Acne

Acne is a common skin condition that affects most people at some point. It causes spots, oily skin and sometimes skin that's hot or painful to touch. Acne most commonly develops on the:

• face – this affects almost everyone with acne
• back – this affects more than half of people with acne
• chest – this affects about 15% of people with acne.

Types of spots

There are six main types of spot caused by acne:

• blackheads – small black or yellowish bumps that develop on the skin; they're not filled with dirt, but are black because the inner lining of the hair follicle produces pigmentation (colouring)
• whiteheads – have a similar appearance to blackheads, but may be firmer and won't empty when squeezed
• papules – small red bumps that may feel tender or sore
• pustules – similar to papules, but have a white tip in the centre, caused by a build-up of pus
• nodules – large hard lumps that build up beneath the surface of the skin and can be painful
• cysts – the most severe type of spot caused by acne; they are large pus-filled lumps that look similar to boils and carry the greatest risk of causing permanent scarring.

What can I do if I have acne?

The self-help techniques below may be useful:

• Do not wash affected areas of skin more than twice a day. Frequent washing can irritate the skin and make symptoms worse.
• Wash the affected area with a mild soap or cleanser and lukewarm water. Very hot or cold water can make acne worse.
• Don't try to "clean out" blackheads or squeeze spots. This can make them worse and cause permanent scarring.
• Avoid using too much make-up and cosmetics. Use water-based products that are described as non-comedogenic (this means the product is less likely to block the pores in your skin).
• Completely remove make-up before going to bed.
• If dry skin is a problem, use a fragrance-free, water-based emollient.
• Regular exercise cannot improve your acne, but it can boost your mood and improve your self-esteem. Shower as soon as possible once you finish exercising, as sweat can irritate your acne.
• Wash your hair regularly and try to avoid letting your hair fall across your face.

Although acne cannot be cured, it can be controlled with treatment. Several creams, lotions and gels for treating spots are available at pharmacies. If you develop acne, it is a good idea to speak to your pharmacist for advice. Products containing a low concentration of benzoyl peroxide may be recommended – but be careful, as this can bleach clothing.

If your acne is severe or appears on your chest and back, it may need to be treated with antibiotics or stronger creams that are only available on prescription.

When to seek medical advice

Even mild cases of acne can cause distress. If your acne is making you feel very unhappy or you can't control your spots with over-the-counter medication, you must see your doctor/ GP.

Also see your GP if you develop nodules or cysts, as they need to be treated properly to avoid scarring. Try to resist the temptation to pick or squeeze the spots, as this can lead to permanent scarring.

Treatments can take up to three months to work, so don't expect results overnight. Once they do start to work, the results are usually good.

Why do I have acne?

Acne is most commonly linked to the changes in hormone levels during puberty, but can start at any age. Certain hormones cause the grease-producing glands next to hair follicles in the skin to produce larger amounts of oil (abnormal sebum).

This abnormal sebum changes the activity of a usually harmless skin bacterium called P. acnes, which becomes more aggressive and causes inflammation and pus. The hormones also thicken the inner lining of the hair follicle, causing blockage of the pores (opening of the hair follicles). Cleaning the skin doesn't help to remove this blockage.

Other possible causes

Acne is known to run in families. If both your mother and father had acne, it is likely that you will also have acne. Hormonal changes, such as those that occur during the menstrual cycle or pregnancy, can also lead to episodes of acne in women.

There is no evidence that diet, poor hygiene or sexual activity play a role in acne.

Table showing the main causes of Acne.

Who is affected?

Acne is very common in teenagers and younger adults. About 80% of people aged 11 to 30 are affected by acne. Acne is most common in girls from the ages of 14 to 17, and in boys from the ages of 16 to 19.

Most people have acne on and off for several years before their symptoms start to improve as they get older. Acne often disappears when a person is in their mid-twenties. In some cases, acne can continue into adult life. About 5% of women and 1% of men have acne over the age of 25.

Causes

Acne is caused when tiny holes in the skin, known as hair follicles, become blocked. Sebaceous glands are tiny glands found near the surface of your skin. The glands are attached to hair follicles, which are small holes in your skin that an individual hair grows out of.

Sebaceous glands lubricate the hair and the skin to stop it drying out. They do this by producing an oily substance called sebum. In acne, the glands begin to produce too much sebum. The excess sebum mixes with dead skin cells and both substances form a plug in the follicle.

