Most of the people who get acne are teenagers. But infants can get acne, too. Even unborn babies in the womb can get acne. (This is called perinatal acne.) People can get acne for the first time at age twenty, thirty,forty, fifty, even older. Why?
As we’ve already mentioned, no one yet knows for sure exactly why acne starts. But for as long as acne has been around, people have been speculating on what causes acne or makes it worse. Things that cause acne are said to be acnegenic, or comedogenic (producing comedones). Some of the speculations sound logical enough but actually have turned out to be wrong.
One of the earliest beliefs about acne was that it was caused by dirt—the result of not keeping the skin properly cleaned. Many people still believe this, but it isn’t so. It is important to clean the skin regularly,because dirt and excess oil on the skin may contribute to blocking pores and slowing down the flow of sebum out to the surface. But dirt does not cause skin cells to clump together and cling to the follicle walls. That happens deep inside the follicle, where cleaning can’t reach.
Another long held belief about acne was that it was somehow related to sex. “Don’t worry,” people would tell a teenaged boy or girl worrying about pimples. “When you get married, your skin will clear up.” The idea that sexual activity could help cure acne also made a good line for someone trying to persuade a reluctant date to “fool around.” Paradoxically, acne has also been associated with having too much sex. That idea got started because people noticed that acne usually occurs during adolescence—the time when a person is becoming sexually mature. (The ancient Greeks were the first to link acne and adolescence, about twenty-five hundred years ago.) Some medical authorities suggested that masturbation was an important cause of acne—a notion that was especially popular during the repressive Victorian era. Such misconceptions about acne and sex persisted until the 1940’s, when scientific studies established that sexual activity and acne are not related.
Do Foods Cause Acne?
Perhaps the most popular idea links acne breakouts to diet. Doctors used to tell their patients to avoid certain foods thought to cause acne. However, over the years so many different foods have been called acnegenic that a person who avoided them all would have practically nothing left to eat. The most notorious acnegenic foods were thought to be chocolate, colas, and greasy foods such as French fries and potato chips. Today most doctors do not feel that diet plays a very important role in acne breakouts. They point to studies of patients who ate large quantities of chocolates or peanuts and did not break out afterwards as proof that diet does not affect acne.
The topic of diet and acne, however, is still under debate. Some doctors claim that the effect of foods should not be ruled out just because a breakout does not occur immediately after eating a possible acnegenic food. Pimples can take weeks or even months to develop. How, then, can we be sure something eaten now will not cause a breakout of pimples several days or weeks from now?
Many doctors who do feel diet has a role in the development of acne have noticed some of their patients had definite breakouts after eating chocolate, sugar, or greasy foods. Others answer that only sensitive people break out after eating these foods. They point to studies such as one that found one out of four people are sensitive to chocolate and may have an acne-like reaction to it. These doctors claim that the reaction is not really acne at all, but rather an allergic reaction that is mistaken for the common acne vulgaris.
Foods that contain iodides have also been linked with acne. Many shellfish are high in iodides. So are pretzels and potato chips, which contain iodized salt. Gluten bread has also been blamed. Excess amounts of iodides probably contribute to the acne process by making the response of the white blood cells to inflammation less effective. But not all doctors agree that iodides are major contributors to acne. Some claim that the levels required to cause breakouts are very high, and normal eating habits would not pose a problem.
Many doctors avoid the debate about acne and food and simply advise their patients to stay away from any foods that seem to cause a problem. If a breakout occurs, they suggest, stay away from the food for a while. Then, after the flare-up goes away, try it again. If the problem recurs, this is a food you should avoid. This is a highly individual matter, to be determined by each person by trial and error.
Hormones and Puberty
The question of hormones is even more complex. There is no doubt that the hormones secreted by an adolescent’s body play a role in acne.
