Acne (teenage spots)

What is acne?

Acne is a skin condition in which the sebaceous (oil) glands and pores (the openings of the hair follicles) become blocked more easily and inflamed. This produces blackheads and whiteheads, pimples and spots. Acne is usually found on the face, back, chest and shoulders. It is common in puberty, but also occurs in adults. Acne is not contagious and has nothing to do with being “dirty”.

In brief: acne is an inflammation around the sebaceous glands, giving blackheads, whiteheads and pimples. Treatment mainly works against new spots, and you usually only see a clear difference after 6–8 weeks. In severe acne (or when scarring occurs), prompt treatment is important to prevent lasting damage.

What can worsen acne?

Heredity (it runs more often in families).
Hormones (puberty, menstruation, pregnancy, starting or stopping contraception).
Stress (can worsen acne, but is usually not the only cause).
Greasy or pore-clogging cosmetics (choose “non-comedogenic” products).
Friction or pressure on the skin (for example a tight collar, helmet, headband or backpack straps).
Certain medicines (for example corticosteroids, some hormones) — discuss this with your doctor.

Diet. Acne is not caused by poor hygiene or “eating dirty”. In some people, however, acne does seem to worsen with a lot of dairy and/or a lot of sugar (fast carbohydrates). This does not apply to everyone. If you wish, you can try it for 6–8 weeks — less dairy and fewer fast sugars — and see whether it makes a difference.

How does acne develop?

Four things usually play a part:

the skin (temporarily) produces more sebum;
the pore becomes blocked (a blackhead/whitehead);
inflammation develops in and around the pore;
bacteria that normally live on the skin (such as Cutibacterium acnes, formerly P. acnes) can influence the inflammation.

Important: washing “until it squeaks” does not help and often just irritates the skin.

What does it look like?

Acne can consist of different kinds of spots:

Blackheads and whiteheads (comedones) — open (black dot) or closed (white bump). The black colour is not dirt.
Pimples and spots — red and sometimes painful, sometimes with a white/yellow head.
Deep, painful inflammations (nodules/cysts) — mainly in more severe acne. These can cause scars.

Marks after acne. Once acne has settled, you may still see red marks for a while; this is often the skin healing. In darker skin types, dark spots can also form. These usually fade slowly.

Which types of acne are there?

There are several forms. The best known is acne vulgaris (“ordinary” acne). Other, less common forms are:

Acne conglobata — severe acne with deep inflammations, often on the back and chest.
Acne fulminans — rare and severe; you are often also unwell (fever, pain). This is an emergency.
Acne infantum / neonatal acne — acne in babies (usually mild, often resolves on its own).
Acne tarda — acne in adults.
Acne inversa (hidradenitis suppurativa) — inflammations in the groin/armpit (this is actually a different condition).

What looks like acne but is not?

Yeast spots (Pityrosporum folliculitis) — often small, fairly uniform, itchy spots, mainly on the chest, back and shoulders. If “acne” does not respond well to normal acne treatment, this may be involved.
Rosacea (acne rosacea) — mainly on the cheeks, nose, forehead and chin. You see redness and inflammatory bumps, but usually no blackheads.
Summer acne (acne aestivalis) — many small, uniform bumps on the chest, shoulders and arms, often in summer. It is more a sun reaction than ordinary acne.
Pseudofolliculitis (ingrown hairs from shaving) — small spots in areas you shave (for example the beard area), caused by hairs (partly) growing back into the skin and causing irritation/inflammation.

How is acne treated?

Important to know: a treatment mainly works against new spots; existing spots need time to fade. You usually have to use a treatment for 6–8 weeks before you see real improvement. Do not stop too soon, and consult your doctor if you have side effects or doubts.

Step 0: what can you do yourself?

Wash once or twice a day with a mild cleanser. Do not scrub or rub hard.
Use a non-greasy, “non-comedogenic” cream if your skin is dry or irritated.
Use sunscreen (especially with retinoids and antibiotics, which make the skin more sensitive to sun).
Try not to squeeze spots (this increases the risk of deep inflammation and scars).

Step 1: mild acne (mainly blackheads/whiteheads and small spots)

Benzoyl peroxide (gel/wash) — works against blockage and reduces inflammation. Can irritate the skin and can bleach fabrics.
Topical retinoid (cream or gel, for example adapalene or trifarotene) — helps against blackheads/whiteheads and reduces inflammation. Usually applied thinly in the evening. Start gently (every other day) if you become irritated quickly.
Combination gel (for example adapalene + benzoyl peroxide) — often works better than a single agent alone.
Azelaic acid — can help with inflammation and with marks after acne. Sometimes chosen when the skin is easily irritated.

Pregnancy: benzoyl peroxide and azelaic acid can usually be used. Retinoids (such as adapalene, tretinoin, trifarotene) are best avoided. Always consult your doctor.

Step 2: moderate to severe acne (more inflamed spots, larger areas)

Often a combination gel (benzoyl peroxide + retinoid) and/or an extra treatment via your doctor or dermatologist.
A topical antibiotic, when needed, is preferably always combined with benzoyl peroxide and not used for too long (to prevent resistance).
Antibiotic tablets (usually doxycycline) can temporarily help with inflammation. This is almost always combined with a topical treatment, usually for a limited period (for example 6–12 weeks), followed by maintenance with a cream/gel.

Note: doxycycline can make the skin more sensitive to sun and must not be used during pregnancy. Discuss side effects and instructions with your doctor.

Step 3: severe acne (deep, painful inflammations, scarring or a lot of distress)

In severe acne there is a greater chance of scarring, so prompt and firm treatment is important.

Isotretinoin (capsules) is the most powerful treatment. It is usually supervised by the dermatologist.
You need check-ups (for example blood tests) and good information about side effects.
Pregnancy: isotretinoin absolutely must not be used during pregnancy. Strict rules on contraception apply.

Extra option in women. In some women a contraceptive pill (or other hormonal treatment) helps against acne, especially acne around the jaw/chin and complaints around menstruation. Discuss this with your doctor or dermatologist. If there are signs of a hormonal cause (for example irregular menstruation, excess hair growth, sudden severe acne), further investigation may be needed.

Acne and scars

Scars can develop with any form of acne, but especially with deep inflammations and with squeezing. Scars usually do not disappear completely, but can improve. There are various treatments, such as laser, microneedling or other techniques, usually carried out by the dermatologist.

Frequently asked questions

Does washing more often help? No. Washing or scrubbing too often irritates the skin. Wash gently once or twice a day.

Can I use make-up? Yes, preferably a “non-comedogenic” product. Remove make-up gently in the evening.

Is acne caused by chocolate? Not directly. In some people diet (such as dairy or a lot of sugar) can worsen acne, but this differs from person to person.

Do antibiotic tablets interfere with the pill? The pill usually remains reliable. But with vomiting or diarrhoea, contraception can become less reliable. Discuss this with your doctor or pharmacist.

What if I am pregnant or want to become pregnant? Always tell your doctor. Some acne treatments (especially isotretinoin and doxycycline) must not be used then.

When to see a doctor

See a doctor if acne troubles you a lot, worsens quickly, is causing scars, or does not improve after 8–12 weeks of good treatment. Acne fulminans (severe acne together with feeling unwell, fever or pain) needs urgent medical attention.