If the plugged follicle is close to the surface of the skin, it bulges outwards, creating a whitehead. Alternatively, the plugged follicle can be open to the skin, creating a blackhead. Normally harmless bacteria that live on the skin can then contaminate and infect the plugged follicles, causing papules, pustules, nodules or cysts.

Testosterone 

Teenage acne is thought to be triggered by increased levels of a hormone called testosterone, which occurs during puberty. The hormone plays an important role in stimulating the growth and development of the penis and testicles in boys, and maintaining muscle and bone strength in girls.

The sebaceous glands are particularly sensitive to hormones. It's thought that increased levels of testosterone cause the glands to produce much more sebum than the skin needs.

Acne in families

Acne can run in families. If your parents had acne, it's likely that you'll also develop it. One study has found that if both your parents had acne, you are more likely to get more severe acne at an early age. It also found that if one or both of your parents had adult acne, you're more likely to get adult acne too.

Acne in women

More than 80% of cases of adult acne occur in women. It's thought that many cases of adult acne are caused by the changes in hormone levels that many women have at certain times. These times include:

• periods – some women have a flare-up of acne just before their period
• pregnancy – many women have symptoms of acne at this time, usually during the first three months of their pregnancy
• polycystic ovary syndrome – a common condition that can cause acne, weight gain and the formation of small cysts inside the ovary.

Other triggers

Other possible triggers of an acne flare-up include:

• some cosmetic products – however, this is less common as most products are now tested, so they don't cause spots (non-comedogenic)
• certain medications – such as steroid medications, lithium (used to treat depression and bipolar disorder) and some anti-epileptic drugs (used to treat epilepsy)
• regularly wearing items that place pressure on an affected area of skin, such as a headband or backpack
• smoking – which can contribute to acne in older people.

Schematic diagram showing the different reasons that cause acne, depending on the body zone that acne is seen. 

Acne myths

Despite being one of the most widespread skin conditions, acne is also one of the most poorly understood. There are many myths and misconceptions about it:

"Acne is caused by a poor diet" - So far, research hasn't found any foods that cause acne. Eating a healthy, balanced diet is recommended because it's good for your heart and your health in general.

"Acne is caused by having dirty skin and poor hygiene" - Most of the biological reactions that trigger acne occur beneath the skin, not on the surface, so the cleanliness of your skin has no effect on your acne. Washing your face more than twice a day could just aggravate your skin.

"Squeezing blackheads, whiteheads and spots is the best way to get rid of acne" - This could actually make symptoms worse and may leave you with scarring.

"Sexual activity can influence acne" - Having sex or masturbating will not make acne any better or worse.

"Sunbathing, sunbeds and sunlamps help improve the symptoms of acne" - There is no conclusive evidence that prolonged exposure to sunlight or using sunbeds or sunlamps can improve acne. Many medications used to treat acne can make your skin more sensitive to light, so exposure could cause painful damage to your skin, and also increase your risk of skin cancer.

"Acne is infectious" - You cannot pass acne on to other people.

Diagnosis

Your doctor/ GP can diagnose acne by looking at your skin. This involves examining your face, chest and back for the different types of spot, such as blackheads or sore, red nodules.

How many spots you have and how painful and inflamed they are will help determine how severe your acne is. This is important in planning your treatment. Four grades can be used to measure the severity of acne:

• grade 1 (mild) – acne is mostly confined to whiteheads and blackheads, with just a few papules and pustules
• grade 2 (moderate) – there are multiple papules and pustules, which are mostly confined to the face
• grade 3 (moderately severe) – there's a large number of papules and pustules, as well as the occasional inflamed nodule, and the back and chest are also affected by acne
• grade 4 (severe) – there's a large number of large, painful pustules and nodules.

Acne in women

If acne suddenly starts in adult women, it can be a sign of a hormonal imbalance, especially if it's accompanied by other symptoms such as:

• excessive body hair (hirsutism)
• irregular or light periods.

The most common cause of hormonal imbalances in women is polycystic ovary syndrome (PCOS). PCOS can be diagnosed using a combination of ultrasound scans and blood tests.

Treatment

Treatment for acne depends on how severe it is. It can take several months of treatment before acne symptoms improve.

The various treatments for acne are outlined below.

