For a long time, acne was often explained as a problem that started with a clogged pore. Then oil would build up, bacteria would become involved, and inflammation would follow. Today, dermatologists understand acne in a more complete way.
Inflammation may not simply be the result of acne; it may be part of the process from the very beginning. That matters because acne is not just a surface-level skin concern. Even small bumps, whiteheads, blackheads, and flat acne marks can involve inflammation beneath the skin. Understanding this can help patients take acne more seriously, treat it earlier, and reduce the risk of long-term acne scarring.
At Adult and Pediatric Dermatology Kansas City, we help patients understand the causes of acne and build treatment plans based on their skin, their symptoms, and their long-term goals.
Why Acne Is More Than Clogged Pores
Acne often begins inside the hair follicle, where oil, dead skin cells, bacteria, and inflammation can interact. The earliest acne lesion has traditionally been called a microcomedone. This is a tiny clogged pore that can eventually become a visible blackhead, whitehead, pimple, or deeper acne lesion.
Previous research suggests that inflammation may already be present before that clogged pore becomes obvious. This means acne may be better understood as an inflammatory condition that can show up in different ways.
Some patients have mostly comedonal acne, which includes blackheads and whiteheads. Others develop more visible inflamed bumps, pustules, nodules, or cysts. Many people have a combination of both. Even when acne looks mild on the surface, there may still be active inflammation beneath the skin. This is one reason early acne treatment can be helpful. Waiting until acne becomes painful or severe may give inflammation more time to damage the surrounding skin.
What Causes Acne?
The causes of acne are usually connected to several overlapping factors. These can include excess oil production, clogged pores, acne bacteria, hormones, genetics, inflammation, and the way a person’s immune system responds inside the skin. For many people, acne is not caused by poor hygiene, so washing your face more often will not necessarily solve it, and aggressive scrubbing can sometimes worsen irritation.
Common contributors to acne include:
- Increased oil production
- Dead skin cells that do not shed properly
- Hormonal changes
- Family history and genetics
- Inflammation within the skin
- Certain medications or products
- Specific strains of acne-related bacteria
- Picking, squeezing, or manipulating lesions
Because acne has multiple causes, acne treatment often works best when it addresses more than one part of the process.
What Dr. Stein Gold Had To Say
“It used to be that dermatologists were taught that the microcomedone was the first step in the pathogenesis of acne. Over the past several years, we’ve learned that might not be true. There may be inflammation that precedes the microcomedone. If it’s true, that means that all acne is inflammatory acne,” she said. “It’s kind of a misnomer to talk about noninflammatory and inflammatory acne. It may be more correct to talk about comedonal acne and superficial inflammatory acne,” Dr. Stein Gold explained. This suggests that the acne lesions are all inflammatory but can appear differently on different people, most likely due to genetics.
Another interesting development in understanding acne involves the microbiome. “When we look at the bacteria, Cutibacterium acnes (C. acnes), it’s probably not the amount of bacteria that’s important. It’s more likely the strain of bacteria. We know some strains tend to be associated with the development of acne, whereas others aren’t. Acne may be the body’s reaction to particular strains that are more inflammatory,” Dr. Stein Gold said. The thinking is acne is due to inflammation, possibly due to the byproducts of the strain of bacteria as well as the person’s immune response to those products. It explains why anti-inflammatory drugs work as well as antibiotics for treatment.
Scarring
Typically, we think of patients with nodular cystic acne as the ones most likely to develop scars, said Dr. Stein Gold. “But we know that people who have more superficial acne are also at increased risk for developing atrophic scars. Studies have looked at scar development and found that the longer a papule is present, the greater risk for scarring to develop. These studies have shown that even if the acne is flat, dermatologists should continue to treat because inflammation is still present,” she said.
A 2018 study published in the American Journal of Clinical Dermatology looked at the fixed combination of adapalene (0.3%) with benzoyl peroxide (2.5%) gel on half the face and vehicle on the other half. After six months, not only were scars prevented from forming, but the study showed, for the first time, that a topical agent had the potential to improve scars, Dr. Stein Gold added. This supports the idea that squeezing or manipulating lesions can lead to scarring by increasing the inflammation
In 1982, isotretinoin was a breakthrough treatment for acne, and to-date it is the only drug that impacts all four of its pathogenic factors, said New York dermatologist Hilary Baldwin, MD, a founding board member and second president of the American Acne and Rosacea Society, as well as a co-author of the Academy’s acne clinical guidelines. “The use of isotretinoin has increased in the last couple of years,” she said. “It’s the answer to a lot of our problems, including the overuse of antibiotics — 80% of people who take isotretinoin never see acne again.”
Current Acne Treatment Insights
Acne treatment has come a long way, and dermatologists now have more options than ever. The best plan depends on the type of acne, severity, skin sensitivity, age, medical history, pregnancy considerations, scarring risk, and whether acne is affecting confidence or quality of life.
Common acne treatment options may include:
- Topical Retinoids
Topical retinoids help keep pores from becoming clogged and can reduce inflammation over time. They are often used for blackheads, whiteheads, inflammatory acne, and long-term acne maintenance.
- Benzoyl Peroxide
Benzoyl peroxide helps reduce acne-causing bacteria on the skin and can be especially useful when combined with other treatments. It may also help reduce the risk of antibiotic resistance when topical or oral antibiotics are used.
- Topical Antibiotics
Topical antibiotics may be used for inflammatory acne, often in combination with benzoyl peroxide. They are generally not used alone because combination therapy is usually more effective and helps limit resistance concerns.
- Oral Antibiotics
For moderate or more widespread inflammatory acne, oral antibiotics such as doxycycline may be recommended for a limited period. These are often paired with topical medications so the skin has a long-term maintenance plan after the antibiotic course ends.
- Hormonal Treatment Options
For some patients, especially those with jawline acne, cyclical flares, or hormonally influenced breakouts, treatments such as certain oral contraceptives or spironolactone may be considered when appropriate.
- Isotretinoin
Isotretinoin is one of the most powerful acne treatments available. It can affect several major factors involved in acne, including oil production, clogged pores, bacteria-related inflammation, and lesion formation.
It may be recommended for severe acne, acne that is causing scarring, acne that has not responded to standard treatments, or acne that creates significant emotional distress. Isotretinoin requires careful monitoring and is not right for every patient, but for the right candidate, it can be life-changing.
When Should You See a Dermatologist for Acne?
You do not need to wait until acne becomes severe to ask for help. A dermatologist can evaluate what type of acne you have and recommend a treatment plan that fits your skin.
Consider scheduling a dermatology visit if:
- Your acne is painful, inflamed, or worsening
- Over-the-counter products are not helping
- Acne is leaving dark marks or scars
- You have deep bumps, cysts, or nodules
- Breakouts are affecting your confidence
- Acne is appearing on the face, chest, back, or shoulders
- You are unsure which products are safe for your skin
- You keep picking or squeezing lesions because they are not improving
Acne treatment takes consistency, and results can take time. However, the right plan can make a meaningful difference in both active breakouts and the risk of future acne scarring.
Take Acne Inflammation Seriously
Acne is not simply a cosmetic issue, and it is not always as simple as a clogged pore. Inflammation, genetics, acne bacteria, oil production, and the immune system can all influence how acne develops and how it heals.
The good news is that acne is treatable. Whether you are dealing with blackheads, whiteheads, inflamed bumps, cystic acne, or acne scarring, a dermatologist can help you understand what is happening beneath the skin and choose treatments that support healthier skin over time.
If you are struggling with acne or concerned about acne scarring, our team at Adult and Pediatric Dermatology Kansas City is here to help. Book an appointment today.