The fact that acne usually occurs at puberty, when sex hormones are released into the bloodstream in large quantities, suggests a definite connection between acne and increased levels of androgen’s, the normal male sex hormones. Eunuchs—men whose testes have been removed or destroyed—do not produce testosterone. Although some androgen’s are produced by the adrenal glands, their overall levels are low, like those of a child before puberty. It’s no coincidence that eunuchs don’t get acne.
Flare-ups of acne in adolescent girls and women are also linked with sex steroid hormones. Typically, pimples peak during menstrual periods, and that is when a woman’s progesterone levels are highest. (Progesterone is chemically very similar to the main androgen, testosterone.)
However, as some research has revealed, higher androgen levels in the blood do not necessarily mean more oil will be produced in the skin. Actually, people with oily skin and a tendency to develop acne usually have normal levels of androgen’s in their bodies. And though the testosterone level remains high in an adult man, most boys do eventually outgrow acne after puberty has ended. So the level of the sex hormones is not the only important factor. What counts is how sensitive the sebaceous glands are to the androgen’s that are present.
Some people’s sebaceous glands are more sensitive than others’. Even in a person’s own body, sebaceous glands differ in their androgen sensitivity. For example, most people’s skin is oilier in the center of the face than anywhere else. The areas on the forehead, nose, cheeks around the nose, and the chin are usually oilier even in people with normal skin and no acne problems. This is because the sebaceous glands in this area are larger and
more sensitive than those in other places. Doctors call this sensitivity end-organ sensitivity. Heredity plays an important role in determining each person’s end-organ sensitivity.
Who Gets Acne?
Increased oil production is obviously related to acne breakouts. But why does acne start? Heredity probably plays an important role in who gets acne and how severe the case will be. However, unlike other conditions that are very rare, acne is so common—nearly everyone gets it—that it is hard to determine how much of a role heredity plays. Some people whose parents had severe cases of acne develop severe cases of their own. Others don’t.
Geography and culture are also uncertain factors. Before white people brought modern ways to Alaska, conditions such as heart disease and acne were very rare among the Eskimos. Now there are many more cases. Did diet play the major role? Was it the change in lifestyle? Research has not yet brought a definite answer.
What Actually Causes Acne?
One current theory about acne has to do with the bacteria that live on the skin and in the follicles, particularly C. acnes. Research has shown that the fatty acids produced by these bacteria sometimes act to speed up the turnover rate of skin cells in the epidermis. New cells are produced in the basal layer at a faster rate. They displace the older cells, pushing them outward and causing more dead outer epidermal cells to be formed. This is a defense mechanism, producing a thicker layer of dead cells as a shield to protect the body. Some scientists feel this might be part of a chain reaction contributing to the start of acne: An increase in the oil production in the skin feeds the C. acnes bacteria present there and creates a population explosion of these microbes. The multiplying bacteria produce more fatty acids, which irritate the skin and prompt it to produce more dead cells. This combination of extra cells and extra oil could set the stage for acne.
Another idea about acne is that the pore openings in an adolescent’s skin are not big enough to handle the increased amount of oil. The pores are still immature and cannot accommodate the growth spurts that the body experiences at this time. This immature pore size makes it more difficult for the sebum to flow. Things get backed up inside, as the body produces more and more oil, and more dead cells are sloughed off inside the follicle. Eventually the pores grow bigger, and the sebum can flow more freely—but this often takes years.
But what about adults who get acne? How does this fit in with the “too-small-pore-size” theory? Dermatologists find that 60 percent of their patients with acne are adult women. In fact, some doctors suggest that between 30 and 50 percent of all adult women have acne flare-ups at one time or another. Many dermatologists believe that the biggest cause of acne in adult women is the cosmetics they use. Makeup foundations and moisturizers are often oily or greasy and can clog the pore openings, causing acne cosmetica. Pores clogged
with oily makeup are similar to the immature pore openings m adolescents. In both cases the flow of sebum is restricted, which can contribute to a backup inside the follicle. Cosmetics manufacturers dispute this theory, contending that most cosmetic products sold to the public are nonacnegenic. Recently dermatologists and cosmetic-industry researchers have been reviewing the results of testing m a cooperative attempt to resolve the question.
