June is Acne Awareness Month and having suffered from acne myself, I take the issue very seriously and personally. In my posts, I call acne a disease, a skin condition or an ailment, but in reality, it’s a skin disease, and like all disorders, it should be treated by a doctor, more specifically a dermatologist. No facials or pore strips and scrubs will help you. You need to see a professional with a medical degree. And before you see a doctor, which I highly encourage you to do, I hope you will find the information in this post helpful. The post includes a mixture of information that I’ve gathered and my experience. 

Diet

First and foremost, I think diet is the most crucial aspect of our lives. What we put inside is very important, and I’m not saying that I eat all the time healthily, but I try my best. I like to keep it 80/20, 80% focused on eating healthful foods. We live in a world where we are surrounded by highly processed junk food with high contents of sugar, saturated fats, and sodium. And it’s becoming harder and harder to avoid foods that are unhealthy as they surround us. Look around in an average supermarket, at least a third of it is technically junk food. 

I encourage you to limit these three: sugar, saturated fats, and sodium as much as you can. I won’t tell you not to eat them, because I enjoy them myself. But there are so many options on the market, now, which allow us to substitute highly processed foods for more nutritious options. Whether it comes to sweets or ready meals, we have a variety of choices; and they don’t necessarily have to cost more. It’s always better to prepare your own meal rather than to get a ready one, but I am aware that sometimes it’s the only option. 

Sugar is not only bad for the skin but the entire body. We are not supposed to consume large quantities of it daily, about 30 grams a day in total. Sugar leads to many diseases, such as heart problems and diabetes. It also contributes to the breakage of collagen in our skin. I enjoy sweets myself, and especially biscuits with my tea, so I always look for options with low sugar content. The NHS in the UK state on their website that foods containing ‘more than 22.5g of total sugars per 100g’ are considered as high in sugar. When I shop, I seek for sweets below or close to that number. However, sugar in fruits shouldn’t be a reason to worry, as fruits contain fibre and other elements needed by our body. This doesn’t apply to fruit juice, which is almost as bad as soft drinks because it delivers pure sugar to the system with little benefit.

Also, you might consider cutting on milk. Although the studies linking milk to worsening of acne give varying results, some people find it helpful when they limit the consumption. I’ve tried limiting my consumption of dairy for some time, but I couldn’t notice any difference. Though, I would say it’s definitely worth giving a try. It’s important to know that it’s better to drink full-fat milk, as it contains a smaller amount of hormones compared to skimmed milk.

If you struggle with acne and haven’t sorted out your diet yet, I want you to start eating loads of fruit and vegetables, especially raw. Go for a variety of fresh produce, whether it’s a humble apple or one of those exotic superfoods; just eat as many as you can. Include foods rich in omegas, and I don’t mean avocados or salmon (one of the most toxic fish out there). There are many other alternatives like flaxseed, hempseed, mackerel, and herring, which are more affordable and equally as good. Don’t forget about having a good-quality protein, which provides us with many beneficial elements. And last but not least, consume fermented foods such as yoghurt, kefir, sauerkraut, and kimchi. Ferments are rich in probiotics important for the health of our gut; this contributes to the condition of our skin (below you can find papers discussing probiotics and acne). You can also opt for probiotic supplements. 

Actives

Now let’s focus on actives, ingredients known to be effective in acne treatment. I think most of the ingredients listed below would be called ‘acne drugs’ in the US; I like the clear labels that they have over there. Acne is usually caused by various factors like stress, hormones, bacteria, trauma, and many others. To treat it, you may want to use more than one of the actives at a time. If you suffer from hormonal acne, you will probably need medicine to control things from the inside, but for that, you need a doctor. Though, the actives listed below can help to some extent too. These ingredients will benefit most, if not all, acne sufferers (a few of the elements might be suitable only for a particular type). 

> Azelaic acid – excellent both for acne and rosacea, as it fights bacteria, P. acnes, responsible for these diseases. It has anti-inflammatory and exfoliating properties; it helps with both inflammatory and non-inflammatory acne. It helps to decrease sebum production and hyperpigmentation. I have reviewed Skinoren/Finacea here.

> Salicylic acid – another wonderful ingredient. Salicylic acid works especially for blackheads, as it’s a beta hydroxy acid which has the ability to break down sebum and reach pores follicles to clean them out (only BHAs can do that). It’s anti-inflammatory, an excellent exfoliant, and it can also reduce redness.

