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June is National Acne Awareness Month, and while we’re certain you know a breakout when you see one, you may not be familiar with the myriad of different types of acne, their distinctive range of potential causes and triggers, and the best ways to treat each different type. We sat down with board-certified dermatologist and CEO of Curology, (the new “customized skincare” service popping up all of over your Instagram) Dr. David Lortscher to get some answers from an expert’s point of view and to offer you some insider insight on the one of the most frustrating (and sadly, common) skincare concerns.
Because we all know that acne isn’t an experience exclusive to teenhood — despite the ever-misleading misconception that it is—I prepared for my conversation with Dr. Lortscher, by asking a slew of different women, (each with different skin types, ages, and additional skin concerns like anti-aging) to get some answers to some prevalent questions about adult acne.
Curology is actually an excellent option for those who struggle with acne, but also want to address anti-aging concerns like fine lines and dark spots because it allows you to consult with a licensed dermatologist online, who then creates a custom serum tailored to your specific concerns, with the prescribed ingredients (including prescription-only retinoids) in one convenient product.
1. What are the main types of acne?
Acne falls into two categories: non-inflammatory and inflammatory. The process begins on a cellular level when excess oil, or sebum, mixes with dead skin cells and bacteria and clogs your pores. Non-inflammatory acne consists of whiteheads and blackheads. Whiteheads are small clogged pores (aka closed comedones), where trapped oil and dead skin cells create a small white “bump.”
Blackheads are small clogged pores (aka open comedones), that expose the trapped oil and skin cells to the air. Oxidation of the trapped substances makes the pimple look black!
Inflammatory acne consists of papules, pustules, cysts and nodules. Papules are tender bumps with redness and swelling caused by inflammation and are usually less than 5mm. Pustules are “squeezable” inflamed lesions with a visible central core of pus and are usually raised 1–5 mm. Nodules are large, firm, and reddish lumps that extend deeper than a papule and are often painful. Cysts (yes, those painful, deep cystic acne that seem to take forever to go away) are highly inflamed and/or draining acne nodules.
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Women often experience acne due to hormonal influences, especially after discontinuing (or starting) birth control pills, around their periods and during pregnancy, perimenopause, and menopause. Generally, women have smaller amounts of the male hormone testosterone, which is normalized by estrogen and progesterone. After ovulation, these “normal levels” of estrogen and progesterone decrease, and testosterone outweighs them. As the cycle approaches menstruation, these higher testosterone levels encourage sebum production, which can clog your pores.
Cystic acne is a more inflamed, nodular type of acne that may leave scars. Although topical treatments may be insufficient to prevent and treat cystic acne, we do see patients improving dramatically and, at times, clearing with topical treatments only.
Cystic acne is different from epidermal (sebaceous) cysts, even though both involve the sebaceous glands, as acne cysts do not have a distinct sac or wall. Still, there is some overlap. As acne cysts are typically inflamed and can appear infected. This type of inflammation can be helped by antibiotic treatment. However, acne cysts are usually associated with “normal” skin bacteria, rather than the more aggressive strains that indicate true infection. A larger inflamed acne cyst can also be helped by a dilute cortisone injection. Since acne cysts don’t have a distinct wall, they don’t lend themselves well to surgical removal—this may leave a scar that is more noticeable than the original cyst.
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2. How can you tell the difference between hormonal and other types of acne?
Although there’s no exact science to distinguishing hormonal and other types of acne, acne caused by hormones in women tend to involve the lower cheek, chin, and jaw areas. It may be helpful to track your acne severity in relation to your menstrual cycle. This helps you determine whether your acne worsens before or during your menstrual cycle.
3. How often do you treat patients with adult acne?
We treat patients with adult acne on a daily basis. In fact, it is not uncommon for women going through perimenopause or menopause to experience a flare in acne due to a relative predominance of androgens (male sex hormones), which stimulate sebum production and worsen acne.
A Harvard study of acne in women revealed that although acne peaked in the teenage years, 45% of women aged 21-30, 26% aged 31-40, and 12% aged 41-50 were affected. The characteristics of acne differed over the years, with younger women having more inflamed pimples, and older women having more comedones (clogged pores).
4. Are oral contraceptives (a.k.a birth control pills) the only way to treat hormonal acne?
Contrary to popular belief, not all birth control can help treat acne. In addition to my work with Curology, I recently led a study, published in the Journal of Drugs in Dermatology, which found that while certain contraceptives can mitigate acne vulgaris, others actually worsen it depending on the types of hormones present.
The presence of a specific progestin in some types of birth control may worsen acne. Certain progestins have more androgenic (male hormone-like) effects on the skin compared to others. Pills that contain the progestin drospirenone are generally the most helpful for the skin, followed by those containing norgestimate or desogestrel due to their low androgenicity.
