Acne

Acne 101: What Causes It and How to Manage It With Skincare

17 minute read

Acne can affect much more than your skin. It can make you avoid photos, cancel plans, or spend extra time every morning covering a breakout, and it can leave you feeling embarrassed or frustrated with your own face. If that sounds familiar, you are far from alone. Acne is one of the most common skin conditions at every age, and with the right routine it can be controlled.

If you are dealing with breakouts, blackheads or clogged pores, everything below is written for you. We will explain what is happening inside a breakout, what causes acne, how to tell which type you have, and which ingredients help with each type, so you can choose a routine that fits your skin instead of trying everything at once.

An unlabeled dropper bottle, tube and jar beside cotton rounds and a folded teal cloth on a warm stone surface.

What causes visible acne?

Your skin has two main types of pores. Sweat pores release sweat, and hair follicle pores hold a fine hair with an oil gland attached to it. Acne forms in the hair follicle pores. Their oil gland makes sebum, the oil that keeps your skin soft. At the same time, the lining of the pore is constantly making new cells and shedding old ones. When everything works as it should, the dead cells and oil travel up and out of the pore without you ever noticing.

Acne starts when that flow backs up. Dead cells stick together instead of shedding, mix with oil, and form a plug inside the pore. We think of it as a traffic jam, because the pore keeps producing oil and cells behind the plug with nowhere for them to go. That plug is called a comedone, and every type of acne starts with one. What happens next decides which type of acne you see.

Illustration of two clogged pores: one with a dark plug at the surface, and one swollen and surrounded by inflammation. — Every breakout starts with a clogged pore. Whether it stays a blackhead or becomes a red, sore bump depends on what happens inside it.

Non-inflamed acne

Non-inflamed acne is a clogged pore that has not become red or sore. It shows up as blackheads and whiteheads. A blackhead is a plug in an open pore, and the top looks dark because the oil and dead cells in it darken when they meet the air. It is not dirt, which is why scrubbing harder does not remove it. A whitehead, also called a closed comedone, is a plug sitting under a thin layer of skin, which keeps it looking like a small white or skin-colored bump. Non-inflamed acne can also feel like rough, bumpy texture, especially on the forehead and chin. Whiteheads can become inflamed, which we explain next.

Inflamed acne

Inflamed acne starts with the same plug, and a whitehead can become inflamed at any point. The bacteria associated with acne, called C. acnes, live on everyone's skin, including those who never break out, and they multiply fastest where there is little or no oxygen.

A whitehead and an inflamed breakout are both sealed off from the air, so what decides whether a clogged pore becomes inflamed is the oil inside it. When oil production is moderate, the bacteria grow slowly and the pore stays a non-inflamed bump. When your oil glands produce an excess of certain inflammatory fatty acids, the bacteria multiply rapidly. Your immune system responds, and that response is the redness, swelling and soreness you see.

Inflamed acne shows up as red bumps, called papules, bumps with a white or yellow center, called pustules, and in more severe cases, deep painful lumps under the skin, called nodules and cysts. Inflammation is one of the root causes of aging skin, and it is why breakouts come up red and sore. Inflammation is also what leaves dark marks behind after a breakout heals, especially on deeper skin tones.

Who should see a doctor first. If you have deep, painful lumps under the skin, or breakouts that leave scars, see a doctor, because acne of that kind can need medical treatment alongside skincare. The same applies if your acne started suddenly in adulthood together with irregular periods or new hair growth, which can be a sign of a hormonal condition such as PCOS.

Why acne happens

Acne is rarely caused by one thing. Some causes come from your genes and decide how likely your pores are to clog. Others come from your daily life and can make breakouts more frequent or more severe.

Causes you are born with

How your skin sheds

In acne-prone skin, the cells lining the pore tend to stick together instead of shedding one by one. They build up faster than the pore can clear them, which is how the plug starts.

How much oil you make

Your genes set how large and active your oil glands are. More oil means more material for a plug, and more of the oxygen-free space the acne bacteria need.

How thick your oil is

The makeup of your oil matters as much as the amount. Oil from acne-prone skin is often lower in linoleic acid, a fatty acid that helps keep oil thinner and supports the lining of the pore. Thicker, stickier oil is more likely to clog.

Causes that come from daily life

Diet

Research links acne to diets high in sugar and refined carbohydrates, which raise blood sugar quickly, and for some people to dairy. Food is rarely the only cause, but if your breakouts seem to follow certain foods, pay attention to that pattern.

Pollution

Pollution and smoke settle on your skin and can react with the oil on its surface, which makes that oil more irritating and more likely to inflame a clogged pore. Cleansing every night removes pollution and smoke from your skin.

Hormones

Androgens, a group of hormones everyone has, increase oil production, and changes in hormone levels can make breakouts flare before a period, in the teenage years, during pregnancy and around menopause. Stress can also make breakouts worse. Hormonal breakouts often appear along the jaw, chin and neck.

What touches your skin

Pillowcases, phone screens and hats collect oil, sweat and product, then press them back onto your skin. Change your pillowcase two to three times a week, avoid sleeping on unwashed hair or hair with styling product in it, and wipe your phone screen once a day.

Birth control

Some birth control methods can make acne worse, particularly progestin-only options such as some hormonal IUDs, the implant and the injection. Others, including some combined pills, can improve it. If your skin changed after starting or stopping a method, talk to your doctor about it.