> Glycolic acid – this is mainly an exfoliant, but it can be useful if combined with other acne treatments. It exfoliates, or literally dissolves, dead skin cells and helps to unblock the area around pores to prevent dead skin build up. Glycolic acid is also great for firming up the skin and brightening hyperpigmentation. If you have a problem with enlarged pores, this is the way to go. I wouldn’t rely solely on glycolic acid for acne, though.

> Sulphur – often omitted due to its smell, but very effective in the treatment of acne, rosacea, dandruff, and other diseases. It is known to kill bacteria (like P. acnes) and prevent dead skin build up. It balances sebum production and decreases whiteheads & blackheads. It’s also helpful for fungal acne. 

> Benzoyl Peroxide – it can fight inflammation, bacteria, and prevent blockage of pores. It works both for blackheads and whiteheads. It’s available in concentrations from 2.5% to 10%, the latter being the most irritating. Treatments with 5% BPO bring good results and lesser sensitivity. If you consider BPO, then I would suggest going for a low concentration, as it can be harsh on the skin. 

> Retinoids – include adapalene, tretinoin, tazarotene, and many others, but the first three are the most potent, and the first two you can get without a prescription. The unique thing with retinoids is that they work on deeper levels of skin than any of the other ingredients; they affect the processes that take place in our skin on the cellular level. They help with the turnover of cells, exfoliation, unblocking of pores, and inflammation. 

Adapalene is an OTC medicine in the United States. I would say that Differin is the mildest of all prescription-strength retinoids, and it can serve as a good starting point to get your skin used to retinoids. In a few European countries, generic tretinoin creams, lotions etc. are available without a prescription. But tretinoin, in my opinion, is much more powerful than adapalene. There are various vehicles and strengths on the market, so you might have difficulty finding the right formulation for your skin on your own.

However, there is one OTC product made by Krymi Pharmaceutical Laboratories with 0.02% tretinoin concentration in Europe (the lowest prescription strength is 0.025%). Besides tretinoin, the product contains an antibiotic (clindamycin) and glycolic acid (there’s a version without the antibiotic too). It falls under the category of a medical device class III (or OTC medicine), as the amount of tretinoin is small. It gives an excellent opportunity to try tretinoin without seeing a doctor. Though, don’t underestimate this product – it’s a potent mix of tretinoin and glycolic acid. You can get it from these pharmacies Difa Cooper Mask Plus, Difa Cooper RetinCare antibiotic-free version, Mediqskin Plus Gel, Mediqskin Plus Gel antibiotic-free version. And don’t be afraid of retinoids, I know that they are heavily marketed for wrinkles, but tretinoin had been first invented for acne, later on scientists discovered the anti-wrinkle properties of tretinoin.

> Ketoconazole, selenium sulphide, zinc pyrithione – these are suitable only for treating fungal acne (Malassezia folliculitis), as these actives fight fungus and yeast. These ingredients are mainly found in shampoos because dandruff and other conditions appearing on the scalp are caused by similar yeast and fungus as fungal acne. However, you can get ketoconazole, under the brand name Nizoral, in a cream form, so it might be a more convenient option for treating fungal acne on the face rather than a shampoo. Though using shampoo is also fine, just make sure you leave the product for a couple of minutes before rinsing off. 

Supplements for Acne

The market is overfilled with supplements for acne from vitamins to herbal extracts; there are loads of them. However, is any of them effective? It’s hard to say without proper research, but it has been proven that zinc gluconate (and zinc sulphate) supplements are beneficial for the management of acne. Personally, I didn’t see any difference while taking zinc supplements, and yes in large amounts. You can read this report, and if you can access these studies 1 & 2 about acne and zinc gluconate supplements.  

There is also some evidence showing that probiotics both ingested and applied topically can be helpful in the treatment of acne. Here are papers: 1, 2, 3; these two are not open access: 1 & 2 – it focuses on the link between gut health and acne.

Blackheads and Sebaceous Filaments 

Blackheads and sebaceous filaments are non-inflammatory forms of acne. Both are technically pore follicles filled with sebum that are open, and the oxidisation causes them to turn black (whiteheads are closed comedones, and they remain white). Both can be treated with salicylic acid, sulphur, and retinoids (adapalene, tretinoin or tazarotene; it depends on the person which one works best). You can squeeze out blackheads when they surface to the top – it’s when you notice small black spots poking out (I recommend using a blackhead extractor). Once removed they shouldn’t reappear or at least a fewer number of them will. 

