Have acne? Welcome to the club! Most people deal with acne at some point in their lives, including 75-95% of teens and 40-54% of adults over 25 years old in western societies.1Cordain, L., S. Lindeberg, M. Hurtado, et al. Acne Vulgaris: A Disease of Western Civilization. Arch Dermatol, 2002. 138(12). https://jamanetwork.com/journals/jamadermatology/fullarticle/479093 Even older adults can struggle with acne – 12% of middle-aged women and 3% of middle-aged men still have it! Should this make us lose hope of ever putting acne behind us? Definitely not! Though acne can seem stubborn, there is almost always a way to improve it.
What causes acne?
Acne is a particularly tricky skin condition to treat because there are several contributing factors, each of which calls for a different type of treatment, and multiple causes can be in play at once. The main factors involved in acne formation include:2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/
- Harmful bacteria colonizing your skin. The bacteria species Cutibacterium acnes (C. acnes; formerly called Propionibacterium acnes or P. acnes) essentially eats excessive oil (aka, sebum) in your pores and uses it for energy. While this might seem like a nice and thoughtful thing for C. acnes to do for you, its existence can trigger an inflammatory immune response and C. acnes itself can release toxins that cause inflammation that leads to acne formation. While people without acne may have C. acnes on their skin as well, there is evidence that they have a beneficial strain of C. acnes, while people with acne have a harmful strain.3Barnard, E., B. Shi, D. Kang, et al. The balance of metagenomic elements shapes the skin microbiome in acne and health. Sci Rep, 2016. 6. https://www.nature.com/articles/srep39491 While C. acnes is the most well-known bacterial culprit, other bacteria and the balance between them can contribute to acne as well.
- Your skin producing too much oil. This is a common cause of teenage acne because hormone changes during adolescence can cause excessive oil production and enlarge oil-producing glands. Too much oil is a problem because it can clog pores and it can feed C. acnes. This is one reason why “oily” and “acne prone” often go together when describing skin.
- Your skin cells not shedding like normal. The normal process of shedding skin cells is called keratinization. Sometimes cells in your hair follicles stick together, which leaves them to clog your pores instead of shedding.
- Your body releasing inflammatory agents into your skin. This can happen because of the hormonal balance in your body or from lifestyle choices and is damaging because skin inflammation can cause acne.
Every person’s acne could be caused by one or multiple of these factors.
How could my lifestyle be contributing to my acne?
Some factors contributing to acne are genetic and can’t be changed, such as having an oily skin type. However, lifestyle factors can affect breakouts as well.
One area backed by research is diet.4Baldwin, H., and J. Tan. Effects of Diet on Acne and Its Response to Treatment. Am J Clin Dermatol, 2021. 22(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847434/ Multiple studies show that sticking to a diet of foods that have a low glycemic index and low glycemic load (i.e., a diet low in carbohydrates and processed meats) can improve acne by reducing the levels of hormones and proteins that cause inflammation. This diet also seems to reduce the size of oil-producing glands. Having a diet rich in omega-3 is also shown to improve acne. Conversely, milk and whey protein have the opposite effect and can exacerbate acne.
One often overlooked area is the cleanliness of everything that touches your skin, including your hands, makeup brushes, pillowcases, towels, and hair. The dirt, oils, bacteria, and other substances found on these items can contribute to acne. Making sure to wash items like pillowcases, towels, and makeup brushes at least once each week may make a big difference by keeping your pores clear and preventing harmful bacteria from colonizing your skin, as discussed by dermatologists in this video.
In a similar way, other products that you put on your skin or medications that you take may trigger or contribute to acne.2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/ Common aggravating products include makeup and sunscreen. Drugs like corticosteroids and anabolic steroids are known to cause acne in many people. If you suspect that these items may be contributing to your acne, you may want to switch formulations and see if your acne improves over time. A good dermatologist can help you pick types of makeup and sunscreen that are not aggravating.
Besides changing my lifestyle, what can I do to get rid of my acne? Can colloidal silver work?
Acne treatments are personal because each person’s skin and combination of factors causing their acne are different. Therefore, it is impossible to make a one-size-fits-all skincare regimen that would work for everyone. While there is a lot of research backing different acne treatments, you may need to do a lot of testing to figure out what treatments work for you. A dermatologist can guide you and provide informed recommendations based on your skin.
