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Acne

Overview

Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells. It often causes whiteheads, blackheads or pimples, and usually appears on the face, forehead, chest, upper back and shoulders. Acne is most common among teenagers, though it affects people of all ages.

Effective treatments are available, but acne can be persistent. The pimples and bumps heal slowly, and when one begins to go away, others seem to crop up.

Depending on its severity, acne can cause emotional distress and scar the skin. The earlier you start treatment, the lower your risk of such problems.

Symptoms

Acne signs and symptoms vary depending on the severity of your condition:

  • Whiteheads (closed plugged pores)
  • Blackheads (open plugged pores)
  • Small red, tender bumps (papules)
  • Pimples (pustules), which are papules with pus at their tips
  • Large, solid, painful lumps beneath the surface of the skin (nodules)
  • Painful, pus-filled lumps beneath the surface of the skin (cystic lesions)

When to see a doctor

If self-care remedies don't clear your acne, see your primary care doctor. He or she can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from a doctor who specializes in the skin (dermatologist).

For many women, acne can persist for decades, with flares common a week before menstruation. This type of acne tends to clear up without treatment in women who use contraceptives.

In older adults, a sudden onset of severe acne may signal an underlying disease requiring medical attention.

The Food and Drug Administration (FDA) warns that some popular nonprescription acne lotions, cleansers and other skin products can cause a serious reaction. This type of reaction is quite rare, so don't confuse it with the redness, irritation or itchiness where you've applied medications or products.

Seek emergency medical help if after using a skin product you experience:

  • Faintness
  • Difficulty breathing
  • Swelling of the eyes, face, lips or tongue
  • Tightness of the throat
Common acne

Acne occurs when the openings of hair follicles become clogged and blocked with oil secretions and dead skin cells. If the clogged pore becomes infected with bacteria, inflammation results.

Common acne

Acne occurs when the openings of hair follicles become clogged and blocked with oil secretions and dead skin cells. If the clogged pore becomes infected with bacteria, inflammation results.

Cystic acne

Cystic acne — the most severe form of acne — occurs when oil and dead skin cells build up deep within hair follicles. The resulting rupture within your skin may form boil-like infections.

Causes

Four main factors cause acne:

  • Excess oil production
  • Hair follicles clogged by oil and dead skin cells
  • Bacteria
  • Excess activity of a type of hormone (androgens)

Acne typically appears on your face, forehead, chest, upper back and shoulders because these areas of skin have the most oil (sebaceous) glands. Hair follicles are connected to oil glands.

The follicle wall may bulge and produce a whitehead. Or the plug may be open to the surface and darken, causing a blackhead. A blackhead may look like dirt stuck in pores. But actually the pore is congested with bacteria and oil, which turns brown when it's exposed to the air.

Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected with bacteria. Blockages and inflammation that develop deep inside hair follicles produce cystlike lumps beneath the surface of your skin. Other pores in your skin, which are the openings of the sweat glands, aren't usually involved in acne.

Factors that may worsen acne

These factors can trigger or aggravate acne:

  • Hormones. Androgens are hormones that increase in boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy and the use of oral contraceptives also can affect sebum production. And low amounts of androgens circulate in the blood of women and can worsen acne.
  • Certain medications. Examples include drugs containing corticosteroids, testosterone or lithium.
  • Diet. Studies indicate that certain dietary factors, including skim milk and carbohydrate-rich foods — such as bread, bagels and chips — may worsen acne. Chocolate has long been suspected of making acne worse. A small study of 14 men with acne showed that eating chocolate was related to a worsening of symptoms. Further study is needed to examine why this happens and whether people with acne would benefit from following specific dietary restrictions.
  • Stress. Stress can make acne worse.

Acne myths

These factors have little effect on acne:

  • Greasy foods. Eating greasy food has little to no effect on acne. Though working in a greasy area, such as a kitchen with fry vats, does because the oil can stick to the skin and block the hair follicles. This further irritates the skin or promotes acne.
  • Hygiene. Acne isn't caused by dirty skin. In fact, scrubbing the skin too hard or cleansing with harsh soaps or chemicals irritates the skin and can make acne worse.
  • Cosmetics. Cosmetics don't necessarily worsen acne, especially if you use oil-free makeup that doesn't clog pores (noncomedogenics) and remove makeup regularly. Nonoily cosmetics don't interfere with the effectiveness of acne drugs.
How acne develops

Acne develops when sebum — an oily substance that lubricates your hair and skin — and dead skin cells plug hair follicles. Bacteria can trigger inflammation and infection resulting in more severe acne.

Risk factors

Risk factors for acne include:

  • Age. People of all ages can get acne, but it's most common in teenagers.
  • Hormonal changes. Such changes are common in teenagers, women and girls, and people using certain medications, including those containing corticosteroids, androgens or lithium.
  • Family history. Genetics plays a role in acne. If both parents had acne, you're likely to develop it, too.
  • Greasy or oily substances. You may develop acne where your skin comes into contact with oily lotions and creams or with grease in a work area, such as a kitchen with fry vats.
  • Friction or pressure on your skin. This can be caused by items such as telephones, cellphones, helmets, tight collars and backpacks.
  • Stress. Stress doesn't cause acne, but if you have acne already, it may make it worse.

