Complete Guide to Acne Causes and Treatments
Table of Contents
- Quick Facts
- What Is Acne?
- What Are the Stages of Acne Development?
- What Type of Acne Do I Have?
- Does Acne Go Away After Puberty?
- What Causes Acne?
- Top 10 Acne Myths
- Acne and Depression
- What Are the Best Over-the-Counter Acne Products?
- What Prescription Acne Medications Work Best?
- Cortisone Shots for Acne
- Is Light Therapy An Effective Acne Treatment?
- What Is Photodynamic Therapy for Acne?
- What Is the Difference Between Light and Laser Treatments?
- Chemical Peels for Acne
- Types of Acne Scars
- Acne Scar Treatments
- Frequently Asked Questions
- How long should I use an over-the-counter acne treatment?
- I've heard I can use toothpaste to dry up a pimple. Is that true?
- Is there any treatment that will clear up acne immediately?
- How severe should my acne be before I see a doctor?
- Are acne scar treatments covered by health insurance?
- Can acne scarring be prevented?
- At what age can acne scarring begin?
- Will my acne scars fade over time?
- Finding a Dermatologist
- Acne is a grouping of skin issues that are characterized by skin inflammation caused by an overproduction of sebum — an oil produced by sebaceous glands at the base of hair follicles.
- There are five major forms of acne that range in severity from common whiteheads to nodules and cysts.
- While acne is often associated with puberty and adolescence, it can occur at any age, particularly as a result of hormone fluctuation. Stress, diet, and environment also play a role in developing acne.
Over-the-counter treatment is often the first step towards an acne solution. Options like benzoyl peroxide, salicylic acid, and alpha hydroxy acids (AHA) are readily available online and in most major drug stores.
Dermatologists can also offer patients move advanced treatments tailored to their specific needs. These include prescription topicals, isotretinoin, and oral antibiotics.
Serious cases of acne can result in scarring, particularly when the acne is improperly treated.
There are many types of acne scars and each scar responds differently to the treatments available.
While it’s possible to treat mild scarring at home, proper treatment typically requires the help of a dermatologist, or in extreme cases, a plastic surgeon.
- With such a wide range of options available, the price of acne treatments can vary drastically.
- Professional treatment options, like photofacials and laser therapy, typically cost approximately $500 per session. At-home treatments, like light chemical peels, are priced between $35 and $70.
- The price of treating acne scars runs the gamut from home treatments that cost as little as $10 a month, to clinical options like laser resurfacing that can cost as much as $3,000 per treatment.
Find a dermatologist
While dermatologists specialize in skin procedures, cosmetic surgeons and aesthetic laser technicians are more than qualified to administer certain types of acne treatments.
That said, a dermatologist who specializes in acne treatments can offer patients a wide range of options, particularly for those with severe acne or acne scarring.
This guide provides a list of effective acne prevention and treatment options, as well as advice for improving the appearance of acne scars.
Common acne, medically known as acne vulgaris, is a condition that the vast majority of us have to go through at one point or another in our lives.
Some of us are fortunate enough to have only a mild, temporary case during puberty, but many aren't so lucky. In fact, acne is the single most common skincare issue seen by dermatologists.
This guide dispels some of the most common myths concerning the causes of acne. It also provides a list of effective prevention and treatment options, as well as advice for improving the appearance of acne scars.
What Is Acne?
Though there are a variety of different kinds of acne, in general it is described medically as a localized skin inflammation resulting from overproduction of oil by the glands at the base of specialized hair follicles.
These special oil glands are found just under the skin. Once active, they continuously produce and secrete “sebaceous” oils through pores in the skin. Known as “sebum,” the oil both protects and lubricates your skin. However, it is common for these pores to become blocked, leading to a buildup of oil under the skin.
As unpleasant as it might be to think about, we all have bacteria that lives on and in our skin. This bacteria usually keeps to itself, feeding off the sebaceous oil. But if the pore becomes blocked or clogged, the multiplying bacteria have nowhere to go. The surrounding skin becomes inflamed if the follicle breaks.
Different types of acne will then form, depending on how deep into the skin the blockage forms and the nature of the pore's opening.
What Are the Stages of Acne Development?
Generally speaking, there are four stages of acne development:
- The sebaceous oil glands in the skin are stimulated to begin producing more sebum by androgenic (or male) hormones. Though usually associated with puberty, any changes in hormone levels can cause these glands to begin making more oil.
- The pore or follicle is obstructed, either by dead skin or a plug of skin cells and sebum.
- Bacteria infects the blockage. The bacteria Propionibacterium acnes and staphylococcus epidermidis are naturally found in hair follicles, but if too many of them build up within a follicle they can start to release an enzyme that breaks down the sebum. This causes inflammation in the follicle.
- The follicle ruptures, causing inflammation in the surrounding tissues.
What Type of Acne Do I Have?
There are 5 main types of acne blemishes. Whether you suffer from mild acne vugaris of severe acne rosacea, chances are you've experienced several -- if not all of them.
1. Whiteheads (closed comedones)
Aptly named, these blemishes appear with whitish or flesh colored “heads” that are a result of the follicle becoming blocked by sebum (the oil produced by our follicular pores) and dead skin cells. In this case, the blockage is close to the surface, and the pore itself is completely closed off. There is usually very little or no inflammation associated with whiteheads.
2. Blackheads (open comedones)
Also taking their name from their appearance, blackheads appear as tiny dark or black dots. Similar to whiteheads, this kind of acne is the result of a blockage caused by sebum and dead skin cells. However, the pore remains open, rather than closed. This blemish is caused by the formation of a “plug” forming in the pore opening.
As the material in this plug is exposed to air, it oxidizes, and changes to a darker color. Think about how an apple wedge darkens as it's left out exposed.
Like whiteheads, this kind of acne does not cause inflammation.
Papules are the phase of acne beyond the whitehead, when sebum, skin cells, and bacteria beneath the skin start to cause irritation and inflammation. These blemishes can be identified by some swelling, redness, and pain, but have no visible pus. They’re usually small to medium in size. Papules are a result of blockages that occur a little deeper in the skin.