Acne caused by bacterial colonization on your skin can be treated with antimicrobial agents. The most popular of these is benzoyl peroxide, which can be found in many types of over-the-counter face washes and leave-on products.5Mills, O.H., A.M. Kligman, P. Pochi, et al. Comparing 2.5%, 5%, and 10% benzoyl peroxide on inflammatory acne vulgaris. Int J Dermatol, 1986. 25(10). https://pubmed.ncbi.nlm.nih.gov/2948929/6Korkut, C., and S. Piskin. Benzoyl peroxide adapalene, and their combination in the treatment of acne vulgaris. J Dermatol, 2005. 32(3). https://pubmed.ncbi.nlm.nih.gov/15863861/ Benzoyl peroxide is extremely potent against bacteria, but does not cause bacterial resistance like antibiotics.2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/ It is common to start with a 5% formulation for mild to moderate acne, since it can cause irritation and dryness (also worth noting, it can bleach fabrics that touch the treated area, like your towel). Another common treatment is topical or oral antibiotics prescribed by a doctor, but antibiotic resistance can be a concern in this case, so it is often recommended to use along with benzoyl peroxide.2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/7Leyden, J.J., L. Krochmal, and A. Yaroshinsky. Two randomized, double-blind, controlled trials of 2219 subjects to compare the combination clindamycin/tretinoin hydrogel with each agent alone and vehicle for the treatment of acne vulgaris. J Am Acad Dermatol, 2006. 54(1). https://pubmed.ncbi.nlm.nih.gov/16384759/8Harrison, P.V. A comparison of doxycycline and minocycline in the treatment of acne vulgaris. Clin Exp Dermatol, 1988. 13(4). https://pubmed.ncbi.nlm.nih.gov/2977578/ Other ingredients like azelaic acid and tea tree oil can also be helpful.9Chilicka, K., A.M. Rogowska, R. Szygula, et al. A comparison of the effectiveness of azelaic and pyruvic acid peels in the treatment of female adult acne: a randomized controlled trial. Sci Rep, 2020. 10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387545/10Kainz, J.T., G. Berghammer, P. Auer-Grumbach, et al. Azelaic acid 20% cream: effects on quality of life and disease severity in adult female acne patients. J Dtsch dermatol Ges, 2016. 14(12). https://pubmed.ncbi.nlm.nih.gov/27897372/11Baladon, P.T., B.M. Burke, W.J. Cunliffe, et al. Topical azelaic acid and the treatment of acne: a clinical and laboratory comparison with oral tetracycline. Br J Dermatol, 1986. 114(4). https://pubmed.ncbi.nlm.nih.gov/2938615/12Katsambas, A., K. Graupe, and J. Stratigos. Clinical studies of 20% azelaic acid cream in the treatment of acne vulgaris. Comparison with vehicle and topical tretinoin. Acta Derm Venereol Suppl (Stockh), 1989. 143. https://pubmed.ncbi.nlm.nih.gov/2528257/13Iraji, F., A. Sadeghinia, Z. Shahmoradi, et al. Efficacy of topical azelaic acid gel in the treatment of mild-moderate acne vulgaris. Indian J Dermatol Venereol Leprol, 2007. 73(2). https://pubmed.ncbi.nlm.nih.gov/17456913/14Bassett, I.B., D.L. Pannowitz, and R.S. Barnetson. A comparative study of tea-tree oil versus benzoylperoxide in the treatment of acne. Med J Aust, 1990. 153(8). https://pubmed.ncbi.nlm.nih.gov/2145499/15Malhi, H.K., J. Tu, T.V. Riley, et al. Tea tree oil gel for mild to moderate acne; a 12 week uncontrolled, open-label phase II pilot study. Australas J Dermatol, 2017. 58(3). https://pubmed.ncbi.nlm.nih.gov/27000386/16Enshaieh, S., A. Jooya, A.H. Siadat, et al. The efficacy of 5% topical tea tree oil gel in mild to moderate acne vulgaris: a randomized, double-blind placebo-controlled study. Indian J Dermatol Venereol Leprol, 2007. 73(1). https://pubmed.ncbi.nlm.nih.gov/17314442/ Colloidal silver has antimicrobial properties and therefore could have a beneficial effect if used topically, but it hasn’t been extensively tested and there is currently no scientific evidence that it would be more effective than well-studied ingredients like benzoyl peroxide. That said, it does not appear to be harmful when used topically.17Jurairattanaporn, N., T. Chalermchai, S. Ophaswongse, et al. Comparative Trial of Silver Nanoparticle Gel and 1% Clindamycin Gel when Used in Combination with 2.5% Benzoyl Peroxide in Patients with Moderate Acne Vulgaris. J Med Assoc Thai, 2017. 100(1). https://pubmed.ncbi.nlm.nih.gov/29911775/
Acne caused by excessive oil production can be treated with products that decrease oil production. A topical 2% niacinamide formulation is shown to decrease oil production after 2-4 weeks of use.18Draelos, Z.D., A. Matsubara, and K. Smiles. The effect of 2% niacinamide on facial sebum production. J Cosmet Laser Ther, 2006. 8(2). https://pubmed.ncbi.nlm.nih.gov/16766489/ Use of topical 2% L-carnitine can also be effective.19Peirano, R.I., T. Hamann, H.J. Düsing, et al. Topically applied L-carnitine effectively reduces sebum secretion in human skin. J Cosmet Dermatol, 2012. 11(1). https://pubmed.ncbi.nlm.nih.gov/22360332/ In addition, combination oral contraceptives (i.e., birth control pills) and spironolactone can decrease oil production.2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/ Individuals with oily skin can also stick to oil-free moisturizers to prevent oil build-up.
