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December 31, 2018

Acne and Breakouts

1. What is a spot?

All skin has oil glands (‘sebaceous glands’) attached to hair follicles that produce natural oils (‘sebum’) to lubricate your skin’s surface. When too much oil is produced, or the dead skin cells lining the pores aren’t shed normally, the pore can become blocked.

This causes a blackhead or whitehead (‘comedone’). The skin’s normal bacteria (propionibacterium acnes) can become trapped in the blocked gland and multiply, which causes inflammation. This shows as red or pus-filled spots.

2. What is acne?

When spots occur regularly or recurrently, this is known as acne.

What are the different kinds? (hormonal/cystic/teenage) Do they cause any visible difference in acne appearance?

Dermatologists usually classify acne based on the type of spot that is formed:

  • Blackheads (open comedone) – the blocked follicle is near the pore surface opening, and its contents are visible
  • Whiteheads (closed comedone) – the blockage is deeper in the follicle and the pore has closed around it
  • Papules and pustules – bacteria in the blocked follicle multiply and cause inflammation, with pus associated.
  • Nodules and cysts – larger versions of papules and pustules, where the blocked follicle splits and causes inflammation in the surrounding skin. These should always be treated by a doctor as there is significant risk of permanent scarring if left untreated.

These different types of spot can affect anywhere on the body, but usually the face, scalp, neck, chest and back. It is not usually possible to link a particular location with a specific underlying cause (unless there is a clear association, such as oily hair products causing acne to the forehead).

There are many factors that impact on whether skin is acne-prone, and usually more than one factor is present. Your DNA is influential in how much oil you produce, how your pore lining is shed and your hormone levels. Stress, puberty, pregnancy and menstruation can all exacerbate this. Some external products (oils, cosmetic products) can block the pores further.

Medicines (such as steroids) and rarely underlying medical conditions can all worsen your tendency to acne.

Acne vulgaris is the most common cause of acne, often referred to as hormonal/teenage acne, but in truth can persist much longer than teenage years.

3. How long does it take for a spot to become visible once a follicle is blocked?

The ‘inbuilt’ process of spot formation is complex, and a comedone (spot) is thought to take around two weeks to form. Products or external agents that block the pore can speed this process up a little. The hair follicle attached to sebaceous glands can become more quickly inflamed by irritation, causing a condition called folliculitis. This can look like acne but often doesn’t involve the sebaceous glands in the same way. [Cunliffe et all. Comedone formation: etiology, clinical presentation, and treatment.Clin Dermatol. 2004 Sep-Oct;22(5):367-74.]

4. Is there a scientific definition of comedogenic? How do I know if something is going to break me out?

‘Non-comedogenic’ or ‘oil free’ is a marketing term suggesting that a product will be less likely to block pores in acne-prone individuals.

However, the term is not currently regulated by any scientific governing body or for specific ingredients, so isn’t a guarantee. Most cosmetic companies will test a product on human subjects by applying to the back over a four-week period and frequently assessing for comedone (spot) formation. Although this is partially helpful, the skin on the back is different to the face and results may not always correlate.

I would suggest in anyone with acne prone skin, they should test the product on a small area for at least two weeks before applying to the whole face. [Clinical utility of marketing terms used for over-the-counter dermatologic products. JOURNAL OF DERMATOLOGICAL TREATMENT 2018, VOL. 29, NO. 8, 841–845]

5. Are all oils comedogenic?

Some oils are consistently worse than others at blocking pores when tested. The testing criteria explained above ranks products as 0-5 (5 is most likely to block pores).

However, this is an unregulated process, and this ranking does not take in to account the individual chemistry of a person’s skin. Even ‘low-rated’ oils and oil-free formulas can have the potential to block hair follicles, leading to acne forming or worsening, but these remain the best option for someone with acne prone skin.

6. Can a cleanser or other rinse-off product break me out?

If you have had a very quick breakout (hours to days) this is more likely to be a folliculitis type reaction. The hair unit is susceptible to becoming inflamed if it is irritated (either by a product left on the skin or over enthusiastic rubbing/shaving etc). This can look a bit like acne, but isn’t quite the same.

Try to ensure that you gently smooth on the product rather than rub, and ensure the product it is thoroughly rinsed away so none is left on the skin. Gentle use of a wet muslin cloth can be helpful for proper rinsing. If this doesn’t help, it may be that this isn’t the right product for you.