Pustules are very similar to papules, except that they contain pus. The classic pimple or “zit,” these tend to be bigger, “uglier” whiteheads. They’re usually painful to the touch, red around the base, and contain whitish or yellowish pus.
5. Nodules & Cysts
The most severe forms of acne are called nodules and cysts. Both of these are quite large, bigger than either papules or pustules, and appear as painful bumps beneath the skin.
Both nodules and cysts can take a long time to fade, and can cause significant scarring. While they’re both located deep within the skin, nodules tend to be hard and not filled with pus, while cysts are filled with pus, and feel like little fluid sacs under the skin.
Does Acne Go Away After Puberty?
Not always, unfortunately. While acne is most commonly caused by the hormonal changes associated with puberty, it's a fairly common condition among babies and adults as well. However, an estimated 90 percent of teenagers experience acne, whereas approximately a third of adults suffer from occasional outbreaks.
Acne can appear as early as birth. This “baby acne” is called acne neonatorum. It’s a fairly common skin condition that affects around 20% of newborns. Usually appearing about two weeks after birth, the blemishes last a few weeks to a few months, though they rarely linger longer than 3 months.
Acne generally starts around puberty. This is when particular oil glands “wake up” as they are stimulated by male hormones, like testosterone, which are produced in the adrenal glands of both boys and girls.
Most teens are affected by puberty-induced acne to some degree. The hormones associated with all the other changes happening in the body are also responsible for increasing the size and number of sebaceous oil glands in the skin, as well as how much sebum each gland produces.
30-50% of adults suffer from some form of acne. In some cases, acne that starts in your teen years can continue well into adulthood. However, most sufferers will find that their breakouts go away by the time they’re in their 30s. Severe adult acne can also develop in people who only had mild cases as teenagers.
What Causes Acne?
The two biggest factors to play a role are thought to be genetics and hormones, but other variables like stress, your environment and habits, and diet/medications may also play an important part in the development of acne.
Thought to be the single most important factor in the development of acne, your genetic makeup dictates everything your body does, including how it responds to a buildup of dead skin cells and sebum in a hair follicle.
Once the pore is clogged, one person's immune system may react by forming a simple blackhead, while another person might develop a red, explosively painful nodule.
Genetics are unpredictable, but at least one study performed on identical twins found that a person's genes can explain up to 81% of acne prevalence.
While your body's genetics and immune system reacting to clogged pores is the reason pimples develop, your hormone levels are what cause the blockages in the first place.
As puberty begins, male-associated hormones are produced in the body, and as these hormone levels rise the oil glands beneath the skin enlarge and start producing more sebum, filling the follicle. This can cause some of the surrounding skin cells' walls to break, creating the perfect home for the P. acnes bacteria to feed and grow.
High levels of stress can trigger or worsen your acne. Your body's natural response to stress is to release cortisol and male-associated hormones into your system. This in turn increases oil production in the sebaceous glands in your skin.
Some healthcare providers believe that “adult acne” is on the rise because of how hectic modern life has become, with the constant and high levels of stress many people face every day.
4. Environment and Habits
Although things going on inside your own body are the biggest contributors to acne, external factors like pollution, heat and humidity, and even the products you use can trigger a breakout.
Strong pollutants can cause a rare form of acne called “chloracne,” which is characterized by common acne-like eruptions of blackheads, whiteheads, pustules, and cysts.
The products you use can also play a role. Certain health and beauty products, like makeup, shampoos, pomades, or hair gels and sprays can contribute to blocking pores, leading to acne breakouts on the forehead and along the hairline. Acne that’s caused specifically by makeup is called acne cosmetic. (Look for products with “non-comedogenic” or “non-acneic” labeling to avoid increased risk of breakouts).
Prolonged sun exposure can also have a negative impact, as it increases the rate of cell death and replacement, leading to excess dead skin cells plugging your pores.
A specific, almost exclusive, form of acne at the base of the hairline at the back of the neck of African Americans (usually males) is called Acne Keloidalis Nuchae. It is associated with hard, fixed papules at the base of the hairline that can be treated with similar treatments as most acne types, but can benefit from steroid injections to flatten papules and retinoids to prevent recurrence.
Lastly, acne is often aggravated by friction from hats or sports gear, which can trap bacteria, increase sweating, and inflame the skin.
5. Diet & Medications
Despite what you may have been taught as a teenager, diet is not a primary cause of acne. That said, there is a growing body of evidence to suggest that in some people, certain foods and medications may play a contributing role in the development of breakouts:
- Carbohydrates in sugary, starchy, or highly processed foods spike your blood sugar levels, and eventually lead to insulin resistance. Your skin's response to this is to increase production of a thick, sticky oil into your pores, which, of course, leads to a breakout.
- Antibiotics and hormones found in dairy products and meat might also add to acne in some people who are especially sensitive to them.
- High iodine levels found in seafood, seaweed, and iodized salt has also been connected to breakouts.
- Medications that have side effects that can alter your body's chemistry or hormone levels can also cause acne breakouts. These include lithium, androgenic steroids, DHEA, progesterone-dominant birth control, and any medications containing bromides or iodides.
Top 10 Acne Myths
There's a lot of information out there regarding acne, but much of it isn't very good. Before you start your search for a treatment, it's best to separate the myths from the facts. These are the top 10 most common misconceptions about acne, any why they're nothing more than myths:
1. Only teens get acne.
Since around 90% of teenagers develop acne, it can seem like it's a burden they alone must bear. But in reality, adult acne is quite common, with up to 30-50% of adults experiencing it in some form.
2. It's okay to pop your pimples.
As tempting and satisfying as it may be, it's never a good idea to pop your pimples. The most common idea behind this myth is that popping releases the bacteria from the follicle, allowing the pimple to heal.
Unfortunately, this is simply wrong, on many different levels. First and foremost, squeezing can actually drive the bacteria deeper into the follicle, and since it's so abundant and microscopic, some will always be left behind. Secondly, popping can cause unnecessary damage and lead to scarring.
