Acne is not caused by eating chocolate and French fries, or sleeping on a dirty pillowcase or not washing your face enough. Acne is not your fault.
So what is the cause of acne? Genetics and hormones are the main culprits here. Because you can't choose your parents, genetics are totally beyond your control. If you have a family history of moderate-to-severe acne, you have the greatest risk of developing it yourself, especially during your teenage years. Beginning in puberty the release of androgen hormones is the primary triggering event. And the hormonal influence continues through adulthood as hormone levels fluctuate, especially in women, often triggering acne in women who may have escaped it in their youth. Further complicating the picture are cofactors or promoters - stress, medications, diet, cosmetics, environment, pollution, and rubbing your skin - which can make your acne worse.
Ultimately, your journey to clear skin depends on treating your skin on a daily basis and doing your best to avoid the cofactors you can control.
The mechanics of acne are pretty much controlled by your genetics. So, don’t blame yourself for having acne-prone skin. Genetics determine how your body’s immune system responds to bacteria; one person may have only blackheads while another gets explosive red and tender nodules. Genetics also play a role in how easily your pores become plugged. For example, you may have inherited the ability to overproduce dead skin cells, and then shed them in a way that clogs your pores. Redness and pigmentation are functions of your skin color. The lighter your skin, the more redness you are likely to see, while dark pigmentation hides the red, inflammatory response. Darker skin clears with a brownish pink spot (postinflammatory hyperpigmentation) that often remains for months or even years. The bottom line is your genes are the underlying reason for your acne, as well as what type of acne you have. Other factors, which we will discuss later, are influencers.
And genetics are unpredictable. Even in identical twins, one person may get tiny little pimples that last a week, while the other develops cysts that scar. If both of your parents had significant acne, your risk for developing acne also is very high. Because 85% of the population experiences breakouts at some point in their lifetime, you won’t be alone.
Hormones play a huge role in acne. During puberty, everyone - boys and girls - starts to produce masculinizing hormones called androgens. In women, the hormones include testosterone, DHEA-sulfate and progesterone. In men, the hormones are testosterone, dihydroxytestosterone and androstenedione. Androgen hormones cause oil-producing glands to enlarge, stimulating oil production. When there’s more oil and less shedding of dead skin cells, pores become clogged, and there you have it - acne. That's why 80 to 85 percent of teens get acne.
HORMONAL ACNE – WOMEN
The rate at which you produce oil within the oil or sebaceous glands is affected by your hormonal balance, which often fluctuates in both men and women throughout their lives. Normal variations in women's estrogen and androgen levels can cause acne. This explains why women often experience it, not only in puberty, but later in life as well, especially the week before their period. The increase in hormones during pregnancy and postpartum can also wreak havoc on a woman's skin. As the years go by, during perimenopause and menopause, hormone levels become more erratic, often triggering another bout of acne. Women with abnormally high levels of androgen hormones, like those with polycystic ovarian syndrome, have a higher risk of developing acne. Another hormone, cortisol, is released from the adrenal glands during times of stress, often instigating the acne cycle too. To sum it up, hormones explain why 30-40% of women experience some form of acne in adulthood.
HORMONAL ACNE – MEN
Men's hormone levels fluctuate too. Androgens are the male sex hormones that surge during puberty. So it's no surprise that acne in teen males is more severe and longer lasting than in females. Adult males produce about ten times as much testosterone as women do. By adulthood, the oil production in most men normalizes, making acne less of an issue with age. In fact, testosterone has the benefit of increasing the skin thickness in men, explaining why they wrinkle less with age.
Stress can trigger or worsen your acne because it causes the body to release cortisol and androgens from your adrenal glands, increasing oil production. Because women produce a greater percentage of their androgens in the adrenal gland than men, women are more prone to stress related breakouts. Some researchers believe adult acne is on the rise because of the constant stress in our society. Stress can also make your breakouts last longer. And as you well know, having acne adds to your emotional stress, perpetuating the vicious acne cycle. We recommend lowering stress levels with plenty of sleep, exercise and calming activities like meditation and mindful breathing.
Environments & Habits
Outside factors like pollution, exposure to oil and grease may clog pores and flare acne. Heat and humidity, which increase oil production, are also well-documented acne triggers.
The skin is the largest organ of the body. One of its main functions is to protect us from noxious substances. Strong environmental pollutants can result in a rare variation of acne called chloracne, which is characterized by acne like eruptions of blackheads, whiteheads, cysts and pustules. Chloracne is different from the more common acne vulgaris because it's not caused by hormones or genetics.
Personal habits, including the types of products you use, also make a significant difference. Shampoos, conditioners, pomades, hair gels and hairspray may be blocking pores, causing acne on the forehead and around the hairline. The wrong moisturizers or makeup can also clog pores, creating blackheads and whiteheads. Looking for “noncomedogenic” or “non-pore clogging” designations on a product label is worthwhile. Additionally, oil from greasy hair may migrate to the forehead and temples, triggering small breakouts along the hairline, along with scalp acne. So if your hair is especially oily or flakey, consider shampooing more frequently with a medicated product.
Acne is often flared by friction from hats or athletic gear, which traps bacteria, increases sweating, and inflames the skin. To avoid “stewing in your own sweat,” shower and clean your equipment as soon as possible.
Small amounts of sun exposure may seem to help your acne at first because the blue band of visible light helps to sterilize the p. acnes bacteria and a tan masks redness. But prolonged sun exposure increases the shedding of dead cells on the surface of your skin, plugging your pores, eventually producing blackheads, whiteheads and small pimples. Heavy sunblocks are occlusive and can increase the temperature inside your hair follicles, creating small pimple-like bumps. These “sun bumps” are not true acne but a medical condition called miliaria, which is especially common on the torso during the hot, humid summer months. Avoidance of prolonged sun exposure, along with daily use of a lightweight, noncomedogenic sunscreen formulated for acne-prone skin, is best for protecting your skin and minimizing breakouts.
Diet and Medications
While we don't believe diet is the primary cause of acne there is more and more evidence linking certain foods to acne, in some people it may play a contributing role. Carbohydrates found in sugary, starchy, or processed foods have what is known as a high glycemic index. These types of food spike your blood sugar level and eventually create insulin resistance. When this occurs, your skin responds by releasing thick, sticky oil into the pores, which results in breakouts.
Hormones and antibiotics in dairy and meats may also contribute to acne in some people. Looking for “organic” or “hormone-free” foods may make a difference in your skin. High iodine levels in people consuming lots of seafood, seaweed, or iodized salt has also been reported to trigger breakouts.
As you can see, the link between diet and acne is being actively investigated. What can you do in the meantime? We suggest keeping a food diary. Because each of us responds differently to foods, keeping track of what you eat for several weeks may help you identify whether certain foods are flaring your skin. Your next step is to eliminate that food. However, keep in mind, that because acne starts in your pores weeks before a breakout appears on your skin, you will need to eliminate a suspected food from your diet for at least 3-4 weeks. This is the best way to determine whether or not your diet is contributing to your acne.
Drinking six to eight glasses of water a day is healthy for you, but it won’t flush away acne. There’s simply no proof that water can clean the skin from the inside out.
Also watch out for certain over-the-counter and prescription medications that may have side effects that can alter your body’s chemistry and hormones, leading to an acne outbreak. Lithium is one example. Androgenic steroids, DHEA, progesterone-dominant forms of birth control, and medications containing bromides or iodides also fall into this category. Make sure to ask your doctor about any possible side effects of your prescription meds because alternative medicines may be available.