Different Kinds of Acne and Successful Home Treatment Options

This is going to be a lengthy post. Unfortunately, acne isn't as simple as a one-sentance or even a one-paragraph or one-page solution. Different things work for different people, and different kinds of acne. Although an esthetician or doctor can put you on products with ingredients that have a great track record, it still may not work effectively for you. Unfortunately your routine may need gradual tweaking through trial and error. However, through experience, we'll be more equipped to recommend something that will work its best than you will probably be perusing the rows and rows of products at the drug store.


Coming to terms with it

We've likely all experienced acne at some point in our lives. It's important to accept it as a fact of life. Many people are genetically predisposed to acne-prone skin, but other factors including environment and hormone fluctuation can affect acne formation. The idea that acne only affects teenagers is one of the most widely held misconceptions about this common skin condition. In 1998 Neutrogena conducted a survey of women between 25 and 39, and discovered that 59% of them had suffered from some kind of breakout in the last year. 

Why some so-called remedies don't work

For starters, everywhere you turn there is a product that promises you clear, smooth skin--the sheer quantity is part of the issue. It becomes difficult to choose, and to figure out which ingredients are honestly effective.  Because there are various kinds of acne (inflammatory, non-inflammatory, whiteheads, blackheads, papules, pustules...) different ingredients are also better for different kinds.

Unfortunately, if you've sought help from a dermatologist, many aren't very good at conveying exactly how they intend the medication to be used, how they work, and how long it will be before you see results. Misuse can cause side-effects like over-drying, causing frustration, and eventually discontinued use.

Just like losing weight, treating acne (or any other skin condition for that matter, such as hyperpigmentation or wrinkles) requires patience and most of all consistency. No matter how perfect the plan you, your esthetician, or even your dermatologist devises for you---it will never work if you don't stick to it.

De-bunking the myths

Long ago, many people (including doctors!) thought that rich or greasy foods made the skin excessively oily, causing acne. It seemed a reasonable assumption--but it is coincidental that many people crave mood-elevating chocolate, or sometimes greasy, salty foods when they are under stress or for women, when they are on their menstruation cycle---both of which can trigger acne.

It's also a wide misconception that blemished skin is caused by poor hygiene.  Acne is not caused by unclean skin, but rather, by using products with effective ingredients, it can help alleviate the problem. For example, you do not get strep throat because you didn't take antibiotics---but antibiotics can heal the illness. You could diligently use an expensive, well-formulated product, that just doesn't have the right ingredients for your skin, or your condition--and still have regular breakouts.

There are two kinds of "pores" on your face. One are your hair follicles, the tiny openings out of which, hair grows. The other are miniscule openings to sweat glands. oil glands are only present in the hair follicles, which means that sweat glands and sweat production are not directly linked to acne.

To better understand how acne is formed, you need to know this first:

Sebum is a technical term for oil. Oil is produced by the body as a natural lubricant and moisturizer for the skin. It is important to help the skin to stretch with your every move (think about how your skin stretches over your knee when you bend your leg---the skin would simply crack if it were not kept lubricated).  If you've ever accidentally put a bottle of olive oil in the refrigerator like I have, you'll know that when it's chilled, it solidifies--becoming thick and dense. This is one of the reasons why in facials, estheticians use steam and hot towels---to soften the oil, making it easier to press out of the skin.

Sebum (oil) is produced in the "sebaceous gland" which is attached near the base of each hair follicle. This allows the hair to effectively wick the oil to the surface of the skin.

How it all happens

Although high quantities of oil may help acne to form, it does not guarantee a break out---there are many people with oily skin who are not acne-prone, and even several people who actually have dry skin, that are prone to acne.

Acne starts when something goes wrong with the skin cells that line the follicular walls.  These cells are an extension of the top layer of the skin, which folds in and out of the follicles.  The top layer of the skin regularly replaces itself as a normal part of skin renewal--forming a new layer of skin at the bottom, and pushing new cells toward the surface. The skin cells are lost during regular human contact--rubbing against clothing, or being washed away in the shower. Humans discard skin cells at more than a million every hour.

For some reason, there is a glitch in the system in some of these follicles.  Acne-prone follicles produce new skin cells at a faster rate than normal cells, causing an excess of skin cells that mix with oil, stick together, and are retained in the follicle causing a blockage. The follicle continues to produce more skin cells, and more oil--keeping them blocked, often causing a visible bump under the skin.

