Most of us have had to deal with acne at some point or another as it is a common chronic inflammatory skin condition that affects about 89% of adolescents, and often persists into adulthood due to a myriad of reasons.
Before we dive in deeper to acne and it’s causes, let’s take a look at the appendage of the skin central to acne development: the Sebaceous Gland.
The Sebaceous Gland
A sebaceous gland secretes sebum, the skin’s oily substance. These glands are found within the dermis and are typically attached to a hair follicle.
Sebaceous glands that aren’t associated with a hair follicle open directly onto the surface of the skin via a duct. These are called sebaceous follicles and are typically found around the upper lip and corners of the mouth, the chest, back and genital area.
On the face and scalp, there are as many as 400-900 sebaceous glands per square centimetre — compared to just 100 glands per square cm on average for other areas of the body. This explains why we tend to feel more “oily” on our face (and in particular, the t-zone) compared to elsewhere on our bodies.
Note that sebum is NOT the same as sweat. While sweat is primarily water, sebum is made up of triglycerides, fatty acids, wax esters, squalene, and cholesterol.
As estheticians we typically hear clients complain about sebum but, it actually plays an important role in skin health. In particular, it helps lubricate and protect the skin, as well as prevent a certain level of dehydration. However, when sebum production becomes imbalanced problems can begin to arise in the skin.
Causes of Acne
While many factors can lead to the development of acne, the mechanism that causes all acne is the same. Essentially, a combination of corneocytes (hardened, late-stage keratinocytes) and sebum build up within a follicle and block oxygen from entering — creating an ideal environment for the anaerobicbacteria c. acnes (previously p. acnes) to proliferate. In some cases, this blockage can become inflammatory trigger an immune response).
Note: Acne bacteria was recently reclassified from p. acnes to c. acnes with the recent discovery that this bacteria is not more present within the skin of those who suffer from acne — but actually it is more likely to become inflammatory due to the specific conditions of one’s skin. It is the presence of an inflammatory response to c. acnes bacteria that makes a skin condition truly acne vulgaris
The sebum and skin cells within a follicle react with the c. acnes bacteria present, causing it to proliferate and increasing the likelihood that an infection will develop. An infection triggers our natural immune response: white blood cells rush to the area to heal the infection, inflaming the surrounding cells and increasing sebum production, which can further block oxygen from the pore. In turn the inflammation increases, which can create pustular or cystic acne in more severe cases.
There are many factors that can lead to or contribute to the conditions that result in acne. Some common ones include:
-Use of heavy cosmetics
-Candida overgrowth in the gut
-Hormonal imbalances or fluctuations in androgen levels (caused by hypothyroidism, poly-cystic ovarian syndrome, or even a normal menstrual cycle)
-Stress (which triggers the overproduction of cortisol, resulting in increased sebum production)
-Food sensitivities (for example, dairy, sugar and gluten may trigger inflammation)
-Overly drying or “stripping” products that disrupt the skin’s natural moisture factor (aka the NMF) causing overproduction of sebum
-Environmental factors such as humidity or pollution
-Over keratinization (build-up of corneocyte cells in the stratum corneum)
-Fatty, rich or fried foods (may contribute to higher levels of inflammatory fatty acids within sebum).
Types of Acne
- Open Comedones (aka blackheads):Follicles that have formed a block or “plug”of sebum at the surface of the skin. Exposure to the environment causesoxidation of the sebum, creating the darkgrey or black colour.
- Closed Comedones (aka whiteheads):Similar to open comedones, however, a layerof corneocyte cells are protecting thesebum plug from oxygen exposure andoxidization.
- Papules: Pimples that appear as a red and elevatedbump on the skin. They develop whensebum and keratinocyte build up and c.acnes inflammation begins to form underthe skin.
- Pustules: Papules that have become overburdenedwith sebum and bacteria, causing visibleinflammation of the follicle – including pus(what we see as a “white head”)that appears at the surface of the skin.
- Cysts: Large, deep pustules that form when thecontents of the pustule burst through thefollicle wall, causing a spread ofinfection into the surrounding areas underthe skin. They usually appear as a large, redor boil-like lump at the surface of the skin.
- Nodules: Similar to cysts, nodules are pustules formed deep under the skin – however, they have not yet “burst” through the follicle wall. Instead, with no place to go, the inflammatory contents harden and nodules appear as large, skin colored or red lumps under the skin. Their depth makes them difficult to treat and they can often take weeks or even months to heal.
Grades of Acne
Grade 1 acne is considered MILD ACNE and is characterized by the presence of comedones (i.e. blackheads and white heads), and a few or infrequent papules and pustules.
Grade 2 acne is considered MODERATE ACNE and is characterized by the presence of comedones like in grade 1, as well as more consistent papules and pustules. Bothgrade 1 and 2 acne is typically confined tothe face.
Grade 3 acne is considered MODERATE TO SEVERE ACNE and is characterized by the presence of papules and pustules, as well asoccasional cysts or nodules. Grade 3 acnemay also present on the back and chest.
Grade 4 acne is considered SEVERE NODULOCYSTIC ACNE. Grade 4 acne is characterized by large, painfulpustules, cysts and nodules with significant inflammation. Often grade 4 acne will spreadto the back and chest as well.
While there is no cure for acne, it can be managed with lifestyle modifications and by the skincare products we use. Acne is very complex and there are usually multiple nuanced factors contributing to active acne- I highly recommend consulting with a professional before taking matters into your own hands.
Although it can be really frustrating, the good news is that all acne is essentially the same in that it starts with a clogged pore, and there are universal steps that can be taken for relief.
It can be so tempting, but the most important step is to avoid picking or popping pimples. First, we’re interrupting the natural healing process and actually prolonging the condition. We’re also likely to spread the acne bacteria, giving it the opportunity to clog surrounding pores. And most importantly, we run the risk of rupturing the pore wall and spreading the infection further under the skin – which causes cysts and nodules. These more severe forms of acne take longer to heal and are more likely to scar due to being inflamed for a longer period of time. Post Inflammatroy Erythema (PIH) are the pesky post acne marks that linger for months or years, and are usually what bothers us the most about our acne.
Touching or picking at an acne lesion is a guarantee that there will be PIH left behind even once the acne is healed. While I know simple ‘not picking’ isn’t the quick fix you were hoping for, I promise consistency here is key when it comes to acne.
Ice your face! Using a cold compress multiple times a day helps bring down inflammation and relief from painful acne lesions.Always use a barrier on your skin and note that your face should never hurt from using ice.
Sunscreen sunscreen sunscreen. The more you apply, the less inflammation, and the less likelihood of scarring.
Hydrocolloid patches like the one from Hero Cosmetics https://www.sapienskin.com/collections/acne/products/mighty-patch are helpful in aiding the healing process and reducing inflammation aka lessening the chances of scarring.
Minimize inflammation in your diet. Sugar, gluten, alcohol and dairy are the biggest sources of inflammation from what we put in our mouths.
Stress management. The emotional and physical effects of stress take a toll on our bodies and can exacerbate acne.
Minimize bacteria being introduced to your face. This includes any type of face touching by any object, frequently changing pillow cases (3x a week), using bleach on towels and bedding, cleaning makeup brushes, washing your hands before washing your face, cleansing your scalp daily, and double cleansing your face in the shower twice daily.
For everything else related to your own personal acne management, it truly comes down to your unique needs and triggers. This almost always requires professional guidance so that you can get a skin education that lasts a lifetime.
I have personally suffered from acne for years, but after making some changes, I now manage my skin health with ease so I can get back to living my best life. The emotional and physical toll of acne is worth investing in yourself.