*For severe and cystic acne breakouts, we recommend finding an awesome dermatologist who is willing to help shape and build your acne routine from cleanser to treatment. Dermatologists are the only ones that will be able to prescribe more effective medication. Bring your products in to show your dermatologist so they can get a full understanding of your current regimen and what you’ve already tried.
**As a nice supplement, checkout our oily skin guide to build out your skincare routine fundamentals!
For many, acne is the sole reason why anyone would start paying attention to your skin and skin routine in the first place. This taboo subject plagues so many (it shouldn’t even be that taboo anymore) and can be a continual skin concern well into your 40s. While there’s no single cure for acne, there are a number of topicals that you can incorporate into your routine to help minimize acne breakouts and shorten the time of healing. But before we get into products, let’s first explain the biology and wrap our minds around why there’s still no cure for acne.
The Biology: Four Culprits Behind Acne
Forget what you’ve heard about bacteria overgrowth being the root cause of acne. Up until even the 2010s, many believed that acne was simply caused by an overgrowth of the bacteria Propionibacterium acnes (P. acnes). This ultimately led to treatment regimens that included oral antibiotics and bacteria-killing topicals. But with all the work in microbiome research, the research community has realized that acne is much more complex than a bacteria overgrowth.
Since then, the bacteria responsible for causing acne has been rebranded as Cutibacterium acnes (C. acnes) and we’ve learned a few more things about who are the culprits behind acne lesions and breakouts. At the core of acne breakouts is hormones, stress, genes, basically factors that we have little control over. But despite the root issues, we've been able to identify 4 resulting factors that contribute to breakouts. So let’s dive deeper and take a look at the sebaceous gland, the heart and center of acne growth.
There are four mechanisms involved in acne breakouts:
- Increase and altered sebum production: Refer back to our oily skin blog post, but there is a direct correlation between excess sebum production and acne growth. In fact, there’s work being done to analyze the profile of your sebum components and understand its impact on Cuti bacteria overgrowth.
- Hyperkeratinization of the pilosebaceous follicles: Remember how timely skin shedding equates to healthy skin? Even the skin cells in your follicles can overstay their welcome. This build-up of cells causes the lesion to form and also builds a nice haven for Cuti bacteria growth.
- C. acnes overgrowth: C. acnes feed on your excess sebum and with your follicle providing a nice headquarters for them, presto! You have Cuti bacteria overpopulation.
- Inflammatory mediators: Pain, redness, swelling, sensitivity, basically everything that contributes to an angry breakout.
Main Acne Fighting Actives
The interesting thing is that there’s only one prescribed drug out there that tackles all four of these focuses and that’s isotretinoin, Accutane. Again, just want to remind you that if you’re struggling with long-term, severe, cystic acne, it’s best to onboard a derm to really give you the arsenal of treatments to tackle your acne breakout.
In fact, here’s a fun little guide of some top acne treatments and the mechanisms they tackle to help give you an idea of why it can take an cocktail of ingredients to reign in your breakout:
***one last asterisk! This chart is not to be used as material to argue with your derm. We will 100% take their side.
We made the chart above to give you a general idea of acne ingredients and their benefits. The real takeaway here is that you’ll need more than one active ingredient to really tackle acne from all angles. Don’t think your 10% azelaic acid cream is going to be your sole miracle product. Validating mechanisms (mode of action) is rare and requires some reach into in vitro data. Not to mention it can depend on concentration.
Overview of Support Products
Outside dermatologist prescribed treatments, if you take a look at all the “touted” acne treatments it can be quite the circus. So before we build up your routine, let’s break down all the touted products and cult favorites. Look for Acne Pt. 2 for our guide to building your acne routine with products and tips on how to assess your breakout progress.
Cleansers: Because of classic, timeless cleansers like Neutrogena Oil-Free Acne Wash, cleansers can get slightly religious for acne-prone skin types. This probably extends back to when people thought “ acne = dirty”. But that’s not the case! If anything, acne-prone skin types are the most on top of their routines, and can’t help but overachieve in the hygiene area. The actual concern here is overwashing your face, stripping your skin barrier of its necessary hydration components to keep skin healthy. Stick to twice a day cleansing. A good cleanser is an absolutely boring cleanser that performs its simple function of cleansing without going overboard. This is also a good place to add in your salicylic acid if you’re running out of room in your routine.
