Acne Vulgaris

Topic Overview

What is acne vulgaris?

Acne vulgaris, or acne, is a skin problem that starts when oil and dead skin cells clog up your pores. Some people call it blackheads, blemishes, whiteheads, pimples, or zits. When you have just a few red spots, or pimples, you have a mild form of acne. Severe acne can mean hundreds of pimples that can cover the face, neck, chest, and back. Or, it can be bigger, solid, red lumps that are painful (cysts).

Most young people get at least mild acne. It usually gets better after the teen years. But many adult women do have acne in the days before their menstrual periods.

How you feel about your acne may not be related to how bad it is. Some people with severe acne are not bothered by it. Others are embarrassed or upset even though they have only a few pimples.

The good news is that there are many good treatments that can help you get acne under control.

What causes acne?

Acne starts when oil and dead skin cells clog the skin's pores. If germs get into the pores, the result can be swelling, redness, and pus. See a picture of how pimples form .

For most people, acne starts during the teen years. This is because hormone changes make the skin more oily after puberty starts.

You do not get acne from eating chocolate or greasy foods. But you can make it worse by using oily skin products that clog your pores.

Acne can run in families. If one of your parents had severe acne, you are more likely to have it.

What are the symptoms?

Symptoms of acne include whiteheads, blackheads, and pimples. These can occur on the face, neck, shoulders, back, or chest. Pimples that are large and deep are called cystic lesions. These can be painful if they get infected. They also can scar the skin.

How is acne treated?

To help control acne, keep your skin clean. Avoid skin products that clog your pores. Look for products that say "noncomedogenic" on the label. Wash your skin once or twice a day with a gentle soap or acne wash. Try not to scrub or pick at your pimples. This can make them worse and can cause scars.

If you have just a few pimples to treat, you can get an acne cream without a prescription. Look for one that has benzoyl peroxide or salicylic acid. These work best when used just the way the label says.

It can take time to get acne under control. Keep using the same treatment for 6 to 8 weeks. You may even notice that it gets worse before it gets better. If your skin is not better after 8 weeks, try another product.

If your pimples are really bothering you or are scarring your skin, see your doctor. A prescription gel or cream for your skin may be all you need. Your doctor may also order antibiotic pills. A mix of treatments may work best. If you are female, taking certain birth control pills may help.

If you have acne cysts, talk to your doctor about stronger medicine. Isotretinoin (such as Accutane) works very well, but it can cause birth defects. And using Accutane may be associated with depression. Let your doctor know if you have had depression before taking this medicine. And if you are female, you must protect against pregnancy by using two forms of birth control. Even one dose of this medicine can cause birth defects if a woman takes it while she is pregnant. You cannot take isotretinoin if you are breast-feeding.

What can be done about acne scars?

There are skin treatments that can help acne scars look better and feel smoother. Ask your doctor about them. The best treatment for you depends on how severe the scarring is. You can have scar tissue removed or have a shot of collagen. Collagen smoothes a pitted scar by plumping up the skin underneath. You may get the best results with a combination of treatments.

Frequently Asked Questions

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	Should I see my doctor for acne?
	Should I take isotretinoin for severe acne?

Cause

There are different types of acne. The most common acne is the type that develops during the teen years. Puberty causes hormone levels to rise, especially testosterone. High hormones cause signal skin glands to start making more oil (sebum). Oil releases from the pores to protect the skin and keep it moist. Acne begins when oil mixes with dead cells and clogs the skin's pores. Bacteria can grow in this mixture, and if it leaks into nearby tissues, it causes swelling, redness, and pus. A common name for these raised bumps is pimples.

See an illustration of how pimples form .

Certain medications can cause acne to develop. This type of acne usually clears up when you stop taking the medication.

It isn't just teens who are affected by acne. Sometimes newborns have acne because their mothers pass hormones to them just before delivery. Acne can also appear when the stress of birth causes the baby's body to release hormones on its own. Young children and older adults also may get acne.

A few conditions of the endocrine system, such as polycystic ovary syndrome and Cushing's syndrome, can lead to outbreaks of acne.

Symptoms

Acne develops most often on the face, neck, chest, shoulders, or back and can range from mild to severe. It can last for a few months, many years, or come and go your entire life.

Mild acne usually causes only whiteheads and blackheads. At times, these may develop into an infection in the skin pore (pimple).

Severe acne can produce hundreds of pimples that cover large areas of skin. Cystic lesions are pimples that are large and deep. These lesions are often painful and can leave scars on your skin.

Acne can lead to low self-esteem and sometimes depression. These conditions need treatment along with the acne.