Yaz and Ortho Tri-Cyclen (or any of their generic forms) may help acne by decreasing the production of androgens in the ovaries. This reduces oil gland activity and decreases the severity of premenstrual acne. On the other hand, pills containing levonorgestrel or norethindrone are the least likely to help acne because of their higher androgenicity.
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4. What are the main differences between Salicylic Acid and Benzoyl Peroxide?
Salicylic acid is a type of phenolic acid, while benzoyl peroxide is a peroxide. Salicylic acid has a similar chemical structure to aspirin. Benzoyl peroxide absorption through the skin is minimal compared to that of salicylic acid. Salicylic acid is exfoliating. It works by clearing out build-up in your pores. Benzoyl peroxide is a bactericidal agent that kills P. acnes (the bacteria involved in acne) by releasing oxygen within the follicle.
5. What are the pros and cons of Salicylic Acid & Benzoyl Peroxide?
Salicylic Acid Pros:
Salicylic acid is a beta hydroxy acid (BHA) that encourages exfoliation to prevent and treat blocked pores.
It may help diminish some types of superficial hyperpigmentation.
It’s best for oily skin types, as may produce a drying effect in some users.
Salicylic acid penetrates and dislodges the sebum in your pores, avoiding the sebum and dead cells combination that tends to build up in the pores and trigger acne breakouts.
Since it’s chemically similar to the active component of aspirin, it decreases inflammation and is beneficial for both inflammatory and noninflammatory acne.
BHAs like salicylic acid don’t cause photosensitivity, so you can use it in the morning or at night.
Unlike benzoyl peroxide, salicylic acid doesn’t bleach fabrics.
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Salicylic Acid Cons:
Low concentrations of salicylic acid in skincare (no more than 2% for toners and cleansers) are generally safe. However, high doses of salicylic acid, when taken orally, may cause some problems in pregnancy.
Additionally, using higher concentrations of topical salicylic acid (such as in peels or over large areas of the body) may not be safe.
Salicylic acid has a similar chemical structure to aspirin, and aspirin may cause birth defects and complications.
Salicylic acid may cause some dryness, irritation, and flaking in some individuals. It’s best to start out using it just 1-2 times a week, then increase the frequency of use once you know your skin can tolerate it.
Salicylic acid may not be the best option for those who already have dry skin, as it can exacerbate irritation and dryness.
Benzoyl Peroxide Pros:
Benzoyl peroxide is a topical microbial that offers an effective treatment for acne.
Since the use of salicylic acid has raised some concerns during pregnancy, OTC (over-the-counter) benzoyl peroxide offers a safer option. Benzoyl peroxide absorption through the skin is minimal, so there are no expected or known risks to the mother/infant.
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Benzoyl Peroxide Cons:
Benzoyl peroxide may trigger an allergic reaction in some people, causing an itchy rash.
Just like salicylic acid, benzoyl peroxide may cause some dryness, irritation, and flaking in some individuals. It’s best to start out using it just 1-2 times a week, then increase the frequency of use once you know your skin can tolerate it.
5. What are the biggest acne triggers? What are the best ways to prevent acne?
Acne is very multifactorial. Factors such as hormones, genetics, lifestyle, diet, exercise/sweating, choice of skincare products, and even fabric choices may influence the different stages of acne development.
1. Reduce sugar in your diet.
Diets high in sugar or simple carbohydrates (high glycemic-index) foods may predispose some people to acne. These types of food cause blood sugar levels to spike. Your pancreas responds by releasing insulin, which in turn stimulates production of insulin-like growth factor (IGF-1). Ultimately, this increases sebum production and feeds the severity of your acne.
2. Cut down on excessively hot and long showers.
Cut down on excessively hot and long showers. Hot showers and baths cause vasodilation, or enlargement of the capillaries (tiny blood vessels near the surface of your skin). When you have inflamed active acne lesions or post-acne inflammatory erythema (redness), capillaries are already more dilated in these areas. Heat causes further dilation, making these areas appear even more red than your surrounding skin. I recommend protecting your skin from exposure to extreme temperatures if you have acne.
3. Don’t scrub.
We see a lot of acne aggravated as people try to scrub it away! The friction from aggressive scrubbing will backfire. This causes irritation, and irritation leads to more acne.
4. Don’t pile on every product in your medicine cabinet.
When it comes to skincare, simpler is sometimes better. There are some good over-the-counter ingredients that help fight acne, including benzoyl peroxide, BHA (salicylic acid), and AHA (glycolic acid, lactic acid or similar). These are fine to use, but start with one ingredient, and add another only after you know that your skin is tolerating the first, without dryness or irritation.
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5. When your skin needs more help, take the next step.
Visit your local, board-certified dermatologist. Or, go online and start the process with Curology to get expert care and custom-prescribed formula for your skin.
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