still present, the blemish is much less apparent. If only it was always this easy!

There are a few ways to bring down inflammation to help acne. The first way is obviously steroids, but this should be avoided at all costs. You can have thinning of the skin from steroid use (steroid atrophy), but use of topical steroids can even cause "steroid acne". So, definitely no steroids! Instead, take advantage of the anti-inflammatory side effects of some of the other treatments, such as topical antibiotics and Salicylic Acid.

To help decrease sebum production you can use Retinoids (oral and topical both decrease oil production), or a hormonal treatment such as a birth control pill. There aren't any other ways to really decrease oil production, but you should also remember to not do things that increase oil production. Over washing of the skin will increase oil production quite a bit, so definitely stick to 2x a day at most.

You may have noticed something about all of the above Acne treatments. Very few of them work on blemishes that you already have. Instead, they work on changing the way your skin acts, so they prevent future blemishes. Which means that rather than seeing results quickly, you'll need to wait about 6-8 weeks to really see a result.

If you want to see immediate results, you should look for Salicylic Acid, Benzoyl Peroxide and steroids (with your physician). I've also had results using heat, with either a warm compress or my Tanda Zap.

 photo differential-diagnosis-acne.jpg
Keep in mind that not everything that looks like acne, is actually acne. If you've tried the typical over the counter treatments without any effect, then it is definitely time to head to your doctor. There's a huge list of alternative diagnoses, but they include things like Pityrosporum folliculitis, Rosacea, and Seborrheic dermatitis.

So, that's acne and acne treatment made super simple. Obviously there's a lot more to this than I've explained (I'm but a simple pediatric intensivist, not a dermatologist), and when in doubt I recommend seeing your doctor. Most primary care doctors do treat a lot of derm issues (we did a lot of rashes and acne back in my general peds days), and if needed they'll refer you on to a dermatologist.


  1. This is a great thorough review, Christine! I will share this with my skin-savvy readers.

  2. This is such great advice! I was prescribed Lymecyline antibiotics for my mild acne, and combined with a good ol' face wash every morning and night, my face has never been so clear!
    Another great post!
    Jennifer xx
    Please check out my blog at

  3. This is excellent! I have had acne for 50 year (amazing but truly I've had it since I was 10 and am soon turning 60)and you have covered everything that they know today about acne. One the biggest lessons I learned was the need to always moisterize no matter how oily your face seemed. Like you explained so well, all those dry flakey cells are the devil when it comes to zit formation!

  4. Wonderful post thanks - so helpful! I LOVE using lavender and tea tree oil in acne washes and moisturizers (even have a really nice non greasy recipe for acne serum thats antibacterial) and like your ideas on calming iinflammation Cheers

  5. Thank you for the great info on acne! I've noticed that my 13-year-old daughter is developing acne on her forehead and back. I want to help her but I don't know how to talk to her about it--she is super sensitive about many things and I'm worried she will shut me out even though I'm trying to help (I do speak lovingly & gently to her). Wish me luck :)

  6. APE- that can be a hard talk! I HATED whenever it was brought up with me when I was a teen, though part of that might have been because it was my dad who brought it up (he's a pediatrician) and he was prescribing me things that I hated. (I had Gentamycin pads for my face, they made is super dry and tight, though they got rid of the pimples)

    Anyways, you might want to check out Bonding over Beauty, it will help you navigate some of those tricky things over the next few years!

  7. Thank you for the encouragement! And I just read your post on Bonding over Beauty--my library doesn't carry it, so I'm going to buy the e-book this evening! What a fantastic resource. Thanks again, Christine!

    (April) :-)

  8. Very well written and informative article on acne! The being patient part is probably the hardest part for everyone!!

  9. I was surprised you didn't mention niacinamide or vitamin C at all. In the recent years there have been several well controlled studies that show both are very effective against acne. If my memory serves me well, niacinamide has been tested twice against topical antioxidants. Both studies show it's as effective as antioxidants. Vitamin C (as sodium ascorbyl phosphate) has been shown to be as effective as BP as monotherapy for acne.

    There are also some substance that can reduce sebum production, namely 5-alpha reductase inhibitors. So far 2 studies have shown green tea can reduce sebum production and there are individual studies showing the same for other ingredients. Unfortunately, most of those studies leave something to be desired, but it's an interesting option to keep an eye on.

  10. This post is geared towards basic Acne care. There are a few small studies looking at Vitamin C and Niacinamide and its derivatives in acne treatment, but they are no where near the standard of care like BP and SA are.

  11. This is such a helpful post! Can you explain what the bigger, harder pimples are and any prevention methods? I think it's called cystic acne--but I'm not sure. I get one or two every month before my period these days. They are painful!

  12. Yeah, it's cystic acne and is hormonally driven. You can moderate your hormones (aka- use birth control pills) but sometimes spironolactone (a prescription diuretic) actually helps as well. Either way, I'd ask your doctor!


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