While there is a right way to pop a pimple to minimize scarring and inflammation, even the most skilled at the task can do it wrong. For that reason, it’s better to just leave your pimples alone.
3. The sun can clear up acne.
As far as acne goes, the sun is not your friend. It might feel like it's helping to dry out your skin, or covering up breakouts and redness with a nice tan, but it's only an illusion. In fact, the sun may be helping your acne spread by adding inflammation to the surrounding tissues.
What's more, some acne medications, like benzoyl peroxide, retinoids, salicylic acid and doxycycline, can make you more susceptible to the sun's damaging effects – increasing your risk of sun burns (and ultimately increasing your risk of skin cancer).
4. Acne can be cured.
Unfortunately, acne is a chronic condition that can't be cured. Since it can last between 6 and 7 years in teens, and sometimes over 20 years in adults, it's considered a “condition,” which means it's a continuous, on-going issue. However, it can be controlled.
5. Pimples appear overnight.
Some mornings it might seem like an irritatingly large pimple has developed overnight, right in time for that big event. But while it might have come to the surface while you slumbered, it was formed by a process that took weeks.
6. You can “spot treat” pimples to clear up acne.
Acne is a chronic condition, and pimples are the result. Treating one pimple at a time takes care of the inflammation and discomfort of each pimple, but it will not do anything to prevent future breakouts from happening.
7. Pores open and close.
We've all heard this at one time or another: cold water “closes” pores, while hot water or steam “opens” them. This idea is just plain wrong. Your pores, those tiny little holes all over your skin, don't have muscles so they can't open and close.
However, there are certain things that can make them seem smaller. Oily pores appear larger, and steam can help loosen the excess sebum that builds up, allowing it to leave the pores more easily. Exfoliating scrubs loosen dead skin and help lessen the “crater-like” shape that builds up around a pore. Even just simply washing your face can remove dead skin cells and leftover makeup that gets stuck in your pores.
The key is to keep your pores clean if you don’t want them to look bigger.
People with fairer skin tend to have less visible pores, while those with darker, oilier skin usually have more prominent pores. Age can also change the appearance of your pores. Over the years your skin starts to lose collagen, which gives it its elasticity, causing your pores to slacken and stretch. But remember -- they do not open or close.
8. Acne is caused by dirty skin.
Acne isn't caused by dirt or uncleanliness. Period. The bacteria that causes acne is naturally found in and on your skin, and grows in number as it feeds on extra sebum.
Simply washing your face twice a day should be enough to keep the bacteria in check, remove extra surface oils, and get rid of any loose dead skin cells still hanging around.
9. All exfoliators are the same.
As a matter of fact, exfoliators are all very different, and knowing the differences is extremely important.
A physical exfoliator, commonly called a “scrub,” uses a physical grit to remove dead cells from your skin. Chemical exfoliators, like glycolic acid and salicylic acid, create a reaction in the skin that causes dead cells to be shed. Always be sure of the percentages and strengths of these solutions, as incorrect use can be very irritating and/or drying.
10. Greasy foods cause acne.
Probably the longest running and most known acne myth is that greasy foods, like french fries, chocolate, or pizza can clog up your pores. This has been clinically proven as untrue. It doesn't make any sense once you think about it: how can oil in the food you eat make its way from your intestines to your pores?
That being said, what you eat can have an impact on your skin. There has been some research that links processed foods, and simple sugars and carbohydrates, likes bread and chips, to breakouts. Similarly, foods that contain hormones and antibiotics, like dairy (for example soy-based foods) and some meats, can trigger breakouts in certain people.
Similarly, foods with high levels of iodine, like seafood or iodized salt, can increase breakouts in light of their impact on hormones.
Acne and Depression
For decades acne has been seen as a rite of passage into adulthood. But unfortunately, our society places a lot of value on appearances, and isn't very tolerant of skin imperfections and blemishes.
As such, even mild acne can have a number of negative emotional consequences, including:
- Social withdrawal
- Decreased self-esteem
- Decreased self-confidence
- Poor body image
- Negative impact on academic or professional performance
What Are the Best Over-the-Counter Acne Products?
When considering acne treatments, most people's first stop is the drug store. There are a huge variety of over-the-counter (OTC) acne products available, including cleansing lotions, gels, foams, towelettes, leave-on products, treatments, and kits, most of which are fairly effective at combating mild to moderate acne.
These products work in a few different ways. Some OTC acne treatments work by killing the excess bacteria that cause inflammation, others remove extra oil from the skin, or speed up the growth of new skin cells while removing dead cells. Others combine all these techniques.
A 2013 study on acne vulgaris found that in most cases, a multidimensional approach to acne is necessary because most people have a combination of symptoms. Look for these 4 common active ingredients in OTC acne products.
1. Benzoyl Peroxide
This ingredient is found in a huge variety of washes and scrubs, and works by killing the bacteria that causes acne, helps remove excess oil from the skin, and gets rid of dead skin cells. OTC benzoyl peroxide products come in a range of strengths, from 2.5 to 10%. This option is best for mild to moderate acne, but it can be combined with other treatments for more severe cases.
While this option is very good at reducing the number and severity of acne blemishes, it can also lead to irritated skin, dryness, or peeling. This chemical is also often used to bleach hair, so be sure to keep it away from your hair and clothing.
2. Salicylic Acid
This OTC treatment (a Beta Hydroxy Acid) option works to remove the outer layer of skin by causing the cells to shed more readily, opening clogged pores, and killing the bacteria inside. This helps prevent your pores from clogging and allows more room for new, healthy cell growth, as well as strong anti-inflammatory effects.
Salicylic acid is usually found in wipes or towelettes. High concentrations of the chemical can lead to a darkening of the skin in people with darker skin types, unless properly applied or prescribed by the appropriate and well-trained provider. This acid is one of the most commonly found in chemical peels which aid in reducing pore size, evening out skin tone/texture, and correcting dark marks and subtle acne scars.
