The last stage in the development of acne is when the wall of the plugged follicle breaks down, spilling everything inside to nearby skin, causing inflammation that leads to the formation of a pimple. [27] Exactly what triggers this process, how fast a pimple develops, and why some pores are affected instead of others remains unknown.
Acne can show up on many areas of the body, including the face, neck, chest, back, shoulders, and arms. When a typical pimple (also called a pustule) forms, it can be one of several types of breakouts, as described below. [53]
Comedones: Comedones are considered non-inflammatory precursors to acne, but these lesions are not acne. In other words, comedones are evidence that conditions are present that could lead to acne breakouts. Comedones come in two forms, whiteheads (sometimes referred to as “closed comedones”) and blackheads (sometimes referred to as “open comedones” because you can see the pore opening).
When too much oil is produced in the pore it can mix with dead skin cells and cellular debris, causing it to get stuck and form a “plug.” This plug pushes to the surface and, if it’s covered by skin, it appears as a slightly raised, whitish, firm bump called a whitehead. These are not pimples.
If these plugs come to the surface and are not covered by skin, they are exposed to the air, which causes the plugs in the pore to oxidize, resulting in a black spot referred to as a blackhead. That dark spot is not dirt showing beneath the surface of the skin!
Papules: These are small, raised bumps that indicate inflammation is occurring in the hair follicles. Papules are unsightly, but typically not painful or sore.
Pustules: Larger than papules, these red, tender bumps have white pus at their tips and are a sign of more advanced, deeper inflammation. They can be painful.
Nodules: One of the most painful forms of acne, these bumps remain below the surface of the skin and are large and solid. They develop when buildup occurs deep within the hair follicles that are severely clogged.
Cysts: These are markedly painful, swollen, pus-filled lumps that form beneath the skin. They present increased risk of scarring due to their depth and collagen-destroying potential. These are also the type of breakout least likely to respond to topical treatments, especially traditional over-the-counter acne products.
Sebaceous filaments: If you look closely at the tip of your nose, you might see tiny dots that resemble blackheads. These marks may be blackheads if they are quite dark, but the dark “dot” you see when you look very closely is also the tip of the columnar structures that fill your pores. They’re known as sebaceous filaments, naturally occurring hair-like formations that channel the flow of oil along the lining of the pore in which they lie. [54] It’s a natural part of skin’s follicle (pore) structure that everyone has, but if your skin is oily or if your pores are large and prone to becoming clogged, you’re more likely to notice it. Removing these filaments manually is possible, but they return shortly, and truth be told, chances are no one besides you and your magnifying mirror notice them anyway. Nevertheless, if sebaceous filaments bother you, regular use of a BHA exfoliant can potentially make them less of a noticeable concern.
Why Does Acne Happen?
You might be wondering: Who gets acne? It’s estimated that 80% of all people between the ages of 11 and 30 will have acne breakouts at some point during this period of their lives, and it’s quite common for many women to have breakouts well into their 40s, 50s, and 60s. [53]
Believe it or not, as long as people have been struggling with acne and even though hundreds of studies have been done, the exact cause remains unknown. Researchers have narrowed it down to a group of several related factors. [27]
Hormonal activity. Androgens (male hormones) increase in both boys and girls at the onset of puberty, causing the body’s sebaceous (oil) glands to enlarge and produce more oil. Oil production can also increase during pregnancy, or with starting or stopping oral contraceptives. In women, it decreases during menopause. [55]
Medications. Medicines that contain or stimulate androgens, corticosteroids, and/or lithium can play a role in the development of acne.
Heredity. Researchers believe that good old genetics could have a hand in whether or not a person gets acne. [56] Thus, if your parents suffered from breakouts, you’re at greater risk of suffering from them, too.
In addition to the actual causes of acne, there are other factors that can make acne worse if you’re already prone to breakouts, such as those below. [27]
Hormonal changes that occur in girls or women two to seven days before the beginning of their menstrual cycle. It’s no surprise to women around the world that breakouts are quite typical during your period.
Breakouts and oily skin can also plague women going through perimenopause (the beginning phase of menopause that normally begins after a woman turns 40) and during menopause. What happens is that estrogen levels (estrogen is the “female” hormone) drop, but the androgen levels (the male hormone that women also have) remain constant. [55] Androgens are a primary trigger of acne and when you have more of them in your body without the estrogen to balance it, your skin can start acting like you have a teenager’s skin, and not in a good way. The extra androgens cause the oil glands to produce more oil, and a stickier oil to boot, that can clog pores. There’s also the issue of older women having excess skin cells due to accumulated sun damage which can also lead to clogged pores.
Sensitizing reactions to makeup, irritating skincare ingredients, specific foods (rarely), allergies, or medicines. Sometimes such reactions aren’t true acne, but rather what’s known as “irritant contact dermatitis.” The red bumps seen with this type of reaction can resemble acne and tend to happen quickly, while true acne develops over a longer period of time. [27,57]
Inflammation caused by conditions inside the pore or by outside influences, such as using products that contain irritating ingredients, trying to “dry” up a pimple, or over-scrubbing. Squeezing pimples doesn’t increase the incidence of acne, but when done incorrectly, it can further inflame the breakout, potentially push the contents deeper into the pore lining, and generally keep it around longer. [27]
Allergic reactions to foods such as milk and milk products, gluten, nuts, or fish can cause acne in some people, but there’s research showing that this may not be true. Nonetheless, if you want to see if certain foods are acne triggers for you, it’s easy enough to experiment to see how your skin reacts if you eliminate one or more of these from your diet for several weeks. [27]
We touched on this above but to elaborate a bit before moving on to the next section: Acne and its typical partners-in-crime whiteheads and blackheads aren’t the result of dirty skin. The black dots that comprise the tip of blackheads aren’t dirt; dead skin cells and oxidized oil make these plugs appear dark. You cannot wash or scrub acne, whiteheads, or blackheads away, so please ignore all products making such claims. In truth, finally getting your acne under control is far more involved than that.
Getting Acne Under Control Is the Same for Everyone
Although there really isn’t a cure for acne, there’s a lot you can do to greatly reduce the problem and get it under control. No matter what else you do, the most important thing to remember about acne is that it’s an inflammatory disorder, which means anything you can do to reduce or avoid inflammation is going to help keep breakouts, the swelling, and the telltale redness at bay.
We describe below key steps you can take to make sure acne doesn’t stick around for long.
Keep skin clean, but don’t overdo it. Clean skin is a good thing because washing removes the excess oil and dead skin cells that contribute to clogged pores and create conditions ripe for acne to occur. However, washing too often, especially if you use harsh cleansers or scrubs, will lead to irritation and chronic inflammation. (Remember, anything that causes inflammation will increase acne conditions