What Happens

Acne develops most often in the teen and young adult years. During this time, both males and females usually produce more testosterone than at any other time in life. This hormone causes oil glands to produce more oil (sebum). The extra oil can clog pores and cause acne. Bacteria can grow in this mixture, and if it leaks into nearby tissues, it causes swelling, redness, and pus (pimples).

Acne usually gets better in the adult years when your body produces less testosterone. Still, some women have premenstrual acne flare-ups well into adulthood.

What Increases Your Risk

The tendency to develop acne runs in families. You are more likely to develop severe acne if your parents had severe acne.

The risk of developing acne is highest during the teen and young adult years. These are the years when hormones such as testosterone are increasing. Women who are at the age of menstruation also are more likely to develop acne. Many women have acne flare-ups in the days just before their menstrual periods.

Acne can be irritated or made worse by:

• Wearing straps or other tight-fitting items that rub against the skin (such as a football player wearing shoulder pads), as well as using equipment that rubs against the body (such as a violin held between the cheek and shoulder). Helmets, bra straps, headbands, and turtleneck sweaters also may cause acne to get worse.
• Using skin and hair care products that contain irritating substances.
• Washing the face too often or scrubbing the face too hard. Using harsh soaps or very hot water can also cause acne to get worse.
• Experiencing a lot of stress.
• Touching the face a lot.
• Sweating a lot.
• Having hair hanging in the face, which can cause the skin to be oilier.
• Taking certain medications.
• Working with oils and harsh chemicals on a regular basis.

When To Call a Doctor

Call a doctor if:

• You are concerned about your or your child's acne.
• Your acne gets worse or does not improve with home treatment.
• You have tried home treatment for 6 to 8 weeks, and your acne has not improved.¹
• You develop scars or marks after acne heals.
• Your pimples become large and hard or filled with fluid.
• You start to have other physical symptoms, such as facial hair growth in women.
• Your acne began when you started a new medication prescribed by a doctor.
• You have been exposed to chemicals, oils, or other substances that cause your skin to break out.

You may want to seek medical assistance sooner if there is a strong family history of acne, you are emotionally affected by acne, or you developed acne at an early age.

Should I see a doctor for acne?

Watchful Waiting

Watchful waiting is a wait-and-see approach. If you get better on your own, you won't need treatment. If you get worse, you and your doctor will decide what to do next.

Mild acne does not need treatment if it doesn't bother you.

If you have severe acne, if your acne does not clear up with home treatment, or if you develop acne scars, call your doctor.

Who To See

The following health professionals can diagnose and treat acne:

• Pediatricians
• Family medicine physicians or internists
• Nurse practitioners
• Physician assistants
• Dermatologists

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

When you see a doctor about acne, you'll have a physical exam, and your doctor will ask about your medical history. Women may be asked questions about their menstrual cycles. This information can help your doctor find out if hormones are playing a role in acne flare-ups. Most often, you won't have any special tests to diagnose acne.

You may need other tests if your doctor suspects that acne is a symptom of another medical problem (such as higher-than-normal amounts of testosterone in a woman).

Treatment Overview

Acne treatment depends on whether you have a mild, moderate, or severe form. Sometimes your doctor will combine treatments to get the best results and to avoid developing drug-resistant bacteria. Treatment could include lotions or gels you put on blemishes or sometimes entire areas of skin, such as the chest or back (topical medications). You might also take medications by mouth (oral medications).

Mild acne

Treatment for mild acne (whiteheads, blackheads, or pimples) may include:

• Gentle cleansing with a mild soap (such as Dove or Neutrogena).
• Applying benzoyl peroxide (such as Benoxyl, Benzac, or Clearasil).
• Applying salicylic acid (such as Clearasil, Propa pH, or Stri-Dex).

If these treatments do not work, you may want to see your doctor. Your doctor can give you a prescription for stronger lotions or creams. You may try an antibiotic lotion. Or you may try a lotion with medicine that helps to unplug your pores.

Moderate to severe acne

Sometimes acne needs treatment with stronger medications or a combination of therapies. Deeper blemishes, such as nodules and cysts, are more likely to leave scars. As a result, your doctor may give you oral antibiotics sooner to start the healing process. Inflammatory acne may need a combination of several therapies. Treatment for moderate to severe acne may include:

• Applying benzoyl peroxide.
• Draining of large pimples and cysts by a health professional.
• Applying prescription antibiotic gels, creams, or lotions.
• Applying prescription retinoids.
• Applying azelaic acid.
• Taking prescription oral antibiotics.
• Taking prescription oral retinoids (such as Accutane).