If you just have a few blackheads, whiteheads and spots, you should be able to treat them successfully with over-the-counter gels or creams (topical treatments) that contain benzoyl peroxide.

Treatments from your doctor/ GP

You should see your GP if your acne is more widespread, as you probably need prescription medication. For example, if:

• you have a large number of papules and pustules
• over-the-counter medication has not worked.

Prescription medications that can be used to treat acne include:

• topical retinoids
• topical antibiotics
• azelaic acid
• antibiotic tablets
• in women, the combined oral contraceptive pill
• isotretinoin tablets.

If you have severe acne, your GP can refer you to an expert in treating skin conditions (dermatologist). For example, if you have:

• a large number of papules and pustules on your chest and back, as well as your face
• painful nodules.

A combination of antibiotic tablets and topical treatments is usually the first treatment option for severe acne. If this doesn't work, a medication called isotretinoin may be prescribed. Hormonal therapies or the combined oral contraceptive pill can also be effective in women who have acne. However, the progestogen-only pill or contraceptive implant can sometimes make acne worse.

Many of these treatments can take two to three months before they start to work. It's important to be patient and persist with a recommended treatment, even if there's no immediate effect.

Flowchart showing one suggested therapy for acne.

Topical treatments (gels, creams and lotions)

Benzoyl peroxide

Benzoyl peroxide works as an antiseptic to reduce the number of bacteria on the surface of the skin. It also helps to reduce the number of whiteheads and blackheads, and has an anti-inflammatory effect.

Benzoyl peroxide is usually available as a cream or gel. It's used either once or twice a day. It should be applied 20 minutes after washing to all of the parts of your face affected by acne.

It should be used sparingly, as too much can irritate your skin. It also makes your face more sensitive to sunlight, so avoid too much sun and ultraviolet (UV) light, or wear sun cream.

Benzoyl peroxide can have a bleaching effect, so avoid getting it on your hair or clothes. Common side effects of benzoyl peroxide include:

• dry and tense skin
• a burning, itching or stinging sensation
• some redness and peeling of the skin.

Side effects are usually mild and should pass once the treatment has finished. Most people need a six-week course of treatment to clear most or all of their acne. You may be advised to continue treatment less frequently to prevent acne returning.

Topical retinoids

Topical retinoids work by removing dead skin cells from the surface of the skin (exfoliating) which helps to prevent them building up within hair follicles. Tretinoin and adapalene are topical retinoids used to treat acne. They're available in a gel or cream and are usually applied once a day before you go to bed.

Apply to all the parts of your face affected by acne 20 minutes after washing your face. It is important to apply topical retinoids sparingly and avoid excessive exposure to sunlight and UV.

Topical retinoids aren't suitable for use during pregnancy, as there is a risk they might cause birth defects. The most common side effects of topical retinoids are mild irritation and stinging of the skin. A six-week course is usually required, but you may be advised to continue using the medication less frequently after this.

Topical antibiotics

Topical antibiotics help kill the bacteria on the skin that can infect plugged hair follicles. They are available as a lotion or gel that is applied once or twice a day. A six- to eight-week course is usually recommended. After this, treatment is usually stopped, as there's a risk that the bacteria on your face could become resistant to the antibiotics. 

This could make your acne worse and cause additional infections. Side effects are uncommon, but can include:

• minor irritation of the skin
• redness and burning of the skin
• peeling of the skin.

Azelaic acid

Azelaic acid is often used as an alternative treatment for acne if the side effects of benzoyl peroxide or topical retinoids are particularly irritating or painful. Azelaic acid works by getting rid of dead skin and killing bacteria. It's available as a cream or gel and is usually applied twice a day (or once a day if your skin is particularly sensitive).

The medication does not make your skin sensitive to sunlight, so you do not have to avoid exposure to the sun. You will usually need to use azelaic acid for a month before your acne improves. The side effects of azelaic acid are usually mild and include:

• burning or stinging skin
• itchiness
• dry skin
• redness of the skin.

Antibiotic tablets

Antibiotic tablets (oral antibiotics) are usually used in combination with a topical treatment to treat more severe acne. In most cases, a class of antibiotics called tetracyclines is prescribed, unless you are pregnant or breastfeeding.

Pregnant or breastfeeding women are usually advised to take an antibiotic called erythromycin, which is known to be safer to use. It usually takes about six weeks before you notice an improvement in your acne.