Probably both mechanisms—a bacterial population explosion fueled by increased oil production and a clogging of follicles whose pores are too small to permit a free flow of sebum—contribute to the acne process. Perhaps other factors will be discovered. When scientists find out for sure exactly why acne happens, a “cure” for acne will be only one step away. For now. though. dealing with acne means learning about as many things that can cause acne (or acne-like conditions) as possible. If you know what may trigger your acne breakouts, you may be able to minimize acne problems.
Sun, Head, and Humidity
Many people find their acne gets better in the summer, while some find it gets worse. For the people whose problems improve, the answer seems to be the greater exposure to sunlight, whose ultraviolet rays can kill bacteria. Sunlight also promotes increased scaling, as the skin thickens protectively and the dead outer layers flake off more rapidly. This scaling can help unblock clogged pores. So doctors used to advise moderate sunbathing or treatments With UV lamps to help clear up acne.
But recently, medical specialists have become more aware of the negative effects of sun exposure. Ultraviolet light is powerful. If it is strong enough to kill bacteria, you might wonder what it can do to your skin. For one thing, it can produce chemical changes in the skin protein collagen. The long chemical chains of this protein get linked together rigidly, instead of providing an elastic framework. Gradually the skin becomes wrinkled, tough, and leathery—old looking. Even worse, the UV rays can strike deep into the skin cells, producing changes in the chemicals that guide and control their activities. Such a changed skin cell may suddenly run wild, multiplying uncontrollably and producing a cancerous growth. A suntan is the body’s defense against UV rays: The dark pigment melanin soaks up the radiation harmlessly and shields the more delicate structures in the cells. A sunburn means that you were exposed to more sun than you were equipped to handle; dermatologists now believe that most skin cancers can be traced back to a sunburn some time in the past.
Doctors today warn against overdoing sunbathing as an acne remedy, and they frown on UV lamps. You should always use a sunscreen when out in the sun, one that blocks out the UV rays effectively. But beware of oily ones that can aggravate acne problems by blocking pores. Alcohol-based sunscreens are better for your skin than oily, greasy ones, since alcohol helps to clean off excess oil and dirt.
The summer sun may be beneficial to the skin, but coupled with humidity, summer heat can cause acne to get worse. Skin cells swell in hot, humid weather, and this can block the follicles, preventing sebum from flowing properly and causing acne breakouts.
In some severe cases, tropical acne can develop. Large nodules and cysts form on the shoulders and back where the skin is rubbed by clothing. This sometimes happens to soldiers, for example, who are stationed in hot, tropical climates and have to do a lot of physical labor. Some research has suggested that a yeast called Pityrosporum ovale may be involved in tropical acne cases.
In hot, humid weather, it might be advisable to use an astringent (a lotion that dries and tightens the skin) a few times a day to remove excess oil. One good thing about astringents is that they come in medicated pads that you can take along anywhere. They can be stashed in a gym bag, purse, or knapsack for use at times when soap-and-water washing isn’t possible.
Pressure and Other Aggravators
During the summer, remember to reduce friction against the skin, which can also cause acne. Sitting in a vinyl seat in a car, at home, or at work can cause sweat to accumulate. The same is true of exercising in tight fitting, nonabsorbent clothes. Moreover, friction produced by rubbing against the chair or by rough clothes rubbing against the body can damage follicles swollen and blocked by humidity. Headbands, backpack straps, and football helmet straps all can cause flare-ups when they touch and rub on the skin, even in cold climates.
Some doctors believe that pressure on the skin alone can cause problems. If you lean your chin on your hand while studying, for example, you may have an acne breakout on your chin. Apparently pressure locks moisture into the skin, causing the surface layer around the pores to swell. This makes the pore openings smaller, so the oil cannot escape properly. Acne that is caused by rubbing, friction, or pressure on the skin is acne mechanics. Placing a towel on the chair, wearing loose, absorbent clothes, using talcum powder, and keeping as little pressure on the skin as possible are good ways to minimize problems.
