We've all found ourselves, standing in front of the mirror, wondering why there's a bunch of pimples looking back at us. My usual reaction is to wish I could turn back the clock and undo whatever evil I must have done to deserve this punishment! I guess it's a pretty common thought. Our hope is that you will learn a few tricks to help prevent the next batch!
If you've read our earlier post on The Structure of Your Skin, you might understand some of the details in this article better, otherwise dive in, you can always go back if you get confused!
Acne is probably the area of skincare that has the most persistent myths of all. According to the myths, acne is caused by 1) too much facial oil, 2) bad hygiene, 3) bad diet, 4) insufficient water consumption, 5) toxins being flushed out of your system or 6) makeup that doesn't allow your skin to breathe. In fact none of these are accurate!
Acne is an emotional subject for a lot of us, and I think that's partly why the myths endure. It may also be partly because the different causes (the whys) of acne are so varied. Let's talk more about all those different causes of acne later. I suggest we start with how acne happens.
All types of acne start with three things: 1) the buildup of dead skin cells in a hair follicle, 2) the Propionibacterium Acnes (aka P. Acnes) bacteria and 3) a blockage of air movement through the follicle opening.
One of the most common misconceptions is that the P. Acnes bacteria that cause acne are introduced to your skin by outside contact or lack of hygiene, but this is not true. Sebum, cellular debris and metabolic by-products from your skin are natural food sources for the P. Acnes bacteria. Because this is where their food can be found, this is where the bacteria naturally live. (I'm told they also live in your intestine, but that's not what we came here to talk about!)
P. Acnes are anaerobic, which means that exposure to air kills them. They can also be killed by UV radiation in sunlight. Because of this they live inside your hair follicles away from the surface of your skin. If a follicle becomes blocked, fresh air is excluded from the follicle. Without oxygen to keep the bacteria in check they multiply at an uncontrolled rate. This causes swelling of the follicle. Sometimes this results in acute inflammation and a buildup of pus, which generally tries to work it’s way to the surface of your skin, forming what we all recognize as a pimple.
We’ve talked about how the surface of your skin is made up of dead skin cells that protect you from the elements. This is also true within hair follicles. The outer layer of skin (aka epidermis) folds down and into each of your hair follicles. This means that the epidermal cells inside your follicles are in a constant process of dying off (keratinization) and being shed (desquamation). [see the diagram above]
The first stage of any pimple is a microcomedo. Inadequate shedding of skin cells within the follicle allows the dead cells to collect and clump. This slows the passage of sebum through the follicle forming a kind of “plug” called an impaction. In the diagram of the microcomedo below you can see the buildup of dead cells in the epidermis has thickened the follicle walls and caused an impaction within the follicle. All types of acne start with this initial stage.
In a blocked follicle, air is excluded and the bacteria start to proliferate. This state is called a comedone: if the opening of the follicle is closed it is known as a closed comedone (or whitehead), and if open it is known as an open comedone (or blackhead).
As you can see from the diagram the closed comedone is not yet inflamed, but impacted cells and bacterial proliferation cause a small white lump to appear below your skin’s surface. If you have ever extracted a whitehead, what comes out is often hard and a bit yellowish. It is not pus, but impacted skin cells and sebum.
In an open comedone the outermost sebum of the impaction is oxidized by contact with air and becomes dark, causing a small dark spot to appear on your skin. This is often thought to be dirt under the surface of the skin, but as you can see the source is native to your skin, not external.
It is common for people with oily skin who have not become interested in skincare to exhibit many tiny blackheads. This is not an issue of hygiene, as normal cleansing cannot break down the oxidized sebum effectively. In fact attempting to clear blackheads by using aggressive cleansers will usually overstrip your skin without removing the blackheads. The best way to treat microcomedones and comedones is to accelerate shedding of the skin cells within the hair follicle. This allows the dead cells and sebum to move through the follicle freely, avoiding blockages. We'll talk more about this later.
Sometimes a blocked follicle becomes so stretched that a rupture occurs in the follicle wall mixing bacteria and blood. Your immune system reacts to the presence of the bacteria by initiating an acute inflammatory response which floods the site with white blood cells to fight the infection by killing the bacteria. This is the root of inflammatory acne. [note the inflammatory route indicated in the diagram above] The bacteria are killed and the end result is pus, which generally make it’s way to the surface of your skin.