Treatment for acne scars

Treatment may improve and even remove acne scars. Sometimes a combination of treatments works best. These treatments include:

• Collagen injections, which smooth the skin by plumping the skin under the scar.
• Dermabrasion, which uses a whirling wire brush to skim off scar tissue.
• Laser resurfacing, which uses a carefully controlled laser to burn away scar tissue.
• Chemabrasion, which uses chemicals to peel away top layers of skin.

What To Think About

• Most treatments for acne take time. It often takes 6 to 8 weeks for acne to improve after you start treatment.^{2, 1} Some treatments may cause acne to get worse before it gets better.
• If your acne still hasn't improved after several tries with other treatment, your doctor may recommend that you take an oral retinoid, such as isotretinoin (Accutane). Doctors prescribe this medication as a last resort, because it has some rare but serious side effects and is expensive.
• Certain low-dose birth control pills may help control acne in women who tend to have flare-ups before menstruation.

Should I see a doctor for acne?

Should I take isotretinoin for acne?

Prevention

Although you cannot prevent acne, there are steps you can take at home to keep acne from getting worse.

• Gently wash and care for your skin every day. Avoid scrubbing too hard or washing too often.
• Avoid heavy sweating if you think it causes your acne to get worse. Wash soon after activities that cause you to sweat.
• Wash your hair often if your hair is oily. Try to keep your hair off of your face.
• Avoid hair care products such as gels, mousses, cream rinses, and pomades that contain a lot of oil.
• Avoid touching your face.
• Wear soft, cotton clothing or moleskin under sports equipment. Parts of equipment, such as chin straps, can rub your skin and make your acne worse.
• Avoid exposure to oils and harsh chemicals, such as petroleum.
• Avoid long periods of time in sunlight, as this doesn't help acne and can increase your risk of skin cancer. Use sunscreens when you are out in the sun.

Home Treatment

Treatment at home can help reduce acne flare-ups.

• Wash your face (or other affected skin) gently one or two times a day.
• Do not squeeze pimples, because that often leads to infections, worse acne, and scars.
• Use water-based skin care products that gently clean your skin. Avoid products such as milky cleansers, cold creams, lipsticks, and lip glosses that contain oils.
• Use over-the-counter medicated creams, soaps, lotions, and gels to treat your acne. Always read the label carefully to make sure you are using the product correctly.

Examples of some over-the-counter products used to treat acne include:

• Benzoyl peroxide (Benoxyl, Benzac, Clearasil), which unplugs pores.
• Alpha-hydroxy acid, which dries up blemishes and causes the top skin layer to peel. You'll find alpha-hydroxy acid in moisturizers, cleansers, eye creams, and sunscreens.
• Salicylic acid (Clearasil, Propa pH, Stri-Dex), which dries up blemishes and causes the top skin layer to peel.
• Tea tree oil, which kills bacteria. You'll find tea tree oil in gels, creams, and oils.

Other products that may help your overall skin condition include skin pore-cleaning strips. When you peel these sticky strips off your skin, dirt and/or makeup is removed by the strip.

You'll have better results if you follow the directions for using topical medications. If you use a product too often, acne can get worse.

Medications

Medications can help manage the severity and frequency of acne outbreaks. A number of medications are available. Your treatment will depend on the type of acne you have (pimples, whiteheads, blackheads, or cystic lesions). These medications improve acne by:

• Unplugging skin pores and stopping them from getting plugged with oil (tretinoin, which is sold as Retin-A).
• Killing bacteria (antibiotics).
• Reducing the amount of skin oil (isotretinoin).
• Reducing the effects of hormones in producing acne (certain oral contraceptive pills for women).

The best medical treatment for acne often is a combination of medications. These could include medication that you put on your skin (topical) and medication that you take by mouth (oral).

Medication Choices

Treatment of acne depends on whether inflammation or bacteria are present. Some acne consists only of red bumps on the skin with no open sores (comedonal acne). Topical creams and lotions work best for this type of acne. However, if bacteria or inflammation is present with open sores, oral antibiotics or isotretinoin may work better.

The most common types of medications that doctors use to treat acne include:²

• Benzoyl peroxide, such as Benoxyl, Benzac, and Clearasil.
• Salicylic acid, such as Clearasil, Propa pH, and Stri-Dex.
• Topical and oral antibiotics, such as clindamycin (Cleocin, for example), sodium sulfacetamide (Novacet), erythromycin (E-Mycin, for example), and tetracycline (Achromycin, for example).
• Topical retinoid medications, such as tretinoin (Retin-A), adapalene (Differin), and tazarotene (Tazorac).
• Azelaic acid, such as Azelex, a topical cream.
• Isotretinoin, an oral retinoid.
• Low-dose birth control pills that contain estrogen (such as Estrostep Fe, Ortho Tri-Cyclen, or Yaz), which work well on moderate acne in women and for premenstrual flare-ups. Estrogen softens the effects of testosterone by lowering oil production.
• Androgen blockers, such as spironolactone. Androgen blockers can be useful in treating acne. These medicines decrease the amount of sebum (oil) made in your pores.

