Acne starts to develop when hair follicles in your skin get blocked with sebum (a natural oil) and dead skin cells. During your teenage years, your skin produces more of this oil because of hormonal changes (an increase in your testosterone level).
This can lead to dark spots, called ‘blackheads’, or light-coloured spots known as ‘whiteheads’. You can also get inflamed spots that look like red bumps (papules), or are yellow in colour (pustules) or spots that contain fluid (cysts).
Sometimes, a bacterium called Propionibacterium acnes (P. acnes) that usually lives harmlessly on your skin can grow inside your hair follicles. It can contribute to inflammation (swelling) in spots.
Symptoms of acne
If you have acne, you may have spots on your face, chest, back, and shoulders. You might not have them on all of these areas. For example, acne can affect just your face, or just your chest or back.
The spots are described as non-inflamed or inflamed. Blackheads and whiteheads are non-inflamed spots. Inflamed spots include red bumps and lumps, yellow pus-filled spots or fluid-filled cysts. In very severe acne, cysts may join together to form larger, deeper inflamed areas (acne conglobata).
Your skin may be greasy and the spots may feel hot and tender to the touch.
You may get one type of spot or a mixture of the different types. The severity varies from person to person but the following is a guide.
- Mild: you mostly have non-inflamed spots.
- Moderate: you have a mixture of inflamed and non-inflamed spots and you may be at risk of them leaving scars.
- Severe: you have a lot of inflamed spots and cysts that are widespread on your skin and are at a high risk of scarring.
Diagnosis of acne
If you think you have acne and it’s affecting how you live your life, see your pharmacist. They can recommend over-the-counter treatments to try. If your acne is severe or over-the-counter treatments haven’t worked, see your GP.
Your GP will ask about your symptoms and may examine you. They may also ask you about your medical history. Your GP will usually be able to diagnose acne based on your symptoms. This is because acne is easily recognisable by the pattern of spots on your body. There are different types of acne, the most common being acne vulgaris. Your doctor will be able to tell you which variety you have and what the best treatment method is.
If your acne is severe, your GP may refer you to a dermatologist (a doctor who specialises in treating conditions that affect the skin).
Self-care if you have acne
Try not to pick or squeeze your skin. This can make acne worse and lead to scarring.
Acne isn’t caused by having poor hygiene, so extra washing or scrubbing doesn't make it better – in fact, that can make acne worse. Gently wash spot-prone areas as normal with a mild soap or an unperfumed cleanser and lukewarm water. You don’t need to wash your skin more than twice a day at most.
Be patient with any treatment you’re having – it can take four to eight weeks to see an improvement and several months to see significant improvement. When you first start treatment, your skin might feel more irritated but this will get better. If this happens, you can try stopping the treatment for a couple of days and then building up slowly.
It’s better for your skin not to wear make-up but it’s understandable that wearing make-up might help you feel more confident and less self-conscious. In which case, choose make-up products that are water-based and oil-free. Also, look on the label and choose products that are non-comedogenic or non-acnedemic (these shouldn’t cause blackheads, whiteheads, or acne). Make sure you completely remove your make-up at night.
If your skin is dry (some acne creams can cause dry skin), you can use a fragrance-free, water-based moisturising cream. Don’t use ointments or oily products because they can block your pores.
If you’re male and need to shave your face, choose shaving products that are moisturising. Shave downwards, following the direction of the hair growth.
There are some products (moisturisers, shaving gels and cleansers) that are designed especially for acne, such as Cetaphil®. Speak to your pharmacist for more information and advice.
Over-the-counter products containing benzoyl peroxide (eg PanOxyl) may help. These treatments are antibacterial and so reduce the amount of Propionibacterium acnes (P. acnes) bacteria on your skin. You can buy these treatments from pharmacies and larger supermarkets. You might not see an improvement immediately and your skin might get a bit worse to start with, but this won’t last. There’s not much proof that other types of over-the-counter acne treatment are helpful.
Take care not to get any of your treatment on your clothes. If products containing benzoyl peroxide accidentally get onto your clothes, they may bleach the colour. Also be aware that benzoyl peroxide can bleach your hair.
For some people, having acne is very distressing. If you’re feeling low or anxious about your acne, talk to your GP. You don’t have to feel this way on your own and there may be ways your doctor can help.
Treatment of acne
Your treatment will depend on the severity of your acne and how much it’s affecting your quality of life. Your GP may prescribe one of the following treatments if you have already used treatments containing benzoyl peroxide from the pharmacist.