Acne caused by clogged pores (altered keratinization) can be treated with chemical exfoliants. Treatment by a professional with a 30% salicylic acid peel every 2 weeks was shown to be effective and most people saw improvement after two treatments, but other chemical agents are also effective, including glycolic acid, azelaic acid, pyruvic acid, and mandelic acid.20Dayal, S., K.D. Kalra, and P. Sahu. Comparative study of efficacy and safety of 45% mandelic acid versus 30% salicylic acid peels in mild-to-moderate acne vulgaris. J Cosmet Dermatol, 2020. 19(2). https://pubmed.ncbi.nlm.nih.gov/31553119/21Kessler, E., K. Flanagan, C. Chia, et al. Comparison of alpha- and beta-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris. Dermatol Surg, 2008. 34(1). https://pubmed.ncbi.nlm.nih.gov/18053051/9Chilicka, K., A.M. Rogowska, R. Szygula, et al. A comparison of the effectiveness of azelaic and pyruvic acid peels in the treatment of female adult acne: a randomized controlled trial. Sci Rep, 2020. 10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387545/ However, similar benefits may be gained using weaker concentrations of these acids more frequently at home.10Kainz, J.T., G. Berghammer, P. Auer-Grumbach, et al. Azelaic acid 20% cream: effects on quality of life and disease severity in adult female acne patients. J Dtsch dermatol Ges, 2016. 14(12). https://pubmed.ncbi.nlm.nih.gov/27897372/12Katsambas, A., K. Graupe, and J. Stratigos. Clinical studies of 20% azelaic acid cream in the treatment of acne vulgaris. Comparison with vehicle and topical tretinoin. Acta Derm Venereol Suppl (Stockh), 1989. 143. https://pubmed.ncbi.nlm.nih.gov/2528257/13Iraji, F., A. Sadeghinia, Z. Shahmoradi, et al. Efficacy of topical azelaic acid gel in the treatment of mild-moderate acne vulgaris. Indian J Dermatol Venereol Leprol, 2007. 73(2). https://pubmed.ncbi.nlm.nih.gov/17456913/22Zheng, Y., M. Wan, H. Chen, et al. Clinical evidence on the efficacy and safety of an antioxidant optimized 1.5% salicylic acid (SA) cream in the treatment of facial acne: an open, baseline-controlled clinical study. Skin Res Technol, 2013. 19(2). https://pubmed.ncbi.nlm.nih.gov/23331850/23Kharfi, M., N. Tekaya, F. Zeglaoui, et al. Comparative study of the efficacy and tolerance of 12% glycolic acid cream and 0.05% retinoic acid cream for polymorphic acne. Tunis Med, 2001. 79(6-7). https://pubmed.ncbi.nlm.nih.gov/11771434/ In addition to chemical peels, retinoids (including tretinoin, adapalene, and tazarotene) and oral hormone therapies like birth control can aid in skin shedding.6Korkut, C., and S. Piskin. Benzoyl peroxide adapalene, and their combination in the treatment of acne vulgaris. J Dermatol, 2005. 32(3). https://pubmed.ncbi.nlm.nih.gov/15863861/24Stein Gold, L., D.M. Pariser, and E. Guenin. Tretinoin 0.05% Lotion for the Once-Daily Treatment of Moderate and Severe Acne Vulgaris in Femailes: Effect of Age on Efficacy and Tolerability. J Drugs Dermatol, 2019. 18(12). https://pubmed.ncbi.nlm.nih.gov/31860209/25Piérard-Franchimont, C., F. Henry, A.L. Fraiture, et al. Split-face clinical and bio-instrumental comparison of 0.1% adapalene and 0.05% tretinoin in facial acne. Dermatology, 1999. 198(2). https://pubmed.ncbi.nlm.nih.gov/10325486/26Shalita, A.R., E.S. Rafal, D.N. Anderson, et al. Compared efficacy and safety of tretinoin 0.1% microsphere gel alone and in combination with benzoyl peroxide 6% cleanser for the treatment of acne vulgaris. Cutis, 2003. 72(2). https://pubmed.ncbi.nlm.nih.gov/12953944/27Rao, G.R., S. Ghosh, R. Dhurat, et al. Efficacy, safety, and tolerability of microsphere adapalene vs. conventional adapalene for acne vulgaris. Int J Dermatol, 2009. 48(12). https://pubmed.ncbi.nlm.nih.gov/20415678/28Baker, M., M. Tuley, F.L. Busdiecker, et al. Adapalene gel 0.1% is effective and well tolerated in acne patients in a dermatology practice setting. Cutis, 2001. 68(4 Suppl). https://pubmed.ncbi.nlm.nih.gov/11845947/29Green, L.J., J.Q. Del Rosso, E.A. Tanghetti, et al. Tazarotene 0.045% Lotion for Moderate-to-Severe Acne Patients: Pooled Phase 3 Analysis by Age and Sex. J Drugs Dermatol, 2021. 20(6). https://pubmed.ncbi.nlm.nih.gov/34076400/