As you can see in the diagram, the most recognizable form of a pimple is called a pustule; the skin’s surface is pushed out into a red bulge with a white tip.
Where inflammation occurs deeper inside the skin a papule is formed. This is usually more painful because it is deeper, therefore nearer the nerve endings in your dermis. After some time the papule disappears naturally as your immune system slowly absorbs the defeated bacteria and pus. But because this all happens in the deeper dermis it is more likely to disrupt the neat organization of collagen deposited in the healing process, leaving a slight scar.
There are different reasons why you might be prone to acne. What they have in common is inadequate follicular desquamation (shedding of skin cells) - resulting in a tendency for your follicles to become blocked. Here are some of the many reasons you might be prone to acne.
Around 80% of teenagers experience some level of acne. Susceptibility to teen acne is inherited and the cause is primarily hormonal. Hormonal changes that happen during puberty cause 1) increased cellular turnover combined with inadequate follicular desquamation that cause a buildup of dead cells within the follicle and 2) increased sebum production during adolescence. This is known as Retention Hyperkeratosis. Together these factors cause numerous follicular blockages resulting in pimples.
It is very common for people to look at teen acne sufferers and assume that their acne is a result of inadequate hygiene. This is based on the fact that one of the three requirements for acne is the P. Acnes bacteria. But this chain of logic is not accurate because the primary cause of acne is really the buildup of dead cells within the follicle. Thorough cleansing with harsh treatments will not change the initiating factors, or the long term outcomes. Very severe teen acne may even require treatment by a medical professional who may prescribe drugs and antibiotics to resolve the problem.
Although teen acne is the most common form of inherited acne, it is also possible for persistent adult acne to be an inherited trait. Because of this, the only solution, like teen acne, is to develop a long-term strategy to effectively treat the symptoms. Unfortunately there is no way to remove the cause!
On the other hand adult acne can also be caused by changes in hormones that may occur during menopause, premenstrual drops in estrogen (which commonly causes acne specifically around the chin), periods of elevated stress, starting or stopping the use of birth control pills, and pregnancy. This type of acne is usually not severe, but can recur persistently, making it annoying for those it inflicts.
Acne can also be caused by follicle clogging (aka comedogenic) ingredients in makeup or skincare products. These ingredients accumulate very slowly inside follicles causing gradual blockages that typically occur over a period of 3-4 weeks. The solution is to avoid comedogenic ingredients. But because comedogenicity is a complex issue, it is hard to pinpoint which ingredients are clogging your pores without the help of a professional. It is a common misconception that pimples that appear overnight may be caused by comedogenic ingredients. Because of the slow nature of comedogenic buildup, this is highly unlikely.
Acne that appears overnight is generally caused by irritation of your skin. The root of the irritation may be as simple as dryness that compromises your natural barrier function, or irritation from a specific ingredient or substance that comes into contact with your skin. Whatever the cause, the irritation results in swelling of your skin, which closes the openings of your pores, allowing P. Acnes to proliferate. Overnight pimples can therefore be attributed to a very specific cause by working through a process of elimination. You could say that this form of acne is a symptom of sensitive skin. You should look for skincare and makeup designed for sensitive skin, to help avoid future outbreaks.
Successful treatment of all long-term forms of acne should be based on interrupting the process of buildup from microcomedone to pimple. To halt the progress of comedones, successful treatment must include effective follicular exfoliation of your entire face, not just spot treatment once you are aware of a pimple!
In order to do this you need a keratolytic exfoliator. A keratolytic exfoliator is weakly acidic, or has a keratolytic enzyme, and can dissolve the protein bonds between dead skin cells allowing their shedding to be accelerated.
Although alpha-hydroxy acids are keratolytic they are water soluble, making them immiscible with fatty substances, decreasing their penetration into follicles. Beta-hydroxy acid (aka salicylic acid) is fat soluble and better for this purpose which is why you'll notice it in many acne treatments. Specific enzymes like the pomegranate enzyme in our Alchemist exfoliator, can also break down impactions effectively.
Remember that for most types of acne you are treating an ongoing condition, not curing it, so ongoing, consistent prevention is the key!
As we've mentioned above, severe cases of acne are beyond the scope of skincare to bring under control. If you are unable to control your acne using skincare alone, we advise you to seek medical help via your general practitioner or a dermatologist.
THE ALCHEMIST - Pomegranate Enzyme Exfoliator - for all skin types
Thanks for reading!
ALEXIARES & ANI