Creams, lotions and gels
- Topical retinoids such as tretinoin and isotretinoin. It may take some time before the effects of these medicines are noticeable. Retinoids can be slightly irritating to your skin, but this should settle over time. You may also become more sensitive to sunlight, so make sure you use plenty of sunscreen if you’re going out in the Sun. You shouldn't use retinoids if you're pregnant because they can harm your baby.
- Azelaic acid. This is an antibacterial medicine usually used as an alternative to benzoyl peroxide and retinoids. It's less likely to irritate your skin as much.
- Antibiotic lotions or gels, such as clindamycin or erythromycin. These can help to reduce inflammation (swelling) by reducing the levels of natural Propionibacterium acnes (P. acnes) bacteria on your skin. Your doctor will monitor this to help avoid antibiotic resistance (when antibiotics stop responding).
If you have moderate or severe acne, your GP may prescribe an antibiotic such as oxytetracycline, lymecycline or doxycycline. They will advise you how many times a day you need to take your medicine and for how long. Most people who try this treatment find their acne gets much better within six months. You may also be given a cream or lotion (explained above) to use at the same time.
If you're a woman with acne and also need contraception, or if your acne is thought be caused by hormones, your GP may advise taking an oral contraceptive pill as treatment. Contraceptive pills suppress the male hormone testosterone, which is responsible for increasing sebum production. This means they can help make your skin less oily. You might also have other treatments alongside the pill.
If you have severe acne and antibiotics haven’t helped, your doctor may suggest that you take a medicine called co-cyprindiol. This works as a type of contraception. It reduces the levels of male hormones in your body. Taking oral contraceptives can increase your risk of getting blood clots. Your doctor will discuss the risks and benefits of this treatment with you.
If your acne is more severe, your doctor may advise you to take an oral retinoid medicine called isotretinoin (also known as Roaccutane). This reduces the amount of sebum your skin produces. This is a strong medicine and is only prescribed by or under the supervision of a dermatologist.
Be aware that your acne may worsen before it begins to improve. Isotretinoin can cause dry eyes, lips and skin, headaches, nose bleeds and pain in your joints. It may also cause more serious problems such as liver problems or raised cholesterol levels. You’ll be advised to have regular blood tests to check for any problems (eg with your cholesterol levels). Experts aren’t sure if isotretinoin can cause depression, but your doctor will monitor you for this. If you’ve had depression in the past, let your dermatologist know before you start treatment.
When having this treatment, you need to try and stay out of direct sunlight and use sunscreen and moisturisers (including lip balm).
If you’re a woman, you’ll need to use contraception while taking this medicine. This is because isotretinoin could cause significant birth defects in pregnancy. You should have a regular pregnancy test and a review meeting to discuss how your treatment is going. You’ll have the opportunity to discuss these and other issues with your dermatologist and ask questions before you start treatment.
Very rarely, isotretinoin may affect night vision. If this is important – for example, if you are planning to be a professional pilot, please discuss it with your dermatologist.
New treatments that involve therapy with light or lasers are being developed. Light therapy isn't usually offered as treatment for acne, because doctors aren't sure how well it works yet. Research into how well these therapies work is still on-going. Before these therapies are offered as treatments, more scientific proof is needed to show how useful they are.
For more information on light treatment, speak to your dermatologist.
Causes of acne
Acne is caused when sebum (a natural oil) and dead skin cells block your hair follicles. Changes in your hormones (increase in the male hormone testosterone) cause your skin to produce more sebum during your teenage years. As a result your skin becomes greasy and spots develop.
If you're a woman, hormonal changes just before your period may cause acne to flare up. Newborn babies can sometimes get acne in the first few months of life.
There’s a chance that acne can run in families. For example, if both your parents had acne, you have an increased chance of having it too.
Other causes of acne may include:
- conditions such as polycystic ovary syndrome
- medicines, such as corticosteroids, medicines for epilepsy and lithium (sometimes used in treatment for depression)
Complications of acne
Acne usually clears up as you get older without leaving noticeable scarring. But it’s possible that acne may leave lasting effects and cause some problems.
Scarring. Up to one in five people with acne get noticeable scarring. Scars can happen with all types of acne, usually with severe acne though milder acne can also leave scars. Picking and squeezing the spots can also cause scarring. Scars can be narrow ‘ice pick’ scars or broader ‘pock marks’. Rarely, ‘keloid’ (firm lumpy) scars may develop on your skin. See our FAQs for information about treatments for acne scars.
Dark and light spots
- Hyperpigmentation (your skin becomes darker in the areas affected by acne). This is usually only noticeable if you have a dark skin tone.
