Acne

Overview

Acne is a very common skin disease that occurs when oil glands and hair follicles become blocked. It is also known as pimples. It appears as blackheads, whiteheads, red bumps, and inflamed swellings on the face, chest, back, and shoulders.

Acne is very common especially in adolescents. Hormonal changes cause oil glands to produce more oil. When this excess oil combines with dead skin cells and bacteria, pores become blocked and acne forms. It can also be seen in adults and is more common in women due to hormonal fluctuations.

Although acne is not a serious health problem, it can affect self-confidence and leave permanent scars on the face. Mild acne can usually be treated with over-the-counter creams. Moderate and severe acne require medication treatment under doctor supervision. Early treatment both relieves symptoms and prevents permanent scar formation.

Acne is a condition that almost everyone encounters at some point in their life. Approximately 85 percent of adolescents experience acne. In adults, it is especially common in women aged 20-40. Genetic predisposition, hormones, stress, and some cosmetic products can trigger or worsen acne.

Symptoms

Acne symptoms range from mild to severe. Different types of lesions form on the skin. Symptoms usually begin on the face but can also spread to the chest, back, and shoulders.

Acne symptoms include the following:

• Comedones (blackheads and whiteheads). These are blocked pores. Whiteheads (closed comedones) appear as small white bumps under the skin. The pore is completely closed. Blackheads (open comedones) are lesions where the pore is open and the oil inside turns black upon contact with air. The black color is not from dirt but from oxidation.
• Papules. These are small, red, and tender bumps. Slightly raised from the skin. There is no visible inflammation inside but they may be painful when touched.
• Pustules. These are inflamed pimples. They resemble papules but have white or yellow inflammation (pus) in the center. Surrounded by a red halo. The risk of infection increases when squeezed.
• Nodules. These are large, hard, and painful swellings that form deep in the skin. Felt under the skin. Larger and more painful than normal pimples. High risk of leaving scars.
• Cysts. This is the most severe type of acne. Large and painful lesions filled with inflammation that form deep in the skin. Soft and mobile. Can leave permanent scars and pits. Cystic acne definitely requires dermatologist follow-up.
• Redness and inflammation. There may be redness, swelling, and tenderness on the skin in the acne area. The more severe the inflammation, the higher the risk of scarring.
• Acne scars and spots. Healing acne can leave dark spots (hyperpigmentation) or pits on the skin. Spotting is more pronounced especially in dark-skinned people.

Acne is usually more concentrated in the T-zone of the face (forehead, nose, chin) because there are more oil glands in these areas. Since there are also dense oil glands on the back and chest, acne is common in these areas as well.

When to See a Doctor

Mild acne can usually be managed with over-the-counter products. However, in some cases it is definitely necessary to see a doctor.

See a doctor in the following situations:

• If your acne is severe (if there are many inflamed pimples, nodules, or cysts)
• If over-the-counter treatments do not work after 6-8 weeks
• If acne is very painful
• If acne seriously affects your self-confidence
• If scarring or spotting is developing on the skin
• If sudden and severe acne has appeared (especially in adults)
• If there are signs of hormonal disorder in women such as menstrual irregularity and excessive hair growth

Early treatment both prevents acne from worsening and reduces permanent scar formation. Prescription medications may be needed for severe acne and these should only be used under doctor supervision.

Causes

Acne occurs when four main factors come together. Excess oil production, pore blockage, bacteria, and inflammation play a role in acne development.

The process leading to acne works as follows:

• Excess sebum (oil) production. We have oil glands in our skin that produce natural oil called sebum. Sebum keeps the skin moist and protected. However, if hormones encourage oil glands to work excessively, too much oil is produced. Especially during puberty, androgen hormones enlarge oil glands and cause more sebum secretion.
• Pore blockage. During the skin's continuous renewal, dead skin cells are shed. Normally these cells are easily removed from the skin's surface. However, when too much oil is produced, dead cells stick together with the oil and block the pores. This blockage creates black or white dots.
• Bacterial multiplication. A bacterium called Propionibacterium acnes (P. acnes) normally lives harmlessly on the skin's surface. However, when the pore becomes blocked, an ideal environment is created for this bacterium. The bacterium multiplies rapidly in an oxygen-free environment. It feeds on the oil and dead cells in the blocked pore.
• Inflammation. Multiplying bacteria trigger the body's immune system. Immune cells flow to the area and fight bacteria. This process creates redness, swelling, and inflammation. The more severe the inflammation, the larger and more painful the lesions.

Risk Factors

There are some risk factors for acne. These factors increase the likelihood of developing acne or can worsen existing acne.