3. Alpha Hydroxy Acids
There are two types of alpha hydroxy acids (AHA’s) used in OTC products and/or chemical peels: glycolic acid and lactic acid. Each of these chemicals treat acne by helping your body remove dead skin cells and reducing inflammation. This treatment has the additional bonus of encouraging the growth of healthy, smoother skin, which in turn improves acne scars and makes pores look smaller.
On the other hand, common side effects include mild skin irritation, redness and flaking, and less commonly blistering, burning, or skin discoloration if the concentration is too high, though these are usually mild and fade after a day or two. If the AHA’s are applied properly by a trained professional, be sure to ask about what to expect during/after the application of these acids either through washes, creams, or peels.
Usually found combined with benzoyl peroxide or salicylic acid, sulfur removes dead skin cells and helps wash away excess oil. Sulfur is found in a wide variety of OTC products, from washes and scrubs to peels. Bear in mind sulfur can cause dry skin, and these products might have an unpleasant smell.
What Prescription Acne Medications Work Best?
If your acne doesn't begin to improve after a few weeks of drugstore treatments, it might be time to visit your dermatologist. There are a wide variety of prescriptions available for all acne types, ranging from simple topical regimens to oral medications that must be taken several times a day.
These make up the majority of prescription acne medications, and are usually applied directly to the areas of the breakouts. There are many options to choose from, but the most common and effective treatments include topical antibiotics like clindamycin, anti-inflammatories like benzoyl peroxide, and the all-powerful comedone-fighting/anti-aging retinoids.
Prescription strength topical medications include:
Dapsone is a topical gel used to treat acne, although its action is not well understood. It is believed that it works to stop the bacterial growth that causes acne, as well as fighting against many of the acids that lead to acne synthesis.
Available only by prescription in 5% and 7.5% strength, a brand name for this drug is “Aczone.” This drug has been found to be quite effective, bringing “clinically meaningful” improvements to acne blemishes after 12 weeks.
More recent data from the newly released 7.5% formulation also suggests its improvement of dark marks associated after active acne marks begin to heal. The most common side effects, although the medication is fairly well tolerated by even the most sensitive of skin types, are dryness, oily skin, peeling, redness.
Rarely, the topical application can be associated with methemoglobinemia, and is used with caution in individuals with a G6PD deficiency.
Retinoids make up a general category for any and all forms of vitamin A, and despite their still unproven method of action, it is known that retinoids enhance epithelial cell turnover. Essentially, this means that it exfoliates your skin from the inside-out.
Retinoids improve how your skin cells are shed, while also unclogging pores and significantly reducing inflammation. Prescription tretinoin include name brands like Retin-A, Avita, and Atralin, vitamin A derivatives like tazarotene (brand names Tazorac and Avage), and adapalene (brand name Differin).
Side effects of retinoids include dry skin and increased sun sensitivity. Be sure to follow proper sunscreen/block protocol as advised by your provider before going on your Caribbean vacation.
In 15-20% concentration, Azelaic acid works against acne-causing bacteria while also carrying an anti-inflammatory one-two punch. Used in topical gels and foams, this naturally occurring acid is found in whole grain cereals and animal products. It is sold under the brand names “Azelex” and “Finacea”.
Side effects associated with Azelaic acid are short term, and in rare cases can include discomfort like burning, tingling, stinging, dryness, or redness. Some studies have supported Azelaic Acid as improving rosacea-type acne by reducing redness and papules.
Used somewhat less frequently than topical treatments, the most common oral prescription medications for acne are antibiotics, spironolactone, isotretinoin (Accutane), and some types of birth control pills.
Oral antibiotics are usually extremely effective treatments, but they also carry a risk of some more serious side effects than topical treatments.
Basically, oral antibiotics kill the bad bacteria that contribute to acne, but they also kill much of the good bacteria that your body relies on. That means that prolonged, continued use can lead to chronic vaginal yeast infections and stomach issues.
There is also the risk that the acne-causing bacteria will become immune or resistant to the antibiotics. If you use an oral antibiotic for more than 6 months, which you're almost certain to do, it will slowly lose its effectiveness, but the negative side effects will continue.
However, the immediate benefits for severe acne with scarring that may be apparent on a visit with a healthcare provider could warrant the use of oral antibiotics like doxycycline.
It is important to keep in mind that in extremely low doses of doxycycline, the profile of the antibiotic changes. In low doses, the “antibiotic” has less anti-bacterial power and more “anti-inflammatory” power, essentially keeping it at a “sub-microbial” profile so that it can be used long term without adding to the conundrum of antibiotic resistance.
The medication itself is unique and intriguing: in low doses (like 50-150mg daily) doxycycline can reduce inflammation, while in high doses (like 100mg twice daily) it can treat pneumonia (a severe bacterial lung infection).
Minocycline is also used as an oral antibiotic/anti-inflammatory to treat acne with typically more tolerable gastric side effects than doxycycline.
Certain types of birth control (oral contraceptive) pills have been shown to be effective at reducing acne blemishes and overall oil production. However, there is no guarantee of acne reduction with this approach. In fact, it’s possible that instead of improving acne, oral contraceptive pills will actually worsen acne.
Birth control pills are generally a combination of a variety of synthetic female hormones, some of which block the male hormones that promote oil production in the skin. Therefore, only birth control pills that block male hormones have been approved by the FDA for acne treatment, including brand names like Ortho Tri-Cyclen, YAZ, and Estrostep.
Hormonal birth control may cause the following side effects:
- Weight gain
- Mood swings
- Decreased libido
- Breast tenderness
- Intermenstrual spotting
- Missed periods
- Vaginal discharge
Isotretinoin is an oral prescription derivative of vitamin A. Originally tested as a chemotherapeutic drug, Isotretinoin earned a new place in the dermatologic market when in 1979 it was discovered to have a dramatic and permanent effect on all acne symptoms.
The medication was first approved by the FDA in 1982 and to date, its efficacy has not been superseded by any other treatment that produces long-term remission and/or substantial improvement in a majority of acne sufferers.