7. Can applying products to skin “cause” breakouts? If so how long can that take?

Yes, if the applied product is too oily for your skin type, blockage of the sebaceous glands can cause comedones (spots) to form. This would usually take around a week to develop. If a product is too irritant for your skin, it could also cause a folliculitis type reaction (see above) that can mimic acne.

8. Does diet affect acne?

There has been no robust scientific evidence to prove this, but anecdotally diet is sometimes thought to impact on acne breakouts. It is thought that foods that lead to high blood sugar levels (such as sugar, carbohydrates and dairy) can increase the amount of the hormone IGF-1 in the body. This turns in to the hormones DHT and testosterone, which binds to hormone receptors in the skin and causes the sebaceous glands to enlarge and produce more oil. The result is increased chance of spot formation.

Most doctors would recommend a healthy, varied diet. If you notice a definite link with what you eat and your breakouts, diet may be playing a part.

9. What are the best ingredients used to fight acne?

If your acne is severe, leaving scars or having a significant emotional impact, I would recommend seeing your GP or dermatologist to discuss prescribable treatment options. These include creams, tablet antibiotics, hormone tablets if you are female, and retinoids (i.e. isotretinoin).

Cosmetically available options (that don’t need prescription) can be very effective for less severe acne. Every person and their skin is different, and often what is helpful for one person may not work as well for another, thus making it hard to recommend a ‘best’ treatment.

Specific ingredients to look for, that have been proven with scientific studies, are listed below:

  • Retinols (regulates skin cells, skin keratin and skin tone)
  • Azeliac acid (anti-bacterial, anti-inflammatory, chemical exfoliator, good for sensitive skin)
  • Salicylic acid (anti-inflammatory, chemical exfoliator, regulates skin cells, sebum and skin tone)
  • Benzoyl peroxide (anti-bacterial, anti-inflammatory, sebum regulator)
  • Nicotinamide (anti-inflammatory, sebum and skin tone regulator)
  • Alpha-hydroxy acids (chemical exfoliator and skin tone regulator)
  • Zinc (anti-inflammatory and sebum regulator)
  • Vitamin A (regulates skin cell and keratin turnover, sebum and skin tone)
  • Tea tree oil (anti-bacterial and anti-inflammatory)
  • Products that gently exfoliate (prevent dead skin build up)

These can be used alone or in combination, building up a routine that works for you and focusing on your skin needs.

It is worth remembering that all products can take some time to reach maximum effect, so unless you have a side effect and need to stop earlier, it is worth persisting for up to 12 weeks before deciding if the treatment has worked for you.

10. Can I have acne and have dry skin at the same time?

Absolutely, and you won’t be alone!

It is worth noting that a lot of the treatments for acne can over-dry and over-exfoliate the skin leading to dryness. Conversely, moisturisers for dry skin can often block pores leading to acne.

You will need to choose your products carefully – a non-foaming cleanser, gentle treatment products (see below), and a non-oily moisturiser used morning and night as a baseline.

11. I have sensitive skin. What products can I use to fight acne? They all seem quite strong.

This is a common issue, as a lot of the effective products can dry, over-exfoliate and burn sensitive skin. A few tips that may help:

  • Don’t use the product every day or overnight at first – perhaps try two or three days a week, leaving on your skin for a few hours before washing off. Slowly build up the ‘contact time’ and frequency of application over several weeks until it is more tolerable.
  • Some acne products can make your skin more sensitive to sunlight, so you should use a non-oily sunscreen alongside them to counteract this.
  • Azelaic acid is a good option for those that cannot tolerate stronger products. Concentrations of 10% in over-the-counter products or 20% in prescribed products can help.

Katie's Bio!

Dr Katharine Warburton MBCHB, MRCP (London), MRCP (Dermatology)

Dr Warburton graduated with distinction from University Of Leeds School of Medicine in 2008. She then undertook her postgraduate and dermatology training in Leeds, Oxford and Bristol NHS Trusts. She currently holds a training post in Leeds’ Department of Dermatology.

Her interests are in general dermatology, inflammatory skin conditions and women’s genital dermatology. She has published work on acne and contact dermatitis in the international literature, and presented nationally in these topics, amongst others.