Depending on how well you react to the treatment, a course of oral antibiotics can last four to six months. Tetracyclines can make your skin sensitive to sunlight and UV light, and can also make the oral contraceptive pill less effective during the first few weeks of treatment. You will need to use an alternative method of contraception, such as condoms, during this time.

Hormonal therapies

Hormonal therapies can often benefit women with acne, especially if the acne flares up around periods or is associated with hormonal conditions such as polycystic ovary syndrome.

If you do not already use it, your GP may recommend the combined oral contraceptive pill, even if you're not sexually active. This combined pill can often help improve acne in women, but may take up to a year before the full benefits are seen.

Co-cyprindiol

Co-cyprindiol is a hormonal treatment that can be used for more severe acne that does not respond to antibiotics. It helps to reduce the production of sebum. You will probably have to use co-cyprindiol for two to six months before you notice a significant improvement in your acne.

There is a small risk that women taking co-cyprindiol may develop breast cancer in later life. For example, out of a group of 10,000 women who haven't taken co-cyprindiol, you would expect 16 of them to develop breast cancer by the time they were 35. This figure rises to 17 or 18 for women who were treated with co-cyprindiol for at least five years in their early twenties.

There is also a very small chance of co-cyprindiol causing a blood clot. The risk is estimated to be around 1 in 2,500 in any given year. It is not thought to be safe to take co-cyprindiol if you're pregnant or breastfeeding. Women may need to have a pregnancy test before treatment can begin. Other side effects of co-cyprindiol include:

• bleeding and spotting between your periods, which can sometimes occur for the first few months
• headaches
• sore breasts
• mood changes
• loss of interest in sex
• weight gain or weight loss.

Isotretinoin

Isotretinoin has a number of beneficial effects:

• it helps to normalise sebum and reduce how much is produced
• it helps to prevent follicles becoming clogged
• it decreases the amount of bacteria on the skin
• it reduces redness and swelling in and around spots.

However, the drug can also cause a wide range of side effects. It is only recommended for severe cases of acne that have not responded to other treatments. Because of the risk of side effects, isotretinoin can only be prescribed by a specially trained GP or a dermatologist.

Isotretinoin is taken as a tablet. Most people take a four- to six-month course. Your acne may get worse during the first 7 to 10 days of treatment. However, this is normal and soon settles. Common side effects of isotretinoin include:

• inflammation, dryness and cracking of the skin, lips and nostrils
• changes in your blood sugar levels
• inflammation of your eyelids (blepharitis)
• inflammation and irritation of your eyes (conjunctivitis)
• blood in your urine.

Rarer side effects of isotretinoin include:

• inflammation of the liver (hepatitis)
• inflammation of the pancreas (pancreatitis)
• kidney disease.

Because of the risk of these rarer side effects, you will need a blood test before and during treatment.

Isotretinoin and birth defects

Isotretinoin will damage an unborn baby. If you are a woman of childbearing age:

• do not use isotretinoin if you are pregnant or you think you are pregnant
• use one, or ideally two, methods of contraception for one month before treatment begins, during treatment and for one month after treatment has finished
• have a pregnancy test before, during and after treatment.

You will be asked to sign a form confirming that you understand the risk of birth defects and are willing to use contraceptives to prevent this risk, even if you're not currently sexually active. 

If you think you may have become pregnant when taking isotretinoin, contact your dermatologist immediately. Isotretinoin is also not suitable if you're breastfeeding.

Isotretinoin and mood changes

There have been reports of people experiencing mood changes while taking isotretinoin. There is no evidence that these mood changes were the result of the medication. However, as a precaution, contact your doctor immediately if you feel depressed or anxious, have feelings of aggression or suicidal thoughts.

Non-pharmaceutical treatments

Several treatments for acne do not involve medication. These include:

• comedone extractor – a small pen-shaped instrument that can be used to clean out blackheads and whiteheads
• chemical peels – where a chemical solution is applied to the face, causing the skin to peel off and new skin to replace it
• photodynamic therapy – where light is applied to the skin in an attempt to improve symptoms of acne.

However, these treatments may not work and can't be routinely recommended.

Acne and toothpaste

A hint found on many websites is that toothpaste can dry up individual spots. While toothpaste does contain antibacterial substances, it also contains substances that can irritate and damage your skin.

Using toothpaste in this way is not recommended. There are far more effective and safer treatments available from pharmacists or your GP.