Normally, a course lasts for 15 to 20 weeks, or at a lower dose for six months or longer. It was originally reserved only for the most extreme acne, but with better understanding of the medication, healthcare providers have begun prescribing it more often and for less severe cases.
Some providers are more comfortable prescribing the medication over others, which is typically based on their experiences with patients (or their lack of experience).
It's not known exactly how Isotretinoin works, but it does impact how acne develops in four distinct ways:
- Isotretinoin “shrinks” the skin's oil glands and reduces the amount of oil they produce. More clinically described, isotretinoin leads to a process called “apoptosis” (destruction) of the sebocytes (oil producing cells), which in turn reduces the oil production.
- The oil reduction therefore reduces the number of P. acnes bacteria living in the follicles. More specifically, the actual size of the oil producing units at the follicles (which turn into pimples) is dramatically reduced and therefore makes the environment for the common acne-causing bacteria undesirable.
- It slows down the creation of new skin cells within the pores, helping to prevent clogging in the first place. In medical terms, this is known as decreased hyperkeratinization. Skin cells that slough off are decreased, therefore reducing comedogenesis.
- Isotretinoin is a strong anti-inflammatory, with the ability to increase one’s defense mechanisms and lower the bacterial population, which in turn decreases inflammation of the skin.
Around 30% of Isotretinoin patients can encounter a few weeks of worsened acne, as their bodies becomes used to the medication, but the final results are usually quite dramatic.
In fact, 95% of patients who complete an Isotretinoin cycle see a partial or complete improvement of their acne. That said, a high percentage of people who use this acne treatment unfortunately experience long-term relapses of their symptoms as well.
Studies have shown relapse rates from 14% to 52%, with a real-world average of about 1/3 of all patients experiencing some sort of relapse. This often results in a second course. These relapses seem to be dose dependent, with lower doses resulting in more frequent relapses.
Doses of isotretinoin are generally based on weight, with 0.5mg-2mg/kg/day of body weight being the typical guideline (refer to your healthcare provider for their dosing recommendations and schedule). The best results are reached when a cumulative dose of 100-120mg/kg is reached. Most doctors will prescribe high doses of at least 1mg/kg per day for a fairly short period of 15 to 20 weeks.
Because the number of people who suffer from the medication's side effects can be high, some healthcare providers have recently begun testing lower doses for longer stretches of time. The initial results of this experimentation have shown that patients with mild to moderate acne are able to achieve long-term results with fewer side effects, including scarring, with a lower dose. Similar results have been seen with people suffering from severe cases as well.
If you are prescribed Isotretinoin by your doctor or dermatologist, you'll need to keep in mind that the price will depend on a number of factors, including where you buy your medication. Commercial insurance can lend itself to little or no out of pocket cost, while out of pocket costs can exceed $100/month, not including required office visits or bloodwork monitoring.
Accutane: Risks and Side Effects
Clearly, Isotretinoin is exceptionally effective. The problem, however, lies in its numerous and widespread side effects. As a systemic medication, Isotretinion can impact the entire body and most patients will experience at least some side effects.
These negative effects are almost entirely temporary and typically abate after discontinuation of the medication.
Most common side effects include:
- Dry lips, skin, eyes, nasal mucosa (occasional nose bleeds)
- Rash, likened to eczema, or an activation of previously remiss eczema
- Increased sun sensitivity
- Mild to moderate joint pain
Severe, rare side effects include the following:
- Hair loss (or growth in atypical areas, especially in women)
- Neurological symptoms like headache
- Vision problems (associated with decreased night vision)
- Hearing impairment
- Yellowish deposits on the eyelids
- Bleeding & inflammation of the gums
- Oozing, bleeding bumps
- Severe joint pain
- Acute, long lasting arthritis
- Muscle pain
- Abnormal blood tests
- Low blood platelet count
- Iron deficiency anemia
- Low white blood cell count
- Inflamed pancreas
- Inflammatory bowel disease/Crohn's disease/Ulcerative colitis
- Abnormal menstrual cycles in women
Pregnancy & Isotretinoin
In addition to the side effects for the patient, there are serious risks to your fetus if you're pregnant. A “teratogen” is a medication that disrupts the normal development of a fetus in the womb, causing birth defects; isotretinoin is considered a “category X” in terms of pregnancy risk, which equates to known fetal demise or severe, well-documented birth defects in human documented subjects.
Shortly after Isotretinoin became available, the Centers for Disease Control (CDC) warned that a large portion of pregnant women who took the medication suffered from spontaneous abortions and birth defects, leading to:
- Abnormal development of the skull, ears, eyes and/or face
- Central nervous system and cardiovascular system abnormalities
- Thymus and parathyroid abnormalities
The risk of fetal issues is so great that the FDA created the “iPledge program,” which requires women of childbearing age to commit to using two forms of birth control while on Isotretinoin. Let’s keep in mind that the majority of females that suffer from acne are of child-bearing age and the regulations are meant to protect the patient and their offspring.
Exceptions to the iPledge Program include those women who are no longer able to get pregnant (post-tubal ligation, post-hysterectomy, etc.) and in some cases those who are abstinent. With recent transgender focus in medicine, the ability to get pregnant is of most vital importance to the program and whether the patient is born male or female, if the patient is clinically able to get pregnant, they must comply to the regulations of the program accordingly.
Cortisone Shots for Acne
Cortisone, a corticosteroid, is a chemical that is naturally produced inside your body to help fight off inflammation. Ideal for treating large acne cysts and nodules, the chemical, usually a drug called triamcinolone, is injected directly into the acne lesion to reduce swelling.
How It Works
Generally considered a last resort for most patients, triamcinolone (brand name “Kenalog”) is injected directly into the cyst or nodule. The extreme anti-inflammatory properties of the chemical begin working on the pimple immediately, reducing redness and swelling. The results are so fast and complete that most cysts and nodules disappear within 24 hours.