Toners: Back in the day, astringent (read: alcohol-based) toners were all the rage for oily skin types. It is true that alcohol can help thoroughly remove excess sebum and help with actives penetration. However, now that acne routines are usually a cocktail of multiple treatments, we don’t believe this is a must in a routine since it can cause additional dryness and sensitivity. Hydrating toners are also not a must.
Face Sprays: We joke a lot about witch hazel face sprays being a complete mystery to us. (It’s been hard to find any data on justifying this as a particularly helpful product for acne). We see a whole basket of mists & sprays (mineral water, salt, witch hazel) more as a soothing moment rather than active treatment
OTC Treatments: There are 3 major acne-fighters available at various concentrations without the need for a derm prescription:
- Benzoyl peroxide: We’re sure you know all about the bleaching, irritation, dryness, and pillowcase destruction that comes with benzoyl peroxide. While benzoyl peroxide alone might sound so 2000s, it not only has a long history of helping reduce acne breakouts but seems to do great in conjunction with your other treatments. It’s found to help minimize the development of antibiotic-resistant acne when using antibiotics and even has been shown to have a synergistic effect with adapalene. One issue here is that thanks to topicals like Rapid Clear, persa-gel, and Clean and Clear, many acne-prone skin types believe they should be using the max 10% concentration to tackle their breakouts. Turns out even at 2.5-5%, benzoyl peroxide can still be effective in a routine.
- Salicylic acid: Recently salicylic acid somehow seems to be talked about as the acne savior. Let’s manage expectations here. Salcylic acid is great as an oily skin exfoliator because it’s slightly oil-soluble and can penetrate and exfoliate at the pore level. But this won’t be the sole ingredient that erases your breakouts. Consider this as a secondary ingredient to work in after you’ve got your main acne topicals figured out.
- Adapalene: We’re very happy to see that adapalene is now offered as an OTC. It’s been shown that 0.1% adapalene was found to perform significantly better than 0.025% tretinoin but was still more gentle. Enough said? But wait! It turns out that there is a synergistic effect of using both adapalene and just 2.5% benzoyl peroxide with results showing as early as week 1.
We’ll dive deeper into acne treatments in part 2, but the rule here is that there is no single treatment that will eliminate all your acne breakouts. As we’ve discussed in the biology section, there’s no acne topical that targets all mechanisms. To really tackle acne, you’ll need a cocktail of ingredients, which means you’ll need to do a little more work upfront to figure out your combo of actives and your routine layering strategy.
Moisturizers: Acne-prone skin still needs moisture! Just in different ways than other skin types. It’s important to continue supporting your skin barrier to help your skin adjust to your treatments since dryness is pretty much the most common side effect of acne treatments.
Sunscreens: There’s a myth out there that the sun helps fade your spots. This is very false! Too much sun can end up aggravating your acne and lead to darkening of PIH, prolonging healing time and increasing your potential for sunscreen. Not to mention some of the topicals you’re using require good sunscreen habits or else can compound these negative effects.
- Chemical sunscreens
- Still struggling with SPF 50 texture? We recommend lighter chemical sunscreens with even alcohol to help with compliance and reapplication. If you still have no luck, consider reaching for an SPF 30 or even SPF 15, anything that can help keep skin protected.
- Acne is so much more than an overgrowth of unwanted bacteria
- It takes a tribe to fight your acne but don’t try to add everything all at once. Slowly introduce treatments one at a time into your routine. This way you’ll know how your skin is reacting to each added layer.
- Find your combo of actives that help reduce breakouts without causing long-term skin irritation.
- Probably the two most underrated areas in acne care is soothing & sunscreen. Both help with the overall healing process and prevention of scarring.
I’m curious about acne-prone DRY (and sensitive) skin – does this just tend to be an issue with skin barrier and immune function, which then leads to the overgrowth of C. acne, or is there still an issue with sebum production that just isn’t obvious to the owner of said skin?