Treatment

If you've tried over-the-counter (nonprescription) acne products for several weeks and they haven't helped, your doctor can prescribe stronger medications. A dermatologist can help you:

  • Control your acne
  • Avoid scarring or other damage to your skin
  • Make scars less noticeable

Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection or reducing inflammation — which helps prevent scarring. With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely.

The treatment regimen your doctor recommends depends on your age, the type and severity of your acne, and what you are willing to commit to. For example, you may need to wash and apply medications to the affected skin twice a day for several weeks. Often topical medications and drugs you take by mouth (oral medication) are used in combination. Pregnant women will not be able to use oral prescription medications for acne.

Talk with your doctor about the risks and benefits of medications and other treatments you are considering.

Topical medications

The most common topical prescription medications for acne are as follows:

  • Retinoids and retinoid-like drugs. These come as creams, gels and lotions. Retinoid drugs are derived from vitamin A and include tretinoin (Avita, Retin-A, others), adapalene (Differin) and tazarotene (Tazorac, Avage). You apply this medication in the evening, beginning with three times a week, then daily as your skin becomes used to it. It works by preventing plugging of the hair follicles.
  • Antibiotics. These work by killing excess skin bacteria and reducing redness. For the first few months of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the morning and the retinoid in the evening. The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with benzoyl peroxide (Benzaclin, Duac, Acanya) and erythromycin with benzoyl peroxide (Benzamycin). Topical antibiotics alone aren't recommended.
  • Salicylic acid and azelaic acid. Azelaic acid is a naturally occurring acid found in whole-grain cereals and animal products. It has antibacterial properties. A 20 percent azelaic acid cream seems to be as effective as many conventional acne treatments when used twice a day for at least four weeks. It's even more effective when used in combination with erythromycin. Prescription azelaic acid (Azelex, Finacea) is an option during pregnancy and while breast-feeding. Side effects include skin discoloration and minor skin irritation.

    Salicylic acid may help prevent plugged hair follicles and is available as both wash-off and leave-on products. Studies showing its effectiveness are limited.

  • Dapsone. Dapsone (Aczone) 5 percent gel twice daily is recommended for inflammatory acne, especially in adult females with acne. Side effects include redness and dryness.

Evidence is not strong in support of using zinc, sulfur, nicotinamide, resorcinol, sulfacetamide sodium or aluminum chloride in topical treatments for acne.

Oral medications

  • Antibiotics. For moderate to severe acne, you may need oral antibiotics to reduce bacteria and fight inflammation. Usually the first choice for treating acne is tetracycline — such as minocycline or doxycycline — or a macrolide.

    Oral antibiotics should be used for the shortest time possible to prevent antibiotic resistance.

    Oral antibiotics are best used with topical retinoids and benzoyl peroxide. Studies have found that using topical benzoyl peroxide along with oral antibiotics may reduce the risk of developing antibiotic resistance.

    Antibiotics may cause side effects, such as an upset stomach and dizziness. These drugs also increase your skin's sun sensitivity.

  • Combined oral contraceptives. Four combined oral contraceptives are approved by the FDA for acne therapy in women who also wish to use them for contraception. They are products that combine estrogen and progestin (Ortho Tri-Cyclen, Yaz, others). You may not see the benefit of this treatment for a few months, so using other acne medications with it the first few weeks may help.

    The most common side effects of these drugs are weight gain, breast tenderness and nausea. A serious potential complication is a slightly increased risk of blood clots.

  • Anti-androgen agents. The drug spironolactone (Aldactone) may be considered for women and adolescent girls if oral antibiotics aren't helping. It works by blocking the effect of androgen hormones on the sebaceous glands. Possible side effects include breast tenderness and painful periods.
  • Isotretinoin. Isotretinoin (Amnesteem, Claravis, Sotret) is a powerful drug for people whose severe acne doesn't respond to other treatments.

    Oral isotretinoin is very effective. But because of its potential side effects, doctors need to closely monitor anyone they treat with this drug. Potential side effects include ulcerative colitis, an increased risk of depression and suicide, and severe birth defects. In fact, isotretinoin carries such serious risk of side effects that all people receiving isotretinoin must participate in a Food and Drug Administration-approved risk management program.

Therapies

These therapies may be suggested in select cases, either alone or in combination with medications.

  • Lasers and photodynamic therapy. A variety of light-based therapies have been tried with some success. But further study is needed to determine the ideal method, light source and dose.
  • Chemical peel. This procedure uses repeated applications of a chemical solution, such as salicylic acid, glycolic acid or retinoic acid. Any improvement in acne is not long lasting, so repeat treatments are usually needed.
  • Extraction of whiteheads and blackheads. Your doctor may use special tools to gently remove whiteheads and blackheads (comedos) that haven't cleared up with topical medications. This technique may cause scarring.
  • Steroid injection. Nodular and cystic lesions can be treated by injecting a steroid drug directly into them. This therapy has resulted in rapid improvement and decreased pain. Side effects may include thinning in the treated area.

