Acne is a skin condition that affects areas containing the largest oil
glands, including the nose, forehead, cheeks, chin, back, and trunk. It is
caused by a disorder of the oil glands that results in clogged pores and
outbreaks of lesions commonly known as pimples. Acne affects between 17 million
and 45 million people, making it the most common skin disease in the United
States. While it tends to last longer in females, males are more likely to get
acne and tend to have more severe cases than do females. Some infants may
develop acne, but it is most common in adolescents and it generally disappears
by age 30. Although it is not a serious health threat, severe acne can be
painful and may cause permanent scarring, which can be upsetting for people who
suffer from the condition. An estimated $100 million is spent annually on
over-the-counter products to treat acne and reduce the pain, scarring, and
emotional distress that can be associated with it.
Signs and Symptoms
There are various types of acne lesions:
Comedone — general term for an enlarged hair
follicle plugged with oil and bacteria. This is the first and smallest type of
lesion. It is often referred to as a microcomendone because it cannot be seen by
the naked eye.
Open comedone (blackhead) — a plugged
follicle that reaches the surface of the skin. Although dark in appearance,
blackheads do not indicate the presence of dirt.
Closed comedone (whitehead) — a clogged
follicle that stays beneath the skin. Whiteheads usually appear on the skin as
round, white bumps roughly 1 to 2 mm in diameter.
Papules — inflamed lesions that appear as
small, pink bumps on the skin
Pustules (pimples) — inflamed pus-filled
lesions that are red at the base
Cysts and nodules — large, inflamed,
pus-filled lesions that are lodged deep and can drain, causing pain and
Lesions can cause scars ranging from small, depressed pits to large elevated
blemishes, depending on the severity of the condition and the individual's skin
Acne is a disorder of the skin's oil glands. Oil glands make an substance
called sebum that normally rises up through a hair-containing canal called a
follicle and empties onto the skin surface. The precise cause of acne in
newborns is not known, but some researchers speculate that it may be due to the
transfer through the placenta of hormones from the mother or of acne-causing
medication (such as lithium and phenytoin) that the mother may have been taking.
During adolescence, rising hormone levels are thought to increase the number of
oil glands and the amount of sebum they produce. The increased production of
sebum causes blockage of hair follicles, leading to the formation of small
bacteria-filled cysts called comedones. If these comedones remain intact and no
not rupture, they can progress into open comedones (whiteheads) or closed
comedones (blackheads). When comedones rupture, an inflammatory reaction occurs
and can spread into the surrounding tissue. Papules, pustules, cysts, and
nodules are all forms of inflammatory lesions.
The following may cause or worsen acne:
Family history of acne
Greasy/oily cosmetic or hair products containing vegetable or animal
Hormonal changes associated with adolescence, pregnancy, or
menstruation (acne tends to flare up 2 to 7 days before menstruation
Certain medications such as corticosteroids, androgens, oral
contraceptives, lithium, halogens, isoniazid, phenytoin, phenobarbital, and high
levels of iodine (such as from kelp)
Environmental irritants such as industrial cutting oils, tar, wood
preservatives, sealing compounds, and other pollutants
Sweating and friction, such as from headbands, back packs, bicycle
helmets, or tight collars
High levels of humidity
Squeezing and picking comedones
Although still controversial, some researchers believe that stress and sun
exposure can also cause or aggravate existing acne. This may be due to the use
of oily sunscreens however, as some people with acne actually experience
improvement in symptoms with exposure to the sun.
Acne has a characteristic appearance and is not difficult to diagnose.
General practitioners, pediatricians, and internists can treat most individuals
with mild and moderate forms of acne. People with more severe cases of acne
however, are often referred to a dermatologist or a skin disease specialist. The
practitioner will take a complete medical history that includes questions about
skin care, cosmetic use, and diet; factors that trigger flare-ups; medication
use; occupational and environmental exposures; and prior treatment. The
practitioner will also examine the face, chest, back, and other areas for
blemishes, lesions, and scars. Several factors, including the size of the
blemishes and whether or not they are inflamed, help a practitioner determine
the most appropriate treatment.
The main goals of acne treatment are to prevent scarring, reduce the number
of painful lesions, and minimize the stress and embarrassment related to the
condition. The basic principle of skin care is to wash the affected area no more
than one to two times per day with a mild, nondrying soap. Frequent washing and
the use of harsh soaps can actually make the condition worse. Healthcare
practitioners will often recommend topical
medications as their first choice for
treating acne (generally either benzoyl peroxide or a class of drugs known as
retinoids). These are designed to wear away the top layer of skin (exfoliate) as
well as to reduce abnormal clumping of cells in the follicles, oil and bacteria
production, and inflammation. Additionally, facial steaming with accompanying
manual extraction of the comedones (such as by a professional aesthetician) is
valuable for exfoliation as well. Although more research is needed to
investigate the safety and effectiveness of alternative remedies for acne,
people with mild cases of acne may experience an improvement in symptoms from
Mind/body techniques such as
biofeedback or hypnosis may also help to alleviate feelings of anxiety and
depression that some individuals experience with this skin condition. Expect to
use medications and/or complementary and alternative remedies for at least 6 to
8 weeks before seeing a noticeable improvement in symptoms. Seek medical care if
infantile acne does not improve within three months.