Some lesions stay like this, a "papule" that has no head, and cannot be squeezed out of the skin. Some continue to grow, pressing open the follicle at the top of the skin. Once it is exposed to air, it oxidizes, turning dark brown or black in color (Just like an apple browns after it is cut and exposed to air). These are known as "blackheads"

Some of the lesions take a different course in the papule stage, and turn into "whiteheads". Instead of growing upward and pressing the follicle open, they stay where they are, expanding beneath the pore, which stays constricted. It enlarges into a knot, typically with a tiny white tip at the surface.

Both whiteheads and blackheads can be extracted (pressed from the skin during a treatment from an esthetician or dermatologist---it is not recommended that you do extractions at home, because if not done with the right technique, it can cause significant scarring that can at times be even more unsightly than the acne lesion).

In most cases, when the follicle is closed, it creates a perfect breeding ground for P.acnes bacteria, which are anaerobic (they cannot live in the presence of oxygen) and feed on sebum. This is one of the reasons why strong astringents containing alcohol often do not produce results---it can kill bacteria on the surface, but cannot penetrate and reach the P.acnes.  The bacteria can multiply quickly, and release chemicals that damage the lining of the follicle wall. White blood cells try to heal the problem by destroying the bacteria. This is called a "pustule" and is usually what is happening when an acne lesion feels swollen and tender to the touch. 

Unfortunately, with the follicular wall stretched so far and the damaging chemicals released from the P.acnes, the wall can rupture--spreading to neighboring follicles. (This can also happen manually---if you try to extract something that shouldn't be extracted at home--pressing on something without a head, will likely cause the follicle wall (underneath the skin) to "pop" spreading the bacteria under the surface, and actually taking it even longer to heal. This is what has happened when an "acne cyst" has formed.

So how do I treat it?

Treatment options vary, as it depends on the kind of acne it is treating. Occasionally a person may have all the different types present at once---others may only regularly have blackheads, or yet others, may only get papules. This will affect what is right for you. 

Because acne is a skin disorder, for a product to be truly effective, it needs to be a medecine or a drug. "Cosmetics" generally do not help.  Many products that are made to treat acne are actually over-the-counter medications. Just like you may buy ibuprofen over the counter, you can also get a prescription for a stronger dose of the same medication. It works the same way with topical drugs for the skin.  There are only four FDA-approved active ingredients for acne available in over-the-counter drugs. These must be properly labeled with something that looks somewhat like a nutrition facts label, specifying the "active ingredient" and it's concentration at the top.  Further down on the label, it will specify the "inactive ingredients" (those that are not classified as drugs). Many of these "inactive" ingredients do help, but are not recognized by the FDA. Tea tree oil, for instance is known for it's healing properties. Aloe and Allantoin are known as soothing and anti-inflammatory. Lemon is known as a natural astringent. No matter where you get your product, whether a spa, online, a department store, or the drug store, if it is a cosmetic "drug" with an ingredient recognized by the FDA to treat acne, it must contain one of these four ingredients.


Keep in mind that at times products are grouped together and sold in a set, or as a "line" where all the products are meant to be used at the same time (like Proactiv). In most cases this is done, so the manufacturer can use small quantities of the same ingredient in each product to produce the overall effect. Mixing and matching, therefor, can sometimes be difficult---if you use a cleanser from one line and a treatment lotion from another, you may come up with a treatment that is way too strong.


Try adding products one or two at a time so you have a clear idea of what is improving your skin, what could be giving you a bad reaction, and also to prevent over-irritation. Remember, a good skin care routine does not have to be complicated. Most of the time I recommend acne clients an appropriate cleanser, treatment lotion, and sunscreen. Occasionally I may recommend a moisturizer, depending on the situation.

To get the best results from these drugs, you need to know how they work, and what kind of acne it treats best.

Benzoyl Peroxide- (sometimes spelled Benzyl Peroxide)

Benzoyl peroxide is effective at treating both inflammatory and non-inflammatory kinds of acne. It is the most effective of the four ingredients at ridding the skin of blackheads in particular, but is effective in treating the other kinds of acne as well.

