Comedones (blackheads and whiteheads) must be present to diagnose acne. In their absence, an appearance similar to that of acne would suggest a different skin disorder. Microcomedones (the precursor to blackheads and whiteheads) are not visible to the naked eye when inspecting the skin and can only be seen with a microscope. There are many features that may indicate a person's acne vulgaris is sensitive to hormonal influences. Historical and physical clues that may suggest hormone-sensitive acne include onset between ages 20 and 30; worsening the week before a woman's period; acne lesions predominantly over the jawline and chin; and inflammatory/nodular acne lesions.
Every expert we spoke with said the most critical part of combating acne is combating it every day. “The only way to make any medication work is to use it on a daily basis,” says Dr. Green. Fitz Patrick emphasizes that it really comes down to what you can maintain for the long term: “Kits are great because they take out all the guesswork -- you just follow the instructions. But if four steps is going to be too many for you to keep up week after week, you’ll be better off finding one that has fewer treatments.”
If a pore is open, it’s called a blackhead or “open comedo”. Because of the opening, contact with the air oxidizes the dead skin cells inside the pore. The air contact turns the melanin inside them darker in color, similar to the way a peeled banana left exposed to the air will darken. This is how the blackhead forms. The color of a blackhead is not because of dirt. It’s a mixture of air and the skin pigment called melanin.
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A 2013 study on acne vulgaris in The Nurse Practitioner concurred that a multidimensional approach to acne is usually necessary because most people have a combination of symptoms. Based on the advice of dermatologists and aestheticians, we turned our focus to regimen sets, analyzing the ingredients of more than 40 kits before finding our top picks.
Although combined oral contraceptives are a more popular treatment with women, men can use them as well, as they may also experience hormonal fluctuations. The only downside is that birth control pills tend to produce feminizing features in the person taking them, such as reduced hair growth or enlarged breast tissue. To get a prescription for a combined oral contraceptive, you can talk to your family doctor, a dermatologist, or an OB/GYN, or visit your local Planned Parenthood.
How to Handle It: Your best bet is benzoyl peroxide. "Benzoyl peroxide can kill acne-causing bacteria and reduce inflammation," says Zeichner. Try a cream like the La Roche-Posay Effaclar Duo Dual-Action Acne Treatment ($37), which also exfoliates with lipo-hydroxy acid. Be aware that it can seriously dry out skin so moisturize well after you use it.
“Acne cleansers with these ingredients will gradually unclog pores, reduce the size of existing blackheads and slow or stop the formation of new ones,” she says. “Benzoyl peroxide is also the best ingredient for treating the acne-causing bacteria called p. acnes. In fact, study after study continues to show that benzoyl peroxide is more effective than prescription topical antibiotics at treating p. acnes.”
Pustules, as their name suggests, are filled with pus. They usually have a white or yellow center surrounded by extremely inflamed skin that is pink or red. The pus isn’t just bacteria and skin cells—it contains some dead white blood cells that were trying to fight the bacteria, too. Squeezing these can cause the skin around them to darken and scar.
Genetics play a big part in who gets acne and how severely, but each blemish can be blamed on some combination of sebum production, a bacteria called Propionibacterium acnes (P. acnes), plugged follicles, and inflammation. Finding a good treatment is really about finding the right combination of ingredients to troubleshoot each of those issues. Some factors that might worsen acne include hormones, certain medications, diet and stress.
Flutamide, a pure antagonist of the androgen receptor, is effective in the treatment of acne in women. It has generally been found to reduce symptoms of acne by 80 or 90% even at low doses, with several studies showing complete acne clearance. In one study, flutamide decreased acne scores by 80% within 3 months, whereas spironolactone decreased symptoms by only 40% in the same time period. In a large long-term study, 97% of women reported satisfaction with the control of their acne with flutamide. Although effective, flutamide has a risk of serious liver toxicity, and cases of death in women taking even low doses of the medication to treat androgen-dependent skin and hair conditions have occurred. As such, the use of flutamide for acne has become increasingly limited, and it has been argued that continued use of flutamide for such purposes is unethical. Bicalutamide, a pure androgen receptor antagonist with the same mechanism as flutamide and with comparable or superior antiandrogenic efficacy but without its risk of liver toxicity, is a potential alternative to flutamide in the treatment of androgen-dependent skin and hair conditions in women.
Acne usually improves around the age of 20, but may persist into adulthood. Permanent physical scarring may occur. There is good evidence to support the idea that acne and associated scarring negatively affect a person's psychological state, worsen mood, lower self-esteem, and are associated with a higher risk of anxiety disorders, depression, and suicidal thoughts. Another psychological complication of acne vulgaris is acne excoriée, which occurs when a person persistently picks and scratches pimples, irrespective of the severity of their acne. This can lead to significant scarring, changes in the affected person's skin pigmentation, and a cyclic worsening of the affected person's anxiety about their appearance. Rare complications from acne or its treatment include the formation of pyogenic granulomas, osteoma cutis, and solid facial edema. Early and aggressive treatment of acne is advocated by some in the medical community to reduce the chances of these poor outcomes.
^ Jump up to: a b GBD 2015 Disease and Injury Incidence and Prevalence, Collaborators. (8 October 2016). "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1545–1602. doi:10.1016/S0140-6736(16)31678-6. PMC 5055577. PMID 27733282.
For female adult patients, one medication that Dr. Turner often recommends is spironolactone. Many patients consider it the “miracle drug.” When used at low doses, such as 50 to 150mg per day, the androgen hormones are not cycling so rapidly, which in turn helps to relieve cystic acne, especially located on the lower cheeks, jawline and neck regions. Interestingly, spironolactone is an older drug that has been used since the ’50s, but at different doses, it acts by a completely different mechanism. Thus, it is as though it is two completely different drugs, depending on the dose, but it has the same name. The only negative aspect of spironolactone dosing at these levels is that a woman should never get pregnant while medicating with this due to ambiguity in the fetal genitalia.
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