Acne is a common condition that affects a significant portion of the global population. While adolescent males are more prone to acne during their teenage years, this pattern shifts in adulthood, with females experiencing more frequent and severe breakouts. The severity of acne is often associated with genetic predispositions and hormonal fluctuations, such as those seen in puberty, polycystic ovary syndrome (PCOS), and pregnancy.
Different Types of Acne
Acne manifests in various forms, including whiteheads, blackheads, cysts, and nodules, all originating from clogged pores. Pores, which house hair follicles and release sweat and sebum, can become blocked by dead skin cells and oily material, forming papules or pimples. When a papule fills with pus, it becomes a whitehead, while blackheads occur when oil and debris in the pore oxidize and turn black. Cystic acne occurs when Cutibacterium acnes bacteria thrive in the low-oxygen environment of a papule, triggering deep inflammation and resulting in cysts and nodules that can lead to scarring. Hormonal acne, common among premenstrual women in their late 30s and 40s, flares due to hormonal fluctuations, leading to increased oiliness and breakouts predominantly in the chin and upper neck area.
The Hierarchy of Acne Treatments
To manage acne effectively, it’s always best to start with over-the-counter products including topical salicylic acid cleansers and toners, retinol or retinaldehyde, and/or topical benzoyl peroxide lotions and gels. However, more severe cases of acne require prescription treatments. These medications offer higher potency, are clinically proven, and allow for a more tailored treatment plan with regular dermatologist monitoring.
Two of the most effective topical prescription products for treating acne are tretinoin and hydroquinone. These medications not only treat acne but also help manage post-inflammatory hyperpigmentation (PIH), which may result from severe acne. For cases with significant cysts or inflammatory papules and pustules, an oral antibiotic may be added, or in the most severe cases, oral isotretinoin.
The Importance of Tretinoin
One of the most effective topical treatments for acne is tretinoin, a derivative of Vitamin A. Tretinoin normalizes the skin cell turnover process by promoting the shedding of old, dead skin cells and encouraging the growth of new, healthy ones. This mechanism helps unclog pores and reduces the formation of new acne lesions or scarring.
Tretinoin is more than simply an acne treatment, it also offers significant anti-aging and anti-scarring benefits. By promoting collagen production, tretinoin helps reduce the appearance of fine lines and wrinkles and evens out skin tone and texture, leaving the skin feeling smoother and less rough. Tretinoin helps to diminish the appearance of acne scars by stimulating collagen and elastin production. Tretinoin comes in both a cream and gel form.
Risks of Post-Inflammatory Hyperpigmentation (PIH)
After an acne lesion has healed, dark spots of discoloration may remain on the skin. This is known as post-inflammatory hyperpigmentation (PIH). This condition occurs when inflammation stimulates melanocytes (pigment-producing cells) to release excess melanin, resulting in darkened patches. Although PIH is not classified as scarring, it may take months or even years to resolve. While acne is seen across all ethnicities and races, darker skin patients may experience PIH more often than lighter-skinned patients.
Hydroquinone is a highly effective skin-lightening agent used to treat hyperpigmentation. It functions by inhibiting the enzyme tyrosinase, which is essential for melanin production. By reducing melanin synthesis, hydroquinone helps lighten dark spots and even skin tone. This agent is particularly effective for treating PIH, especially in its more potent prescription strength, as it directly targets the excess pigment produced during the inflammatory response to acne.
Hydroquinone 4%, a prescription product, used under a dermatologist's supervision, is part of a comprehensive treatment plan for more stubborn pigmentation issues and typically shows faster results within 4 to 6 weeks. Consistent application for a minimum of 12 weeks, patience, and proper sun protection is critical in treating PIH, especially in warmer and sunnier climates.
Similar to tretinoin, the choice between hydroquinone creams or gels depends on skin type and concerns. Creams, which often contain moisturizing agents, are beneficial for dry or sensitive skin, preventing dryness and irritation. Gels, which are lighter and quicker to penetrate, are ideal for oily or combination skin types but may be more drying.
As a doctor, my protocols are fairly equal across skin types. However, if I suspect a patient is at risk of PIH or has developed PIH, I factor in a topical cream with hydroquinone twice a day to help reduce PIH.
Alternative Treatments for Acne
Other approaches to treating acne include in-office chemical peels, which can reduce acne lesion counts, unclog pores, and lower bacterial levels on the skin. These peels complement a good home skincare regimen effectively. They can include salicylic acid peels, glycolic acid peels, or combinations of various acids, such as in a Jessner’s Peel.
FDA-approved laser devices are also available to reduce acne formation and decrease oiliness. Many lasers are used in an "off-label" manner to treat acne lesions and scarring as well.
Final Thoughts
Like many teenagers, my kids (and I) battled acne. I utilized the topical therapies mentioned earlier and simultaneously encouraged them to identify which dietary triggers were causing their flares. Every individual with acne will have different triggers; for some, dairy is a major factor, while for others, it may be refined sweets or greasy foods. To identify dietary influences, I recommend patients eliminate one food category for six weeks to observe its impact on their acne. Once a possible dietary trigger is identified, it should be avoided. Adherence to both topical therapies and dietary modifications is crucial to managing acne effectively.
While it is impossible to prevent acne entirely, proper skincare practices such as cleansing the skin well, using a topical retinoid to minimize the formation of pimples, and avoiding touching skin or picking at skin lesions can significantly reduce the likelihood of more lesions and scarring. Identifying and avoiding dietary triggers is also essential. If acne does not respond to these measures, seek professional care. As I often remind my kids, I can provide the best guidance, but it is up to them to adhere to the protocol to see improved skin health.
About Dr. Suzan Obagi
Suzan Obagi, MD Obagi is an Associate Professor of Dermatology and Plastic Surgery at the University of Pittsburgh Medical Center (UPMC) and serves as the director of the state-of-the-art UPMC Cosmetic Surgery and Skin Health Center. Dr. Obagi's academic commitments include clinical research, training residents in dermatologic surgery & cosmetic dermatologic surgery, and in her role as the director of the cosmetic dermatologic surgery fellowship.
Dr. Obagi has worked on various committees with the American Society for Dermatologic Surgery, has formerly served as vice president of the American Board of Cosmetic Surgery and the President of the American Academy of Cosmetic Surgery, and is a past president of the Cosmetic Surgery Foundation. In addition, Dr. Obagi trains physicians from around the world on the latest in cosmetic and laser surgery.