"Peroxide" implies that the chemical compound contains oxygen atoms.  As previously discussed, P.acnes bacteria cannot live in the presence of oxygen.  This particular ingredient is small enough it can be absorbed into the skin, and expose the bacteria to oxygen--therefor killing it. Without the bacteria, there will be no need for the white blood cells to accumulate, causing pus and inflammation.

Other ingredients containing Oxygen have not proven to be as effective, since they often are not small enough to deliver the oxygen where it is needed to kill the bacteria.

Unfortunately most products containing Benzoyl Peroxide are marketed or labeled in a way that is misleading. Most of these products are called "spot treatments". This leads you to assume that when you have a break out, you simply apply the product to only the blemishes (the "spots"), and they go away. However, it is the least effective when used in this manner. Even Rhonda Allison's product labeling says "Apply Blemish Complex directly to acne blemishes and let dry. For best personal results use one to four times a week as an effective acne spot treatment".

 Saying this with personal and professional experience, and backed with scientific research: Benzoyl peroxide should be used to "spot treat" areas that typically break out by covering the entire area with a thin layer of product. It may help reduce the appearance of current lesions, but will do it's job as a preventative treatment to future breakouts. In other words, if you typically break out only on the forehead---you would apply the product in a thin layer over the entire forehead---but you do not need to apply it anywhere else---you are only treating that spot. If you only break out on your cheeks---the same thing.  If, however, you break out in no particular pattern---sometimes on the nose, sometimes on the cheeks, sometimes on the forehead, sometimes on the chin---it is acceptable to apply it to the entire face.

Benzoyl Peroxide can be very hard on the skin--causing redness, dryness, and scaling. Fortunately, many products containing it also feature soothing, moisturizing ingredients to counter these effects. Rhonda Allison's Blemish Complex contains 5.25% Benzoyl Peroxide as it's active ingredient but also features Glycerine (an ingredient that attracts and keeps water in the skin), Allantoin (from the Comfrey plant, also helps with water levels, and provides soothing, wound-healing effects), and Aloe (helps with hydration, soothing, anti-inflammatory) as inactive ingredients. PCA also makes Acne Cream which contains 5% Benzoyl Peroxide, and similar inactive ingredients.

Also, if these products are used appropriately, it is easy to avoid many of these side effects. Available in concentrations up to 10% over-the-counter many consumers and manufacturers alike often think "more is better", but according to a number of studies: Benzoyl peroxide's antibacterial effects are similar at 2.5%, 5%, and 10%, but with higher percentages, the likelihood of dryness and irritation also increases.  I recommend beginning use of the product once a day, every other day for about 2 weeks. After that time, you can increase use to once a day, every day for 2 weeks. If at that time, the condition has dissipated, this may be a sufficient dosage. If acne lesions are still present, you may increase the application to 2x every other day and 1x each alternative day for 2 weeks, finally increasing to 2x every day if necessary.  By slowly introducing the ingredient, your body is less likely to react negatively. You can also try using a cleanser containing the ingredient. It can be less irritating because the benzoyl peroxide does not stay on the skin for a long period of time, but it can also be slightly less effective for the same reason. 

For those with particularly stubborn acne (like my husband) I recommend cleansing with a product containing BPO (short for Benzoyl Peroxide) at least 1x a day (I do recommend weaning yourself on, though, just like with the cream) and then applying the cream 2x daily.  Rhonda Allison does not make a cleanser like this, but PCA (which stands for Physician's Choice of Arizona, if anyone was curious...) does. It is fittingly named BPO Cleanser and contains 5%.

Rhonda Allison also recommends following application of Blemish Complex with her Growth Factor Gel---a product targeted at providing light moisture with healing effects.

Please keep in mind that BPO is a bleaching agent, which means that it can cause your hairline, eyebrows, or facial hair to gradually lighten if applied there. Similarly, if it is not completely dry, it may cause your towels or bed-linens to bleach.  I personally have not had this problem while using Rhonda Allison's Blemish Complex or PCA's Acne Cream or BPO Cleanser, but my husband did practically destroy a towel when he was using a 10% BPO wash by Clean & Clear.  I don't know if my sheets have not been affected because of the finish or how color-fast the dye they used was, if it's because of the lower concentration of the Benzoyl Peroxide, or because of other ingredients in the formula. It could very well be a combination of any or all of those reasons.