Treating children

Most studies of acne drugs have involved people 12 years of age or older. Increasingly, younger children are getting acne as well. In one study of 365 girls ages 9 to 10, 78 percent of them had acne lesions. If your child has acne, consider consulting a pediatric dermatologist. Ask about drugs to avoid in children, appropriate doses, drug interactions, side effects, and how treatment may affect a child's growth and development.

Lifestyle and home remedies

You can try to avoid or control mild acne with nonprescription products, good basic skin care and other self-care techniques:

  • Wash problem areas with a gentle cleanser. Twice a day, use your hands to wash your face with a mild soap and warm water. If you tend to develop acne around your hairline, shampoo your hair every day. And be gentle if you're shaving affected skin.

    Avoid certain products, such as facial scrubs, astringents and masks. They tend to irritate the skin, which can worsen acne. Excessive washing and scrubbing also can irritate the skin.

  • Try over-the-counter acne products to dry excess oil and promote peeling. Look for products containing benzoyl peroxide as the active ingredient. You might also try products containing salicylic acid, glycolic acid or alpha hydroxy acids, which may help with mild and moderate acne. It may take a few weeks before you see any improvement.

    Nonprescription acne medications may cause initial side effects — such as redness, dryness and scaling — that often improve after the first month of using them.

  • Avoid irritants. Avoid oily or greasy cosmetics, sunscreens, hairstyling products or acne concealers. Use products labeled water-based or noncomedogenic, which means they are less likely to cause acne.
  • Protect your skin from the sun. For some people, the sun worsens acne. And some acne medications make you more susceptible to the sun's rays. Check with your doctor to see if your medication is one of these. If it is, stay out of the sun as much as possible. Regularly use a nonoily (noncomedogenic) moisturizer that includes a sunscreen.
  • Avoid friction or pressure on your skin. Protect your acne-prone skin from contact with items such as phones, helmets, tight collars or straps, and backpacks.
  • Avoid touching or picking at the problem areas. Doing so can trigger more acne or lead to infection or scarring.
  • Shower after strenuous activities. Oil and sweat on your skin can lead to breakouts.

Alternative medicine

Alternative and integrative medicine approaches used in the treatment of acne include fish oil, brewer's yeast, probiotics, oral zinc and topical tea tree oil. More research is needed to establish the potential effectiveness and long-term safety of these and other integrative approaches, such as biofeedback and traditional Chinese medicine. Talk with your doctor about the pros and cons of specific treatments before you try them.

Coping and support

Acne and acne scars can cause anxiety and may affect your social relationships and self-image. Sometimes it can help to talk with your family, a support group or a counselor.

Stress can worsen acne. Try to manage stress by getting enough sleep and practicing relaxation techniques.

Preparing for an appointment

If you have acne that's not responding to self-care and over-the-counter treatments, make an appointment with your doctor. Early, effective treatment of acne reduces the risk of scarring and of lasting damage to your self-esteem. After an initial examination, your doctor may refer you to a specialist in the diagnosis and treatment of skin conditions (dermatologist).

Here's some information to help you get ready for your appointment.

What you can do

  • List your key medical information, such as other conditions you're dealing with and any prescription or over-the-counter products you're using, including vitamins and supplements.
  • List key personal information, including any major stresses or recent life changes.
  • List questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Below are some basic questions to ask your doctor about acne. If any additional questions occur to you during your visit, don't hesitate to ask.

  • What treatment approach do you recommend for me?
  • If the first treatment doesn't work, what will you recommend next?
  • What are the possible side effects of the medications you're prescribing?
  • How long can I safely use the medications you're prescribing?
  • How soon after beginning treatment might my symptoms start to improve?
  • When will you see me again to evaluate whether my treatment is working?
  • Is it safe to stop my medications if they don't seem to be working?
  • What self-care steps might improve my symptoms?
  • Do you recommend any changes to my diet?
  • Do you recommend any changes to the over-the-counter products I'm using on my skin, including soaps, lotions, sunscreens and cosmetics?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:

  • When did you first develop this problem?
  • Does anything in particular seem to trigger an acne flare, such as stress or — in girls and women — your menstrual cycle?
  • What medications are you taking, including over-the-counter and prescription drugs as well as vitamins and supplements?
  • In girls and women: Do you use oral contraceptives?
  • In girls and women: Do you have regular menstrual periods?
  • In girls and women: Are you pregnant, or do you plan to become pregnant soon?
  • What types of soaps, lotions, sunscreens, hair products or cosmetics do you use?
  • How is acne affecting your self-esteem and your confidence in social situations?
  • Do you have a family history of acne?
  • What treatments and self-care steps have you tried so far? Have any been effective?

Last updated: October 31st, 2017

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