Acne caused by inflammation can be more difficult to treat because the underlying cause is often hormonal and topical creams can’t change this underlying cause. Therefore, lifestyle changes and oral treatments can make the most difference for this type of acne. Oral hormone therapies like birth control can often help after 3-6 months of use and several are FDA approved for treating acne.2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/30Oge’, L.K., A. Broussard, and M.D. Marshall. Acne Vulgaris: Diagnosis and Treatment. Am Fam Physician, 2019. 100(8). https://pubmed.ncbi.nlm.nih.gov/31613567/ Spironolactone can help by blocking hormone receptors.2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/ Some topical treatments may still be effective by interfering with local receptors, such as topical spironolactone or clascoterone. 31Herbert, A., D. Thiboutot, L. Stein Gold, et al. Efficacy and Safety of Topical Clascoterone Cream, 1%, for Treatment in Patients With Facial Acne: Two Phase 3 Randomized Clinical Trials. JAMA Dermatol, 2020. 156(6). https://pubmed.ncbi.nlm.nih.gov/32320027/
This seems really complicated. Is there one acne treatment that targets all causes of acne at once?
Yes! Oral isotretinoin (Accutane) is the most effective acne treatment available because it targets all four causes of acne.2Cooper, A.J., and V.R. Harris. Modern management of acne. Med J Aust, 2017. 206(1). https://pubmed.ncbi.nlm.nih.gov/28076744/32Accutane 40 mg Capsule Retinoids and Derivatives (Systemic) – Uses, Side Effects, and More. https://www.webmd.com/drugs/2/drug-6661/accutane-oral/details However, it can have some serious side effects, the most common of which are joint and bone pain, eye and lip inflammation, nosebleeds, and skin rashes and infections. It can cause birth defects too, so it can’t be used by women who are pregnant or plan to become pregnant. For these reasons, isotretinoin is only prescribed when all other treatments have failed.
Is there anything else I can do to help my acne go away?
Of course there is! Using a mild face wash twice a day is shown to help improve facial acne, and the face wash that you use can be tailored to your particular skin issues to boost the effect.33Zip, C. The Role of Skin Care in Optimizing Treatment of Acne and Rosacea. Skin Therapy Lett, 2017. 22(3). https://pubmed.ncbi.nlm.nih.gov/28492949/ Experts also recommend using sunscreen daily (at least SPF 30) because many acne treatments can make your skin more sensitive to sun damage and sunscreen can prevent post-inflammatory hyperpigmentation, which you may see as the red or dark spots left behind after acne. Finally, a good moisturizer can also help if you plan to start an acne treatment.33Zip, C. The Role of Skin Care in Optimizing Treatment of Acne and Rosacea. Skin Therapy Lett, 2017. 22(3). https://pubmed.ncbi.nlm.nih.gov/28492949/ Acne-prone skin has less of a barrier than “normal” skin and has fewer ceramides that keep moisture in your skin and germs out. Many treatments, like benzoyl peroxide and topical retinoids, can reduce the skin barrier further, which can dry out your skin, causing it to produce more oil, which can lead to even more acne. A good moisturizer can help maintain a healthy skin barrier and prevent water loss in your skin.
What’s the bottom line?
Acne can be difficult to live with, but many treatment options are available for each factor causing acne. Regarding colloidal silver, it may prove to be an effective treatment in the future, but does not have strong research behind it yet. Having a dermatologist help you find products that work for you can potentially save you a lot of time and money and is especially important if you have certain medical conditions or are pregnant, because certain treatments may be unsafe for you, even if they are topical and over the counter.
It is also important to note that changing your lifestyle or starting a skincare treatment to reduce acne can take time. Some treatments can take at least 2 weeks to produce noticeable results, while others can take 6 months. Consistency and commitment are the only ways to reap the benefits of acne treatments.
You may be in the acne club now, but we hope that you lose your membership soon!