Risk factors for acne are as follows:

• Age. Acne is very common during puberty due to hormonal changes. Usually most common between ages 12-25. However, it can appear at any age. Adult acne is especially common in women.
• Hormonal changes. Androgen hormones (such as testosterone) enlarge oil glands and trigger more sebum production. Hormonal fluctuations can trigger acne during periods such as puberty, menstrual periods, pregnancy, and menopause. Hormonal disorders such as polycystic ovary syndrome (PCOS) also cause acne.
• Family history. If there is an acne problem in your family, the likelihood of it occurring in you is higher. Genetic factors affect oil gland activity and inflammatory response.
• Certain medications. Corticosteroids, testosterone-containing medications, lithium, and some epilepsy medications can trigger or worsen acne.
• Oily or comedogenic cosmetics. Heavy creams, makeup products, and hair products that block pores can lead to acne. Products labeled "non-comedogenic" do not clog pores.
• Friction and pressure. Constant contact of items such as phones, helmets, tight collars, or backpacks with the skin can trigger acne. This condition is called "acne mechanica."
• Stress. The stress hormone cortisol can increase oil production. Stress does not directly create acne but can worsen existing acne.
• Diet. Some research shows that high glycemic index foods (white bread, sugar, potatoes) and dairy products may worsen acne. However, this connection is not the same for everyone.
• Sweating. Excessive sweating and staying in sweaty clothes for long periods can contribute to pore blockage.

Diagnosis

Acne diagnosis is usually made by visual examination of the skin. The doctor looks at the type, prevalence, and severity of lesions. In most cases, no special tests are needed.

The methods used in acne diagnosis are as follows:

• Physical examination. The dermatologist carefully examines the skin. The type (comedones, papules, pustules, nodules, cysts), number, and distribution of lesions are evaluated. It is determined whether the acne is mild, moderate, or severe. The presence of scars and spots is recorded.
• Medical history. The doctor asks when the acne started, how it progressed, and what treatments you have tried before. The medications you use, cosmetic products, and family history are queried. In women, menstrual pattern and hormonal disorder symptoms are evaluated.
• Hormone tests. In adult women, if there is sudden and severe acne, menstrual irregularity, or excessive hair growth, hormone tests may be performed. Testosterone, DHEA-S, and other hormone levels are measured. Hormonal disorders such as PCOS are investigated.
• Culture taking. Rarely in resistant acne cases, culture may be taken from the lesion to determine which bacteria are present and which antibiotics they are sensitive to.

Acne classification is generally done as follows. Mild acne (small number of comedones and small papules), moderate acne (more papules and pustules, some nodules), severe acne (many nodules, cysts, and widespread inflammation). This classification determines the treatment plan.

Treatment

The goal of acne treatment is to prevent new pimples from forming, heal existing lesions, and prevent scar formation. Treatment is personalized according to the severity of acne.

The methods used in acne treatment are as follows:

Topical (applied to skin) treatments. This is the first choice for mild and moderate acne.

• Benzoyl peroxide kills bacteria and helps open pores. Sold over-the-counter.
• Retinoids (tretinoin, adapalene, tazarotene) prevent pore blockage and accelerate dead cell shedding. This is the most effective topical treatment for acne but requires a prescription.
• Topical antibiotics (clindamycin, erythromycin) reduce bacteria. Usually used together with benzoyl peroxide.
• Azelaic acid opens pores, kills bacteria, and reduces spotting.
• Salicylic acid opens pores and reduces inflammation. Sold over-the-counter.

Oral (taken by mouth) medications. Used in moderate and severe acne or cases that do not respond to topical treatments.

• Antibiotics (doxycycline, minocycline, azithromycin) reduce bacteria and control inflammation. Usually used for 3-6 months. Resistance can develop with long-term use.
• Combined oral contraceptives (birth control pills) reduce acne by regulating hormones in women. Used only in women.
• Anti-androgens (spironolactone) block the effect of androgen hormones. Especially effective in adult women.
• Isotretinoin (Roaccutane) is the most powerful acne medication. Used in severe cystic acne or cases resistant to other treatments. Shrinks oil glands and significantly reduces sebum production. Requires close monitoring due to serious side effects. Absolutely not used during pregnancy because it causes serious birth defects in the baby.

Light and laser treatments. Blue light therapy kills P. acnes bacteria. Red light therapy reduces inflammation. Photodynamic therapy (PDT) uses a combination of light-sensitive medication and light. Laser treatments target oil glands and improve acne scars.

Chemical peeling. The upper layer of the skin is peeled with salicylic acid, glycolic acid, or other chemicals. Pores are opened and dead cells are cleaned. This is an adjunct treatment for mild and moderate acne.

Injections. Corticosteroid injection can be given to large, painful nodules or cysts. Rapidly reduces inflammation and lowers scar risk.

Extraction (squeezing). This is the dermatologist cleaning blackheads and whiteheads with special tools. Squeezing on your own at home increases the risk of infection and scarring.

Treatment usually begins to show effect after a few weeks. Complete healing can take months. Being patient and continuing treatment regularly is important.