Risks & Side Effects
Since cortisone is a naturally occurring chemical found in your body, the side effects are few, mild, and short lived. The most common is atrophy of the fatty tissues around the injection, leading to a dimple. This is temporary, but it can take a few months to return to normal.
Other side effects include mild, temporary pain and lightening of the skin at the injection site in darker skinned patients. Lightening of the skin is also temporary and resolves within days to months (longer duration of lightening is associated with joint injections of steroids, for example osteoarthritis of the knee or bursitis of the hip).
What It Costs
If this seems like a viable solution to your acne problem, call your healthcare provider or dermatologist to set up an appointment. With health insurance, steroid injections are typically covered, but co-insurance or deductibles may play a role in a possible out of pocket cost after your visit.
If you are uninsured, the costs of injections can vary from $50-200+. A responsible healthcare provider will likely recommend maintenance therapies that work with you and your specific needs during your visit, and not just offer a solitary visit with a steroid injection.
Is Light Therapy An Effective Acne Treatment?
Intense Pulsed Light (IPL) -- also known as photofacials -- can be used to treat a wide variety of skin conditions, including both acne and acne scarring. Photofacial rejuvenation treatments are usually painless and significantly improve the appearance of your skin.
How It Works
IPL photofacials that are specifically designed to target acne use short pulses of yellow, green, and red light. This broad-spectrum light penetrates through several layers of skin to reach the acne blemishes. The yellow and green lights kill the P. acnes bacteria, and the red light targets the overactive sebaceous glands that are producing too much oil, shrinking them. The light also has the added benefit of stimulating collagen production in the area, which reduces scarring.
An effective treatment for all types of acne -- especially cysts -- the procedure is short and painless, with greatest success and fewer side effects occurring in patients with lighter skin.
The entire procedure lasts about 15 to 20 minutes. Usually 3 to 5 treatments are required, spaced out over a few weeks. In the time after your session, your skin will slowly rebuild itself and you’ll notice a gradual improvement.
Risks & Side Effects
Most risks associated with photofacials are short and temporary, including very minor swelling, redness, and visible capillaries. These usually fade within hours. In rare cases blistering, bleeding, and scarring have also been reported, along with both darkening and lightening of the skin.
What It Costs
Used by general medical practitioners, cosmetic surgeons, dermatologists, and aesthetic laser technicians, photofacial treatments are fairly common. However, despite their widespread availability, they remain more expensive than some other options, with an average price tag of about $500 to $600 per session.
Medical grade home versions of this treatment also exist, like the Quasar Baby Blue, which costs about $350, and the Project E Beauty LED 3 Colors Photo-rejuvenation Kit, which costs about $50-$60.
What Is Photodynamic Therapy for Acne?
Designed to fight resistant, hard to treat, active acne, photodynamic therapy (PDT) is another light-based treatment. It's a fast and effective way to clear the skin, stop future breakouts, reduce existing scars, and prevent future scars from forming.
How It Works
A special light-activated solution, usually either a 20% solution of Levulan (5-aminolevulinic acid, or ALA) or a 20% solution of methyl aminolevulinate (MAL), is applied to the target area under a dressing for up to 3 hours. This allows it to be absorbed into the skin and the sebaceous oil glands.
Next, red and/or blue light is directed towards the skin in a session lasting about 15-20 minutes. This light “turns on” the solution, which kills the acne-causing bacteria, and shrinks the oil glands. This is usually done 3 to 5 times, at 2 to 4 week intervals.
Unlike photofacial treatments, photodynamic therapy can be quite painful, causing the skin to be extremely sensitive to light. You'll need to stay indoors, completely out of sunlight and even bright indoor light for two days. For this reason, this treatment is used on moderate to severe acne cases.
That said, most patients see a 75% reduction in inflammatory acne after 3 treatments, and results are semi-permanent. Because the procedure is fairly new, it's hard to know how long the results last, but some doctors have reported 1 to 2 years of reduced symptoms.
Risks & Side Effects
The potential long term side effects of PDT are not yet fully understood. Some of the short-term side effects that have been observed include:
- Peeling and/or crusting for a week or so
- Occasional skin darkening lasting for about a month
- Extreme skin photosensitivity
- Short-term, transient acne breakouts
What It Costs
If you're interested in photodynamic therapy to treat your acne, contact your dermatologist. Generally, this therapy is not covered by insurance, and can cost upwards of $400 per treatment.
What Is the Difference Between Light and Laser Treatments?
Working on a similar premise as light-based acne therapies, laser treatments kill the acne causing bacteria found within the follicles. This treatment is most effective against papules and pustules, as well as acne scars, but doesn't seem to work nearly as well for whiteheads, blackheads, and the more severe cysts and nodules. Like other light options, you'll likely need 3 or more treatments, spaced about a month apart.
How It Works
Similarly to light-assisted techniques, the intense beam of the “fractional laser skin treatment,” commonly known by the name brand “Fraxel”, penetrates the layers of skin to reach the acne-causing bacteria where it lives. The focused energy of the laser not only kills the bacteria, it also helps to smooth out the skin, helping to repair old scars, while preventing new ones from forming.
The biggest difference between light therapy and laser therapy is their method of action: light therapy uses multiple wavelengths of light, whereas lasers use a single wavelength of light. For example, depending on the Fraxel laser type used, it can use a wavelength of 1550nm (nm = nanometers) with the Fraxel Re:Store erbium laser, or a 10,600nm wavelength with the Fraxel Re:Pair carbon dioxide laser.
There's some debate on the usefulness of this technique, however. Studies looking into its effectiveness suffer from small sample sizes, use different devices, don't follow up with patients, and don't use any controls.
The general consensus is that the results should be short term because bacteria tends to grow back quickly. Furthermore, the overall effectiveness of the treatment is fairly unpredictable, clearing anywhere from only 36% to as much as 83% of acne lesions.
It should also be noted that laser treatments are more commonly used to reduce the appearance of fine lines, wrinkles and sun spots.