Acne can be aggravated by anything that prevents sebum from flowing freely through the follicle and out onto the surface of the skin. Some people find that if they wear their hair in bangs, they break out on the forehead. People with long hair sometimes get acne on the neck and upper back. This is caused by the oils from the hair, which may help to clog the pore openings, and possibly by friction of the hair rubbing on the skin.
Over-cleaning your face can also worsen acne pimples and result in what doctors call acne detergicans. Some people scrub very hard and use abrasive cleansers to try to scrub acne away. Sometimes this over-cleaning can irritate plugged-up follicles, causing them to rupture and become inflamed. Instead of washing away the acne, it only makes the area more raw and worse than before.
Acne can also be caused by a person’s work environment. Occupational acne is what sometimes happens when the skin is exposed to a lot of oil or grease on the job. Some people who work in fast-food restaurants, for example, can develop severe cases oi acne if they are constantly exposed to splattering oil and grease in a kitchen. Machinists and mechanics, too, may develop acne on their arms from constant exposure to oil and grease.
Sometimes medications the doctor prescribes for an illness can cause acne pimples as a side effect. Acne medicamentosa is the name for this type of breakout. Steroids and drugs used to control epileptic seizures can sometimes cause acne. So can oral contraceptives. Lithium, phenobarbital, and Dilantin can cause breakouts. Some cough and cold medicines or multivitamins that contain bromides and iodides are sometimes culprits. Danazol, a synthetic androgen used to treat endometriosis, and INH, an anti-TB drug, have sometimes caused eruptions. Excessive amounts of vitamin B12 can also cause breakouts.
Usually breakouts caused by medications will look different from ordinary acne problems. Steroid eruptions, for example, most often occur as a number of small, shallow pustules. If you suspect that a medication you are taking is causing breakouts, don’t stop taking it on your own. Discuss it with your doctor. He or she will examine the pimples, and if the medication seems to be causing you to break out, perhaps another drug will be substituted for it.
Some people notice that the area around the mouth is particularly prone to acne. The culprit may be tooth paste. Some people react to the fluoride in the tooth paste by breaking out in acne pimples. If you think this might be your problem, try a non-fluoridated toothpaste for a while to see if the skin in the area clears up. Soaps used to wash the skin may also contribute to acne if they contain oily cleansing cream or fragrance. (Some people are sensitive to perfumes.)
Sometimes breakouts can occur when something is missing from your diet. Some people break out when their bodies do not have enough vitamin C, for example.
Men with curly hair may develop a particular kind of acne problem. Their facial hairs are curly, too, and the tips may turn back into the pores and become ingrown, causing acne-like pimples. This condition is called pseudofolliculitis barbae. It is often worsened by shaving.
Some people are affected by foods and drinks that cause the blood vessels to expand. These are called vasodilators. Spicy foods and hot drinks such as coffee and tea, as well as alcoholic drinks, are all vasodilators, which cause the face to be flushed. People with an acne-like condition called acne rosacea are particularly sensitive to vasodilators. The capillaries beneath the skin become enlarged and sometimes are damaged, causing the nose and surrounding area to be puffy and red. Pimples break out on and around the nose, as well as on the cheeks and forehead, and the area around the pimples is red and inflamed. Acne rosacea usually occurs in people over thirty, particularly in women, although men who have the condition often have more severe cases. W. C. Fields was one famous acne rosacea sufferer. Sometimes this condition is called * ‘whiskey nose,” but this is an unfair description; although alcohol can worsen the problem, acne rosacea also occurs in people who have never had a drink in their lives. Severe cases of acne rosacea require treatment with prescription drugs: antibiotics or the recently approved metronidazole, which comes in a water-based gel form that is colorless and odorless and can be used under makeup.