Complications

If acne is left untreated or runs a severe course, some complications can develop. Early and appropriate treatment reduces these risks.

Complications of acne are as follows:

• Acne scars (scars). This is the most common complication. Especially nodular and cystic acne leave deep scars. Depressed scars (atrophic scars) are most common. There can be icepick-shaped, round, or wavy pits. Raised scars (hypertrophic scars) are less common. Scar treatment is difficult and may not be completely eliminated. Laser, microneedling, chemical peeling, and filler injections can improve scars.
• Hyperpigmentation (dark spots). Dark spots may remain in healing acne areas. Especially prominent in dark-skinned people. Sun exposure darkens spots. Lightens over time but can take months. Azelaic acid, hydroquinone, and retinoids can reduce spots.
• Psychological effects. Acne can negatively affect self-confidence, self-image, and social life. Especially in adolescents, it can lead to depression, anxiety, and social isolation. Being teased or bullied because of acne deepens psychological effects. Psychological support can be beneficial.
• Gram-negative folliculitis. Infection with gram-negative bacteria can develop due to long-term antibiotic use. Antibiotic change is required.
• Fulminant acne. This is a very rare but very severe type of acne. Sudden and widespread inflamed lesions, fever, and joint pain are seen. Requires urgent treatment.

Living with Acne

Living with acne can be challenging physically and emotionally. However, acne can be controlled with proper skin care, adherence to treatment, and healthy habits.

Daily Skin Care

Wash your skin twice a day (morning and evening) with a gentle, fragrance-free cleanser. Harsh soaps or excessive scrubbing irritate the skin and worsen acne. Use lukewarm water, very hot or very cold water causes irritation.

Pat your face dry gently with a clean towel. Do not rub. Change your towel after each use.

Use oil-free, non-comedogenic moisturizer. Acne-prone skin also needs moisturizing. Moisturizer is essential especially if acne medications are drying the skin.

Sun Protection

Sun rays darken acne scars and spots. Retinoids and some acne medications make the skin more sensitive to the sun. Use oil-free and non-comedogenic sunscreen with at least SPF 30 every day.

Makeup and Cosmetics

If you wear makeup, prefer non-comedogenic and oil-free products. Mineral makeup products are usually more suitable for acne-prone skin. Always remove your makeup in the evening. Sleeping with makeup clogs pores.

Hair products (gel, spray, wax) can trigger acne if they contact the face. Keep your hair away from your face.

Do Not Squeeze Acne

Squeezing pimples, blackheads, or whiteheads may seem very tempting but should definitely be avoided. Squeezing spreads infection deeper, increases inflammation, and raises the risk of permanent scarring. Only a dermatologist should perform professional extraction.

Diet and Lifestyle

Eat a balanced diet. Consume vegetables, fruits, and whole grains. Limit high glycemic index foods (sugar, white flour). In some people, dairy products may trigger acne, observe your own experiences.

• Drink plenty of water. Keeping the skin moist is important for a healthy appearance.
• Exercise regularly. Exercise reduces stress and improves circulation. However, shower immediately after exercise and remove sweaty clothes.
• Manage stress. Meditation, yoga, deep breathing exercises, or hobbies lower stress levels.
• Sleep adequately. The skin repairs during sleep. Aim for 7-8 hours of sleep at night.

Treatment Adherence

Acne treatments do not show immediate effect. Be patient for the first 4-6 weeks. Some treatments may cause temporary worsening (purging) in the first weeks. This is normal and you should continue.

Use your medications as your doctor recommends. Do not skip doses or stop early. Stopping treatment because acne has improved can lead to relapse.

If you are experiencing side effects (excessive dryness, irritation, peeling), notify your doctor. Dose adjustment or product change can be made.

Emotional Support

If acne is affecting your self-esteem, share your feelings. Talk with family and friends. If necessary, seek psychologist support.

Acne is temporary and treatable. Be patient and kind to yourself.

Preparing for Your Appointment

What you can do:

• Note when your acne started and how it progressed
• List all skin care products, makeup materials, and medications you use
• Record acne treatments you have tried before and their effects
• Note your menstrual pattern (for women)
• Observe factors that trigger acne (certain foods, stress, menstrual period)
• Write your questions down in advance

Questions you can ask your doctor are as follows:

• What is my acne type and how severe is it?
• What is the recommended treatment plan?
• When should I expect to see improvement?
• What are the side effects of treatment?
• Can I use these medications during pregnancy?
• What changes should I make in my lifestyle?
• What can I do to prevent scars?
• How often do I need to come for checkups?

Questions your doctor may ask you are as follows:

• When did your acne start?
• Is acne continuous or intermittent?
• Is there a family history of acne?
• What skin care products do you use?
• What treatments have you tried before?
• How is your menstrual pattern in women?
• What are stress levels like?
• What are your eating habits?
• How does acne affect your daily life?