Salicylic Acid-

Salicylic acid is derived from Wintergreen and Birch Bark. It is commonly referred to as a BHA, or Beta Hydroxy Acid. Chemically related to Aspirin, or Ibuprofen, Salicylic Acid similarly reduces inflammation, making this ingredient particularly good for tender, red, swollen lesions like pustules and cysts.  It can be good for other types of acne, but often I will use it and an ingredient like Benzoyl Peroxide in those cases. Because of it's relation to Aspirin, you should not use Salicylic acid if you are allergic to Aspirin.

Salicylic acid works in more ways than one. The first way is by helping reduce the inflammation, but the other is by exfoliating the skin cells.  As I mentioned in a previous post, I prefer mild acids or enzymes to exfoliate, because they can actually penetrate the skin, entering the follicle, and exfoliating more thoroughly than a scrub that just sits on the surface. Salicylic acid does exactly that. To treat acne, it is available over-the-counter in concentrations as high as 2%. The exfoliating action of salicylic acid helps reduce acne by chemically dissolving the excess skin cells that have been retained in the follicular wall---creating an opening that exposes the P.acnes to air, killing it, and also allowing the sebum to be properly wicked to the surface once again.

Although you can expect to notice a dramatic reduction in inflammation as soon as the next day of using Salicylic acid, it can take a seemingly long time for it to exfoliate enough to actually clear up the lesion on its own. Similar to BPO, it is best used as a spot treatment (applied in a thin film to the area you would normally break out) as a part of preventative maintenance.

I like combining the use of Salicylic Acid products with Benzoyl Peroxide for maximum efficacy of each. I feel that after the skin has been exfoliated by the Salicylic Acid, it becomes easier for the Benzoyl Peroxide to absorb and reach the affected area. Therefor, I may recommend you use a scrub like Pumice Wash 2-3x a week that contains Salicylic acid, or daily use of Beta Green Tea Cleanser, followed by an application of a lotion containing BPO.  You could also use a leave-on Salicylic Acid treatment like Rhonda Allison's Blemish Serum 1 or 2 times daily. Sometimes I may recommend you apply the Salicylic Acid product in the morning, and the BPO product at night---so you aren't applying too many products at once, but you can get the benefits of each. The reason I recommend they be applied in that order is so you are exfoliating first, allowing the BPO to penetrate further when you apply it at night. It is common for it to feel like it stings a little when applied, but the stinging dies down as the product dries.

I also love administering treatments in the spa using higher concentrations of Salicylic Acid. As I mentioned, it is only available over-the-counter in concentrations up to 2%, but can be handled by estheticians in concentrations of up to 30%. I have seen fantastic results doing peels with Rhonda Allison's Salicylic Peeling Cream with a concentration of 25%. It's a great way to jump-start any acne treatment regimen (Unless of course, you are allergic to Aspirin). It is applied in a thin even layer to the skin, and allowed to work for 10-20 minutes. It can feel anywhere from mildly irritating, to itchy, "hot", stinging, or even "burning" sensations. This is perfectly normal. The discomfort can be off-set with a hand-held fan, and most of my clients say it is worth it in the end. (I'll also distract you with an awesome neck, chest, and shoulder massage!)

One of the only catches with Salicylic Acid is that because it is an acid it is only effective when the product is within a particular range on the pH scale. [As a reminder: the pH scale goes from 1-14, with 1 through 6 being acids, 7 being neutral, and 8-14 being bases (also referred to as alkali) The closer to 1 the acid is, the stronger it is, and the closer to 14 the base is, the stronger it is. Acids with a pH of 1 or 2 and Bases with a pH of 13 or 14 will create a chemical burn.] The skin is naturally at a pH of 4.5 to 5.5 (it varies depending on the person, and other internal or external factors). In order to be most effective, the Salicylic acid needs to be more acidic, somewhere between a pH of 3 or 4, but also a mild enough acid that it will not be too irritating, or cause a burn. Surprisingly, many products do not fall within the appropriate pH range, making them significantly less effective than those that do.

The only other drawback is that because it is not soluble in water, many products containing it are also formulated with alcohol, which can be irritating and drying. However, most of these products also have ingredients like Green Tea and Tea Tree Oil to help offset the drying properties of the alcohol.