Risks & Side Effects
Pain or discomfort is fairly common during the procedure, but side effects are usually mild and temporary. Depending on the particular laser used they can include:
- Skin peeling
- Occasional blistering and/or crusting
What It Costs
Laser therapy is usually performed by cosmetic surgeons, dermatologists, and aesthetic laser technicians, and costs around $200-$500 per session.
Chemical Peels for Acne
Containing a special acid (or acids), and applied to the skin every two to four weeks, chemical peels can be administered by healthcare providers and medical aestheticians in strengths of up to 70%, and work best for people with superficial acne or acne scars.
Although the exact mechanism is still up for debate, what we do know is that they work to chemically exfoliate your skin, speeding up skin cell turnover, and preventing your pores from getting clogged.
How It Works
Chemical peels work by exfoliating the outer layers of skin. This exfoliating action causes the skin cells to reproduce more quickly, while helping to remove the extra dead cells that lead to clogged pores, shrink those pores, and aid in reducing red/dark marks from previous acne breakouts.
Most patients show about 45-50% reduction in their acne blemishes after a series of 4 to 6 peels, reporting “fair” to “good” results. However, these results are temporary, lasting only about a month or two before acne symptoms reappear.
Risks & Side Effects
The most common side effect is a sun burnt appearance, with various degrees of peeling after the treatment. The intensity of the peeling usually improves after each session, assuming that the strength of the peel remains unchanged. Your provider may decide to adjust or increase the concentration of the peel’s strength at each subsequent visit.
Chemical peels can also remove the outermost protective layer of your skin leaving you much more sensitive to sunlight and UV rays.
Depending on the depth of the peel (superficial, medium, or deep), the risks of post-procedural discomfort, side effects, and the “amount” of peeling vary tremendously. Temporary skin darkening has been reported, which is more common in people with darker skin and those who are prone to keloid scarring. Darkening of the skin and increased sun sensitivity can be prevented or protected through the use of proper sunscreen.
What It Costs
Most doctors and dermatologists offer this treatment, as well as spas, and costs usually run about $100 to $500 per peel, depending on the type, strength, and where is it administered.
Like some other treatments, “at-home” options are available, like Vichy's Double Glow Peel Mask (about $35), and REN's Glycol Lactic Radiance Renewal Mask (about $70). However, it's important to keep in mind that any over-the-counter peels will be much more mild than something you can get from a healthcare provider’s office.
Types of Acne Scars
Scars are usually a result of one of the more severe, inflamed categories of acne, namely papules, pustules, and cysts. As the pore swells due to excess oil, bacteria, and dead skin cells, it can cause a break in the follicle wall. If this happens near the surface of the skin, it's usually mild and heals quickly.
On the other hand, if it happens deeper in the skin layer, the infected tissue can spill out of the follicle and into the surrounding skin, destroying healthy cells. To repair the damage your skin starts to form new collagen fibers. Unfortunately, for many people, the finished “repair” work the skin never looks as smooth and flawless as it was before the breakout.
There are a number of different kinds of scars that can result from acne. They include:
- Atrophic scars are the most common, and are depressed areas that develop where there is a loss of tissue.
- Ice pick scars are long, narrow scars that extend deep into the skin (typically the hardest to treat).
- Boxcar scars are round or oval depressions, giving the skin a pitted look.
- Rolling scars are fairly broad depressions with rounded, sloping edges. These tend to appear in groups, giving the skin a rolling appearance.
- Hypertrophic scars are a result of the body producing too much collagen, which creates a visible, raised scar.
- Keloid scars, or keloids, are similar to hypertrophic scars. The difference is that scar tissue not only expands upward from the surface of the surrounding unaffected skin, but also outward, beyond the borders of the original wound in a “mushroom” like expansion from its original site. This outward expansion can vary greatly and can take weeks to months to form.
Hyperpigmentation commonly refers to the red or dark spots that are often left behind after a pimple heals, but a more clinical term is post-inflammatory hyperpigmentation (PIH). These marks aren't technically scars, but a discoloration from the prior breakout. Hyperpigmentation can be temporary or permanent.
The best way to reduce hyperpigmentation is to keep newly formed scars covered up from the sun for at least a year. UV exposure can permanently darken scar tissue, however various topical therapies and cosmetic interventions can diminish even some of the most recalcitrant and long-standing hyperpigmentation marks.
The opposite of hyperpigmentation is hypopigmentation, in which a scar lacks natural skin pigment (melanin). This can also be temporary or permanent.
Acne Scar Treatments
Acne itself often has a profoundly negative impact on a person's feelings about themselves and their appearance, and it's not hard to imagine how permanent scarring after acne can have an effect on a person's life. Confidence suffers, anxiety increases, and unfortunately, the vicious cycle of added stress caused by acne can increase the amount of acne itself.
Acne scars can be extremely stubborn, and there is no single treatment that is best for everyone. A few different treatments, or even a combination of them might have the best results to improve tone and texture.
These are the 8 main types of acne scar treatments:
1. Home Skin Care Products
Hyperpigmentation and irregularities in skin tone caused by acne scars can often be treated with over-the-counter bleaching products (like Hydroquinone) and sunscreen to limit contrast. Unless it causes irritation, you'll need to use the product often. Even if used daily, it may take 6 months to see a difference.
This is the least invasive and cheapest option, but keep in mind that skin bleaching products can be irritating. Prices range from $10 to over $100.
2. Soft Tissue Fillers
Another option is the injection of hyaluronic acid, polymethylmethacrylate (PMMA), collagen, or fat under the skin, into the indentations made by atrophic scars.
Typically, providers have their preference for different fillers based on their experience and your specific condition. Results from this method are good, but are often temporary, lasting from 6 months to 2 years. It is less invasive than other methods, and usually costs between several hundred dollars to thousands.
3. Laser Resurfacing
Cosmetic laser resurfacing uses a laser to break up the molecular bonds of damaged skin cells, layer by layer, until a smoother, more uniform look is created. This technique can be more invasive than others, and some healthcare providers even consider it a surgery.