Topical medications (those applied directly to the skin) are available in
many forms including gels, lotions, creams, soaps, or pads. The most commonly
used topical medications for acne include:
Benzoyl peroxide — works by killing bacteria
and unclogging pores. This medication comes in prescription and over-the-counter
preparations. Benzoyl peroxide should not be applied at the same time of day as
topical retinoids. To avoid adverse reactions, apply to small area on forearm
and observe the area for two to three days. If no reaction occurs, application
to the face should be safe.
Retinoids — work by unclogging pores and
reducing inflammation. These medications come in prescription form only.
Commonly prescribed retinoids include tretinoin, adapalene, and tazarotene. They
are intended for individuals with significant numbers of both open and closed
comedones as well as papules and pustules. Side effects may include redness,
peeling, and photosensitivity (high risk of sunburn). Most retinoids are applied
at night and should not be applied at the same time as benzoyl peroxide (with
the exception of adapalene). Topical retinoids should not be used during
pregnancy as they may cause harm to the fetus.
Antibiotics — work by killing bacteria and
reducing inflammation. Topical antibiotics such as clindamycin or erythromycin
are available in prescription form. They may be used to treat mild to moderate
In some cases, healthcare practitioners may recommend a combination of
topical medications, such as benzoyl peroxide and clindamycin. Other topical
acne medications available by prescription include sodium sulfacetamide and
Healthcare practitioners may prescribe oral (taken by mouth) antibiotics
either alone or in addition to topical medications for individuals with moderate
to severe acne. For those with severe, inflammatory acne that does not improve
with other medications, healthcare practitioners may prescribe an oral retinoid
called isotretinoin. Further information about these medications is discussed
Antibiotics—work by killing bacteria and
reducing inflammation. Commonly prescribed oral antibiotics include doxycycline,
minocycline, and tetracycline. Oral antibiotics should not be used during
pregnancy or by those under 9 years of age.
Isotretinoin—works by reducing the size of
oil glands and lowering sebum production. It is usually prescribed by a
dermatologist for individuals with severe, inflammatory acne that does not
improve with other medications. Isotretinoin is taken twice a day for 20 weeks.
It should not be used by pregnant women as it may cause harm to the
In some cases, healthcare practitioners may also prescribe certain oral
contraceptives in addition to acne medications.
Surgery and Other Procedures
Individuals with severe acne scars may require surgery or other procedures to
improve the appearance of their skin. Dermatologists can perform skin
resurfacing techniques such as dermabrasion (a procedure that uses a rapidly
rotating brush to remove acne scars or pits) or chemical peeling (a chemical
solution is applied to the skin that causes it to blister and eventually peel
off). Dermatologic surgeons can also perform scar excisions (a technique in
which the scar is removed and the surrounding healthy skin is joined together)
and punch grafting (a method in which the surgeon punches a hole in the skin,
removes the scar, and replaces it with a small plug of new skin) to correct deep
Nutrition and Dietary Supplements
Some people with acne report that certain drinks and foods (particularly
nuts) worsen their symptoms. Studies have yet to confirm a scientific link
between diet and acne, but people with this skin condition should avoid
substances that appear to aggravate their symptoms.
Studies indicate that the mineral zinc may be an effective treatment for
inflammatory acne. In two studies of about 60 people with inflammatory acne,
those who took zinc gluconate daily for roughly two months had a significant
reduction in the number and severity of inflammatory lesions compared to those
who took placebo for the same period of time. Despite these promising findings,
differences in the type of zinc preparations as well as variations in the amount
and duration of treatment, make it difficult to draw definitive conclusions from
these two studies. In addition, certain topical medications such as erythromycin
ointment may contain zinc oxide. It is possible, but not entirely clear, that
the zinc contained in the ointment may contribute to the effectiveness of the
Researchers in Greece showed that a large group of people who had side
effects from isotretinoin got better when taking L-carnitine compared to those
who took a placebo.
The following herbs have anti-inflammatory properties that may be helpful in
the treatment of skin conditions including acne:
German chamomile(Matricaria recutita)
Witch hazel(Hamamelis virginiana)
Licorice root(Glycyrrhiza glabra)
Flaxseed (Linum usitatissimum) and flaxseed
Tea Tree Oil
Some plants contain antimicrobial substances that may help eliminate
Propionibacterium acnes (the bacterial strain associated with acne),
thereby potentially reducing inflammation associated with the skin condition.