Complications

Acne scarring can sometimes develop as a complication of acne. Any type of acne spot can lead to scarring, but it's more common when the most serious types of spots (nodules and cysts) burst and damage nearby skin.

Scarring can also occur if you pick or squeeze your spots, so it's important not to do this. There are three main types of acne scars:

• ice pick scars – small, deep holes in the surface of your skin that look like the skin has been punctured with a sharp object
• rolling scars – caused by bands of scar tissue that form under the skin, giving the surface of the skin a rolling and uneven appearance
• boxcar scars – round or oval depressions, or craters, in the skin.

Treating acne scarring

Treatments for acne scarring are regarded as a type of cosmetic surgery, which is not usually available on the NHS. However, in the past, exceptions have been made when it's been shown that acne scarring has caused serious psychological distress.

You should see your doctor/ GP if you are considering having cosmetic surgery. They will be able to discuss your options with you and advise you about the likelihood of having the procedure carried out on the NHS.

Many private clinics offer treatment for acne scarring. Prices can vary widely (from £500 to more than £10,000) depending on the type of treatment needed. 

The British Association of Aesthetic Plastic Surgeons website has more information about private treatment available in your area.

It is important to have realistic expectations about what cosmetic treatment can achieve. While treatment can certainly improve the appearance of your scars, it can't get rid of them completely.

After treatment for acne scarring, most people notice a 50-75% improvement in their appearance. Some of the available treatments for acne scarring are explained below.

Dermabrasion

Dermabrasion involves removing the top layer of skin, either using lasers or a specially made wire brush. After the procedure, your skin will look red and sore for several months, but as it heals you should notice an improvement in the appearance of your scars.

Laser treatment

Laser treatment can be used to treat mild to moderate acne scarring. There are two types of laser treatment:

• ablative laser treatment – where lasers are used to remove a small patch of skin around the scar to produce a new, smooth-looking area of skin
• non-ablative laser treatment – where lasers are used to stimulate the growth of new collagen (a type of protein found in skin), which helps to repair some of the damage caused by scarring, and improves the appearance.

Punch techniques

Punch techniques are used to treat ice pick scars and boxcar scars. There are three types of punch technique:

• punch excision – used to treat mild ice pick scars. The scar is surgically removed and the remaining wound is sealed. After the wound heals, it leaves a smoother and more even area of skin.
• punch elevation – used to treat boxcar scars. The base of the scar is surgically removed, leaving the sides of the scar in place. The base is then reattached to the sides, but lifted up so it is level with the surface of the skin. This makes the scar much less noticeable.
• punch grafting – used to treat very deep ice pick scars. As with a punch excision, the scar is removed, but the wound is "plugged" with a sample of skin taken from elsewhere on the body (usually from the back of the ear).

Subcision

Subcision is a surgical treatment that can be used to treat rolling scars. During surgery, the upper layer of the skin is removed from the underlying scar tissue. This allows blood to pool under the affected area. The blood clot helps form connective tissue, which pushes up the rolling scar so it's level with the rest of the surface of the skin.

Once subscision has been completed, additional treatment, such as laser treatment and dermabrasion, can be used to further improve the appearance of the scar.

Depression

Acne can often cause intense feelings of anxiety and stress, which can sometimes make people with the condition become socially withdrawn. This combination of factors can lead to people with acne becoming depressed.

You may be depressed if during the last month you've often felt down, depressed or hopeless, and have little interest or pleasure in doing things. If you think that you or your child may have depression, it's important to speak to your GP. Treatments for depression include:

• talking therapies such as cognitive behavioural therapy (CBT)
• a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs).

Support for acne

There is currently no main charity or support group for people affected by acne in England. However, there's a range of informally run message boards and blogs about acne on the web. You may find it supportive to read about other people's experience of living with acne.

For example, talkhealth provides a free acne support and information community. The Mix (formerly Get Connected) also has a website and helpline for teenagers and young people with emotional and other difficulties. 

Make-up

Make-up can help cover up scars and can be particularly useful for facial scars. Camouflage make-up specially designed to cover up scars is available over the counter at pharmacies. You can also ask your GP for advice.

If you are interested in learning more about covering a mark, scar, non-infectious skin condition or a tattoo, you can also visit the Changing Faces skin camouflage service or call 0300 012 0276.

Source: NHS Choices

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