Recovery time varies, but is typically about two weeks, during which your new skin slowly appears as it heals from the procedure. Results are generally quite good, but burning, scarring, and skin discoloration have been reported in certain cases. Costs vary, but are usually around $1,000-$3,000 per session, and multiple sessions are usually required.
4. Other Energy-Based Options
Pulsed light sources and radiofrequency devices can also disrupt the scar tissue, making it less noticeable over time. Results from any of these devices tends to be subtle, and often need to be repeated.
Radiofrequency in combination with micro-needling is a newer approach to various atrophic acne scars that has variable results, depending on the device and provider administering the treatment. Professional costs are usually several hundred to several thousand dollars, with several visits often required. Home devices exist, but have less consistent or compelling results.
Used for variable depths of atrophic acne scars, your healthcare provider essentially removes the outer layer of skin with a high speed rotating brush. Surface scars are often completely removed, and deeper scars can become much less noticeable. These results can be long lasting, but you will likely need a few days to recover.
Temporary side effects may include redness, swelling, an acne flare-up, and infection. The average cost for this procedure is varies between several hundred to several thousand dollars, depending on the depth of the procedure and the individual performing the procedure.
6. Chemical Peels
This option is essentially the same as the chemical peel option for treating the acne itself. Once applied to the skin, the chemical solution causes the skin to blister and peel for a few days. As this skin comes off, fresh, new skin replaces it, reducing the appearance of scars.
Side effects are common and are a result of the chemical irritant: redness, swelling, and peeling. Professionally applied peels range from about $200 to $900. Less effective, but also less expensive, OTC versions run along the $100 range.
7. Needling or Rolling
Acne scar microneedling can be done at home, but is more effective when performed by a professional. The needling device looks a bit like a razor, but with a small rolling tool covered in tiny needles at the end instead of a blade.
The device is rolled across the skin, over your scars. This action pricks the skin beneath the surface, causing minor trauma that your body will rush to repair with collagen, fixing your scars in the process. The treatment is slow, usually taking months, but with persistence results can be impressive.
8. Punch Excision Surgery
In extreme (and rare) cases, especially for the deepest scars, your doctor, dermatologist, or cosmetic surgeon may use a minor surgery called a “punch excision” to treat an acne scar. Individual acne scars are cut out, repairing the wound with either stitches or a skin graft.
Recovery time depends on the method performed and wound closure used. This method will likely still leave a scar, but it will be a lot smaller and less noticeable. Pricing depends on the extent of the scars.
Frequently Asked Questions
How long should I use an over-the-counter acne treatment?
You should always give any new skin care regimen at least 6 to 8 weeks before deciding on how well it's worked for you. Skin turnover occurs gradually over the course of 28-30 days (much like a female menstrual cycle) – not obviously shedding all at once like a salamander – which in turn requires that more than 4 weeks should be allotted before determining a therapy failure. This doesn’t just refer to OTC acne solutions, but in-office treatments and medications as well.
I've heard I can use toothpaste to dry up a pimple. Is that true?
Using toothpaste will not only dry out the pimple, it will dry out and irritate your skin. And as discussed previously, dry/flaked skin only exacerbates acne by providing the clogging material that blocks pores. There are much better products available. Look for a gentle cleanser that is “non-comedogenic” and/or “non-acneic”.
Is there any treatment that will clear up acne immediately?
Unfortunately, no. Even the fastest therapies will take a few hours, and are only useful for spot treatment. See your doctor to get an idea of your best treatment options. You may be referred to a dermatologist.
How severe should my acne be before I see a doctor?
Everyone is different, and visiting a doctor is up to you. A good provider will be able to approach your concerns no matter what severity you present to them at the time of your visit. If you are feeling any kind of physical or emotional distress because of your acne, making an appointment earlier rather than later may be in your best physical (and mental) interest.
Are acne scar treatments covered by health insurance?
Under most circumstances, no. Generally, scar treatment is considered a cosmetic procedure and is therefore not covered under most plans. With that said, it's always best to call your provider and find out for sure from the source.
Can acne scarring be prevented?
Usually, yes. In most cases treating the acne itself early will keep all breakouts and healing under control, preventing the formation of scars. However, if your breakouts are severe and associated with painful cysts or nodules, you will be at a higher risk of developing atrophic and/or hyperpigmented scars.
At what age can acne scarring begin?
Because scar formation is a natural product of the healing process, scarring from acne can happen at any age.
Will my acne scars fade over time?
In some cases, yes, especially in the case of hyperpigmentation (dark or red marks), but in many others, the answer is unfortunately no. Depressed, atrophic scars tend to become more visible as we age. This is because as the skin begins to lose collagen, it starts to sag, making acne scars look more pronounced.
To many people, acne and the scars it causes are a source of anxiety and a major blow to self-confidence. Luckily, there are a number of acne treatments that range from simple over the counter topicals -- like benzoyl peroxide -- to more intensive clinical options -- like cortisone shots.
Those that are left with scars after acne also have multiple treatment options including punch excision surgery, chemical peels, and laser resurfacing.
It can be difficult to determine which treatment is right for you without the help of a dermatologist or other skin care expert. While one treatment may work wonders on one patient, it may leave another acne sufferer with little improvement.
Staying positive and seeking out professional help can make all the difference in your treatment journey.
Finding a Dermatologist
The first step in acne treatment are over-the-counter remedies, however, this is rarely sufficient for those who suffer from severe acne.
If, after a few weeks of over-the-counter treatment, you see little to no improvement, speak with a certified dermatologist who specializes in acne. Treating acne early is the best way to regain control of your skin and avoid scaring.
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- Tanghetti, E. A., Kawata, A. K., Daniels, S. R., Yeomans, K., Burk, C. T., & Callender, V. D. (2014). Understanding the burden of adult female acne. The Journal of clinical and aesthetic dermatology, 7(2), 22-30. ncbi.nlm.nih.gov/pmc/articles/PMC3935648
- The Influence of Genetics and Environmental Factors in the Pathogenesis of Acne: A Twin Study of Acne in Women (2002) ncbi.nlm.nih.gov/pubmed/12485434