Preliminary evidence suggests that tea tree oil (Melaleuca alternafolia)
may have antimicrobial effects. One study compared the effectiveness of tea tree
oil gel with benzoyl peroxide lotion in 119 people with mild to moderate acne.
Individuals in both treatment groups showed a significant reduction in the
number of inflamed and noninflamed lesions over a 3-month period. Seventy-nine
percent of the benzoyl peroxide group compared to 44% of the tea tree oil group
reported side effects included stinging, itching, burning, and dryness. A
laboratory study also found that tea tree oil as well as certain active
components of tea tree oil effectively slows the growth of P. acnes.
While there have been no well-designed studies evaluating the use of
acupuncture for acne, there have been several reports in the medical literature
that auricular (acupuncture applied to the ear) and electroacupuncture therapies
may reduce the symptoms of acne.
There have been few studies examining the effectiveness of specific
homeopathic remedies. Professional homeopaths, however, may recommend one or
more of the following treatments for acne based on their knowledge and clinical
experience. Before prescribing a remedy, homeopaths take into account a person's
constitutional type. In homeopathic terms, a person's constitution is his or her
physical, emotional, and intellectual makeup. An experienced homeopath assesses
all of these factors when determining the most appropriate remedy for a
Belladonna— for people who experience
flushes of heat to the face or who have inflamed pustular acne that improves
with cold applications
Calendula— for skin conditions
involving pustules or blisters
Hepar sulphur— for painful, pus-filled
Kali bromatum— for deep acne,
especially on the forehead, in persons who are chilled and nervous
Silicea— for pustules or pit-forming
Biofeedback and Cognitive Imagery
Emotional stress can worsen acne, so it is possible that relaxation therapies
such as biofeedback together with cognitive imagery may improve acne symptoms.
Biofeedback is a technique in which an individual is trained to control certain
internal bodily processes that normally occur involuntarily, such as heart rate
(measured by an EKG) and muscle tension (measured by an EMG). During biofeedback
training, an individual participates in a relaxation technique, such as guided
imagery, while hooked up to an EKG or an EMG. Guided imagery involves the
formation of mental pictures to promote a variety of favorable physical and
emotional effects. This combination of biofeedback and cognitive imagery allows
the person to visualize and understand the bodily changes that occur when he or
she changes from being tense to being relaxed. In a study of 30 individuals with
acne, those who participated in EMG feedback and guided imagery demonstrated a
significant improvement in acne symptoms compared to those who did not receive
Hypnosis may enhance the effectiveness of treatments for a variety of skin
conditions including acne. It is not entirely clear how hypnosis improves
symptoms of acne, however. Some researchers speculate that it can help an
individual become more relaxed and, as a result, may positively influence the
activity of hormones and the immune system (which may contribute to reduced
In one well-designed trial, 82 people with moderate acne were randomly
assigned to receive either placebo or one of four Ayurvedic preparations. Only
one formulation, Sunder Vati, significantly reduced the number of both
inflammatory and non-inflammatory lesions. The herbs in the Sunder Vati
Ginger (Zingiber officinale)
Some healthcare practitioners have reported that Keigai-rengyo-to (TJ-50), a
Japanese Kampo medicine, may be effective in the treatment of acne. Researchers
speculate that the therapeutic effects of this medication may be due to the
antibacterial and anti-inflammatory activity of its components. The formulation
contains 17 herbs, including:
Skullcap root(Scutellaria lateriflora)
Licorice root (Glycyrrhiza glabra)
Mint (Mentha arvensis)
Angelica root (Angelica archangelica)
Peony root (Paeonia lactiflora)
Pregnant women should avoid all retinoids (oral and topical), isotretinoin,
and the antibiotics tetracycline, minocycline, doxycycline because they can be
harmful to the fetus. The antibiotic erythromycin (in both topical and oral
forms) is safe to use during pregnancy.
Prognosis and Complications
Acne is not a serious health threat, but severe acne can be painful,
emotionally upsetting, and may cause permanent scarring. Squeezing lesions can
rupture comedones and cause inflammation. Infants with acne have an increased
risk of developing acne in adolescence. Symptoms generally diminish after
adolescence and disappear by age 30. However, the incidence of adult acne,
especially in women, seems to be increasing and is not unusual in women in their
30s and 40s.
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Review Date: November 2001
Reviewed By: Participants in the review process include: Jay L. Cohen, MD, Department of
Dermatology, Newton-Wellesley Hospital, Harvard University, Boston MA.; Richard
Glickman-Simon, MD, Department of Family Medicine, New England Medical Center,
Tufts University, Boston, MA; Jacqueline A. Hart, MD, Department of Internal
Medicine, Newton-Wellesley Hospital, Harvard University, Boston Ma and Senior
Medical Editor Integrative Medicine, Boston, MA; Jane Hart, MD, Clinical
Instructor, Case Western Reserve University School of Medicine and Director for
Preventive Medicine Consultations and Medical Director for the Institute for
Total Health at the Cleveland YMCA, Cleveland,
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