Medication side effects In general, doctors prefer to use topical products for acne rather than oral antibiotics, which are more likely to have side effects. Oral antibiotic side effects can include:^{3, 4}

• Yeast infections (women).
• Diarrhea.

What To Think About

If you are pregnant, talk to your doctor about whether you should take antibiotics for acne. Erythromycin is the only safe antibiotic to treat acne for women who are pregnant.⁵

Over time, bacteria can become resistant to antibiotics, which means that the antibiotics are no longer effective at killing or controlling the bacteria causing the acne. This is called drug resistance. When this occurs, a different antibiotic may be used.

After acne is under control, you often need ongoing treatment to keep it from returning. This is the maintenance phase of treatment. Your doctor may suggest treatments other than antibiotics for long-term use, to avoid the risk of drug resistance.

Topical medications usually have fewer and less serious side effects than oral medications. However, topical medications may not work as well as oral medications for severe acne.

Isotretinoin (such as Accutane) and tazarotene (Tazorac) can have serious side effects. Women who take isotretinoin or tazarotene need to use an effective birth control method, to avoid having a baby with serious birth defects. The U.S. Food and Drug Administration (FDA) has announced that the companies that make isotretinoin have a program to register doctors who prescribe isotretinoin and the people who take it. The program is to ensure that women taking this medicine understand the risk of birth defects, take precautions to avoid pregnancy, and know what to do if they become pregnant. If your doctor suggests that you take isotretinoin, you must be registered with iPLEDGE in order to get the drug. You can get more information and register at www.ipledgeprogram.com or by telephone at 1-866-495-0654.

The FDA's Center for Drug Evaluation and Research division has also warned that isotretinoin (such as Accutane) may be associated with depression, psychosis, and, in rare cases, suicidal thoughts or attempts. The link between this medicine and depression is not clear and is being watched very closely. Talk to your doctor about the side effects of isotretinoin to decide whether it is right for you. If you are taking isotretinoin and feel depressed, see your doctor for treatment.

Should I take isotretinoin (such as Accutane) for acne?

Surgery

There are no surgeries to treat acne.

Other Treatment

Your doctor may suggest other types of therapies to treat acne or acne scars.

Other Treatment Choices

For acne scars, you may have:

• Collagen injections and gelatin implants, to improve the look of acne scars.
• Dermabrasion or dermaplaning, to remove scars.
• Chemabrasion, a chemical peel that removes surface scars.
• Microdermabrasion, a gentle skin buffing for mild acne scarring.
• Laser resurfacing, to remove the top layer of skin.

Chemabrasion, dermabrasion or dermaplaning, and laser resurfacing are techniques that remove the top layers of skin. This promotes skin regrowth and collagen production. The results are better-looking skin with less noticeable scarring. At this time, laser resurfacing is the most popular technique.

What To Think About

Health professionals no longer use X-rays or ultraviolet light (from a sunlamp) to treat acne. These treatments may have more risks than benefits.

Other Places To Get Help

Organizations

Related Information

• Cosmetic Surgery and Procedures
• Growth and Development, Ages 11 to 14 Years
• Growth and Development, Ages 15 to 18 Years

References

Citations

1. Krowchuck DP (2000). Managing acne in adolescents. Pediatric Clinics of North America, 47(4): 841-857.

2. Habif TP, et al. (2001). Acne. In Skin Disease: Diagnosis and Treatment, pp. 72-83. St. Louis: Mosby.

3. Leyden JJ (2003). A review of the use of combination therapies for the treatment of acne vulgaris. Journal of the American Academy of Dermatology, 49(3): 200-210.

4. Habif TP (2004). Acne, rosacea, and related disorders. In Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 4th ed., pp. 162-208. Philadelphia: Mosby.

5. Thiboutot DM, Strauss JS (2003). Diseases of the sebaceous glands. In I Freedberg et al., eds., Fitzpatrick's Dermatology in General Medicine, 6th ed., vol. 1, pp. 672-687. New York: McGraw-Hill.

Other Works Consulted

• American Academy of Dermatology (2006). Guidelines of care for acne vulgaris management. Available online: http://www.aad.org/NR/rdonlyres/FAD10239-F59B-486C-8082-28545B54F59A/0/Acne_Guideline.pdf.

• Orringer JS, et al. (2004). Treatment of acne vulgaris with a pulsed dye laser. JAMA, 291(23): 2834-2839.

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