Sulfur, and Sulfur combined with Resorcinol-

Sulfur has been used to treat acne dating back hundreds of years. It is not seen nearly as frequently in OTC (over-the-counter) acne treatments as BPO or Salicylic Acid, though. It is deadly to many kinds of bacteria and softens scaly skin; And like Salicylic Acid, it too exfoliates and acts as an anti-inflammatory. It is most commonly found in spot treatments and masks. (like Rhonda Allison's Impure Skin Mask or Beta Refine Mask (which also contains 10% Salicylic Acid, and is allowed to be sold in higher concentrations than normally available over the counter because it is dispensed by a licensed esthetician)]

Studies have suggested that Sulfur combined with BPO is more effective than either of the two alone, but along with that, produces more sensitivity. Drugs containing both must be used carefully; many are available only by prescription.

It is particularly beneficial for those with fair hair, eyes, and skin--people who are most likely sensitive to Benzoyl Peroxide.

Resorcinol is not FDA approved to fight acne when used alone, but when coupled with Sulfur, it's stronger exfoliating properties allow Sulfur to become more effective.

 When sold in concentrations suitable for use over-the-counter, it's not FDA-approved to treat acne, but I think it's worth mentioning:

Retinol-

Otherwise known as vitamin A, retinol is the compound from which retinoic acid--the active ingredient in prescription drugs Retin-A, Avita, and Renova--is derived.  Retinol can be effective because enzymes already present in human skin manufacture it into trace amounts of retinoic acid.  It needs to be in the right concentration, and part of a very stabilized formula to work effectively.

Retinoic acid is effective against both inflammatory and uninflammatory acne. They are hormone-like chemical messengers whose molecules stick to receptors in skin cells to change the way it behaves.  In acne-prone skin, they turn abnormal cells that stick together in follicles into normal ones that exit the follicle like a normal cell would.  In sun-damaged skin cells, they also help "normalize" the cells that make up wrinkles and age spots.

Unfortunately irritation and peeling are side effects.  Like Benzoyl peroxide, products containing Retinol (or Retinoic acid) must be gradually introduced to the skin for the least amount of irritation.  A small amount may be applied over a moisturizer, or mixed with an equal amount of moisturizer, to dilute it and reduce the side effects as well.

Because of it's recognition from the FDA for reducing the visible signs of aging, this ingredient is particularly appealing for adults who would like to treat both acne and wrinkles or sunspots.

Retinol is popping up in more and more products mainly targeted at anti-aging. Unfortunately, at times this means the creams are also too heavy for skin plagued with acne. When using as a part of an acne regimen, look for a product with a gel-like consistency. You can always use a light moisturizer with it to balance your skin and reduce the side effects of dryness and irritation.(Rhonda Allison's Growth Factor Gel would work well with this, too).  Rhonda Allison's Retinol Supreme and Therapy A Serum could make great additions to many acne regimens.

You could once again consider a peel performed in a spa. Because Retinol can be so irritating, it is often paired with anti-inflammatory ingredients. Some Options include Rhonda Allison's Vitamin A Peel  which uses 15% Retinol and 10% Lactic acid. Much like the Salicylic Peeling Cream, this will likely feel itchy, tingly, or like it is hot/burning. With this, however, the sensation only lasts until it dries, after which time it is left on your skin overnight to be washed off the next morning. It will leave a yellow tint to your skin that evening, and will likely cause flaking a few days after application, causing 1-3 days of "downtime" so doing this on a Thursday when you plan to have a quiet weekend to yourself is recommended. (Often your skin will look normal the next day, and flaking begins 1 or 2 days later).

 Always, Always, Always wear a Sunscreen when on an Acne Routine

With sensitizing ingredients like Retinol, Salicylic Acid, and Benzoyl Peroxide, the skin is left even more vulnerable to the damaging rays of the sun. It is important that you end your morning routine with an application of an effective sunscreen.  If your makeup has sunscreen built in, I'd still recommend application of a separate sunscreen first---simply because with makeup you likely will not cover your neck, or push the product as close to your hair line. If you concentrate the makeup mainly in the areas that need it, some areas may go unprotected altogether.

Look for some of these ingredients, and try these tips. If your skin still doesn't improve *look for a post about prescription treatments in the future* and consult your dermatologist! 

Keeping you beautiful (and unblemished!) one post at a time,
Kate Block