- Hypopigmentation (your skin becomes lighter in the areas affected by acne). This is usually only noticeable if you have a dark skin tone.
Acne can cause anxiety and depression in some people. It can also affect your self-confidence or self-esteem, for example if people comment on your acne. Having acne can be very distressing – if it is making you start to feel low, talk to your GP for help and advice.
FAQ: What are the common myths about acne?
There are lots of myths about what causes acne. Here are some of the most common.
- Acne is caused by bad hygiene. This isn’t true. Cleaning the skin won’t improve your acne and washing too much can make acne worse.
- Acne is the result of a bad diet. There’s no concrete proof that chocolate or fatty foods cause acne. However, if you do notice that a food triggers it or makes it worse, you might find it helps to limit or cut this out. Eating a healthy diet will help your general health.
- Acne is infectious. No, it’s not – it can’t be caught or passed onto anyone else.
- Stress causes acne. Experts aren’t completely sure about this – there’s a link but stress doesn’t necessarily cause acne, though having acne can be stressful for some people. We talk more about this in our skin expert’s blog: Does stress cause skin problems?
- Acne treatments make your skin worse. To start with, some treatments may irritate your skin and take some time to work (up to eight weeks). Usually, this settles and you’ll start to see an improvement, but speak to your pharmacist or doctor for advice.
- Sunlight improves acne. There’s no proof that sunlight will improve or clear up acne. There’s no evidence that actively sunbathing or using sunbeds will help and this isn’t recommended. It will damage your skin.
FAQ: Are there treatments that can improve acne scars?
Several treatments have been designed to reduce and improve acne scars. Unfortunately, at the moment there isn’t very much high-quality research that is strong enough to say any of them will definitely work. Treatments include laser resurfacing, dermabrasion and chemical peels, and a procedure called skin needling.
Dermabrasion and chemical peels can tighten the skin and lift the scars to reduce the depth of them, with the aim of making them less noticeable. Laser resurfacing uses lasers to produce the same effect. These treatments don’t remove scars completely and the end results will vary.
These treatments aren’t available on the NHS because they are considered to be cosmetic surgery. But if you want to find out about treatments for scarring, there are lots of private clinics that offer these treatments. Do make sure that you do your research and that any treatment you have, is carried out by a qualified professional. See our Other helpful websites for more information.
Skin creams can keep your scar moisturised so it doesn’t become dry. Scars can be particularly sensitive to sunlight, so wear sunscreen to protect your skin when going out in the Sun.
There are special make-up products that can help cover up some types of acne scarring. These are creams and powders that match your skin colour – however they can’t fill in scars or flatten out raised scars. You can access these products through a Skin Camouflage Service. You can refer yourself or your doctor may be able to refer you. To find out more about this service run by the charity Changing Faces, see our Other helpful websites.
- Map of Medicine. Acne. International View. London: Map of Medicine; 2016 (Issue 1)
- Acne. BMJ Best Practice. bestpractice.bmj.com, last updated 6 March 2017
- Acne. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised September 2014
- Acne vulgaris. PatientPlus. Patient.info/patientplus, last checked 11 May 2015
- Acne. British Association of Dermatologists. www.bad.org.uk, updated January 2017
- Shaving. Derm Net New Zealand. www.dermnetnz.org, accessed 25 September 2017
- Isotretinoin. NICE British National Formulary. bnf.nice.org.uk, reviewed July 2017
- Rosacea and acne. NICE British National Formulary. bnf.nice.org.uk, reviewed July 2017
- Antibiotics for acne. DermNet New Zealand. www.dermnetnz.org, reviewed 2014
- Acne vulgaris treatment and management. Medscape. emedicine.medscape.com, updated 20 May 2016
- Barbaric J, Abbott R, Posadzki P, et al. Light therapies for acne. Cochrane Database of Systematic Reviews 2016, Issue 9. doi:10.1002/14651858.CD007917.pub2
- Abdel Hay R, Shalaby K, Zaher H, et al. Interventions for acne scars. Cochrane Database of Systematic Reviews 2016, Issue 4. doi:10.1002/14651858.CD011946.pub2
- Scars and keloids. British Association of Aesthetic Plastic surgeons. www.baaps.org.uk, accessed 1 August 2017
- How it works. Skin camouflage. Changing Faces. www.changingfaces.org.uk, accessed 3 August 2017
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Reviewed by Natalie Heaton, Specialist Health Editor, Bupa Health Content Team, September 2017
Expert reviewer Anton Alexandroff, Consultant Dermatologist
Next review due September 2020
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