Whereas, sebaceous filaments usually don’t rise beyond the surface of the skin. When you try to remove them, they will come back within hours. They are common in the T-zone and especially on the nose, hence the abundance of pore strips that are supposed to ‘pull them out’. But, strips are just a temporary solution that won’t resolve the issue, as sebaceous filaments are related to your oil production. The things that work for them are the aforementioned ingredients. Also, you may want to consider looking less at your mirrors; probably they are hardly noticeable to everyone but you. Some people just have them naturally, especially if your skin type is oily or combination, and you can’t help it. 

Acne Triggered by Cosmetics and Skincare

When you have acne, it’s essential that you use skincare dedicated to acne-prone and oily skin types; though such products can also clog pores and cause breakouts. Usually, these type of products are non-comedogenic, oil-free, and they contain ingredients that help with acne. However, sometimes even if you don’t have acne when you start using a new product, you can get blemishes. Reactions can vary from person to person, some people might be okay with specific ingredients, and some can get clogged pores and blemishes. A few potentially comedogenic ingredients include cocoa butter, coconut oil, corn oil, linseed oil, lanolin, isopropyls isostearate & myristate, petroleum and its derivatives, stearic acid, and many others. To be safe, before you start using a product on your face or body, test it out on a small area of your skin. It can also be helpful to narrow down a list of ingredients that your skin doesn’t tolerate very well. 

Acne Caused by Supplements 

Medicines can cause acne, but those type of substances are available on prescription only. Your doctor should inform you about the side effects of drugs prescribed to you, or you can read the leaflet that comes with them. However, there are also supplements that can cause acne, and we can buy them without consulting a doctor. The vitamins that are known to cause acne include B2, B6, B12, and D2. Naturally occurring in foods, these vitamins constitute a vital part of our bodies. We can find these vitamins in dietary supplements, but also fitness supplements and foods, such as protein powders, energy drinks, etc. It’s very common for people who go to the gym and consume such products end up with acne; this type of acne even has its own name – ‘bodybuilder acne’. As for the drinks, quinine found in various beverages can contribute to acne formation, too. If you suffer from acne and take large quantities of supplements with any of the vitamins, whether you are a gym-goer or not, then perhaps you should stop (if you don’t consult your supplement use with a doctor). 

What Doesn’t Work?

Two things that I would recommend ditching are foaming cleansers and physical scrubs. Foaming cleansers are made with sulphates, which are very often found in cleansers for acne-prone skin. Sulphates create foam, and this function of a face wash usually appeals to many people, as it gives a very fresh feeling. However, sulphates also strip skin of moisture, leading to dry skin and micro-cracks. This forms a perfect ground for bacteria inhabitation leading to worsening of acne and the overall condition of the skin; so please stop using foaming cleansers. Scrubs are almost as bad, especially if you have active acne. They rapture the skin and blemishes, leading to the spread of bacteria, which worsens the situation. If you need to exfoliate use either acids or face washing clothes from non-abrasive fabrics (preferably cotton). 

In my opinion, another thing that doesn’t work for acne is extraction facials; they are just a vicious circle. People performing these treatments usually squeeze out too much (often blemishes that shouldn’t be removed) in order to give you the most results and the satisfaction of well-spent money. If you have active acne, it’s the worst thing that can happen because bacteria are spread around, blemishes that are still in formation are removed – all of this causes skin irritation and lets the bacteria thrive freely around open wounds. After a few days, you are back to square one and probably with more issues than before the facial. Acne is a disease, and it requires medicine. There’s a difference when you pop a spot or two that came to a head and an intensive session of extractions of whatever comes under one’s fingers. From me, it’s just a no; such facials bring no results for acne treatment. It’s better to spend the money on a dermatologist. 

Also, no toothpaste, baking soda, and lemon juice will help your acne. They will just irritate your skin and do nothing other than that. Please don’t apply them on your face. 

Update 09/06/2019: After reading an article in Vanity Fair Italia, I find it necessary to add one more point to this post. There is no scientific evidence that exposure to artificial or natural UV light treats acne. UVB rays can reduce the growth of bacteria (P. acnes), but not substantially. The treatments mentioned above do a better job. However, UVA rays are pro-comedogenic. They contribute to the clogging of pores and the formation of blemishes due to squalene peroxidation in sebum. The whole myth of UV rays treating acne comes from the fact that UV rays induce skin erythema, which only covers up acne. So please do not stop using sunscreen, especially during summer, with the hope of getting rid of acne.