A stack of freshly laundered pillowcases on a bed with a silk scrunchie and a glass of water. — Oil, sweat and styling product build up on pillowcases and transfer back to your skin while you sleep.

What skincare can do for acne

Skincare manages acne by stopping the traffic jam from forming. The right ingredients help dead cells shed instead of sticking, dissolve the plugs that are already there, and keep the acne bacteria from multiplying in the pores that do clog. When pores stay clear, there is nothing for a breakout to grow from.

Skincare works best on mild to moderate acne, meaning blackheads, whiteheads, and red or white-headed bumps that come and go. It works on clogs before you can see them, because clogs begin deep in the pore long before they reach the surface. That is why staying consistent matters more than reacting to each new spot, and why results take time, as we explain in the Common questions section below.

Identify your acne type first

Before you choose any acne ingredients, identify which type of acne you have. Non-inflamed and inflamed acne need different ingredients, and the wrong ingredients can irritate your skin without clearing it. Look at your skin over two weeks rather than on one bad day.

Non-inflamed acne

Mostly blackheads, whiteheads and rough, bumpy texture that does not hurt when you touch it.

Inflamed acne

Mostly red, swollen or sore bumps, often with a white or yellow center. They may feel tender or warm, and they often leave dark or red marks behind when they heal.

Combination acne

A mix of both, for example blackheads and whiteheads in some areas of your face, and red, inflamed acne in others. Many people have this mix.

If you are unsure between two types, choose the one that includes inflamed acne. Calming inflammation first is the safer order, for the reason we explain in the Managing combination acne section below.

Managing non-inflamed acne

With non-inflamed acne, bacteria are not a problem yet. There is no inflammation to calm and no need for strong antibacterial ingredients. What your skin needs is for the pores to be unclogged, and kept from clogging again.

A row of unlabeled glass dropper bottles with drops of clear serum and a swirl of gel cream on stone. — Each acne ingredient does a different job, which is why matching the ingredient to your type of acne matters.

Ingredients that unclog pores

Salicylic acid

Because it is attracted to oil, salicylic acid is uniquely capable of penetrating deep inside the pore to break apart the oil and dead skin plug from within. It suits blackheads and oily skin especially well.

Retinoids

Retinoids, the vitamin A family that includes retinol, change how the cells lining your pores behave. They stop dead cells from sticking together and help them shed at a steady pace, which prevents new plugs from forming. They take time to show their full effect, and they are one of the most studied acne ingredients there is.

Glycolic and lactic acid

These exfoliate the surface layer of your skin, which loosens the dead cells sitting over a clogged pore and helps whiteheads open and clear. Lactic acid hydrates while it exfoliates, and glycolic travels further into the skin and helps with anti-aging.

A scrub once a week can also help non-inflamed acne by lifting dead cells from the surface. Keep it to once a week with light pressure. Scrubbing more often can irritate the skin, and this matters even more for deeper skin tones, because irritation and the dryness that follows it can trigger dark marks, and deeper skin pigments much easier.

Starting several exfoliating ingredients right away, or layering several at once, can cause irritation if your skin is not used to them. Start with one product, and add the next one after a couple of weeks if your skin is doing well.

Managing inflamed acne

Inflamed acne needs two things at the same time: clearing the plug, and stopping the acne bacteria from multiplying inside it. That is why the ingredients for inflamed acne are different from the ones for clogged pores alone.

Ingredients for inflamed acne

Benzoyl peroxide

Acne bacteria thrive where there is little or no oxygen. When benzoyl peroxide breaks down on your skin, it releases oxygen into that sealed space, and the bacteria cannot survive it. It also helps break down the dead cells clogging the pore.

Bacteria do not become resistant to benzoyl peroxide, because it floods the pore with oxygen rather than targeting one part of how they function. Strengths of 2.5 to 5 percent work well on the face, and 10 percent is mostly a body strength, used on the chest and back.

Azelaic acid

Azelaic acid reduces the acne bacteria, calms redness, helps clear the plug, and fades the dark marks breakouts leave behind. The combination of all four is what makes azelaic acid unique. It suits sensitive skin and deeper skin tones especially well, and it is usually recommended during pregnancy and breastfeeding.

Sulfur

Sulfur dries out individual breakouts and reduces bacteria, which makes it a good choice to apply only on a breakout that has already appeared. It has a strong smell, so you may want to use it at night.

Mandelic acid

Mandelic acid works in a similar way to azelaic acid, with antibacterial and exfoliating action, and it is the stronger of the two. It has a larger molecule than glycolic and lactic acid, which is why it is a great choice for acne-prone, deeper skin tones dealing with breakouts and dark marks together.

Avoid scrubs while you have inflamed acne. Scrubs do not spread acne across your face, which is a common worry, but rubbing breakouts that are already inflamed adds irritation and can make the redness, and the marks left afterward, worse.

Managing combination acne

With combination acne, the order matters. Clear the inflamed acne first, with azelaic acid, mandelic acid or benzoyl peroxide. Once the redness and sore breakouts have calmed down, keep going with those products and add salicylic acid or a retinoid for the clogged pores that remain.

Retinoids are excellent at keeping pores clear, but on skin that is already inflamed they can add irritation and make the inflammation worse. Calming your skin first means you can use them afterward without that setback.

Step 1: Calm the inflammation

Calm red, sore breakouts with azelaic acid, mandelic acid or benzoyl peroxide.
Support your barrier with a hydrating serum and moisturizer.
Wait until new inflamed breakouts have stopped appearing.

Step 2: Clear the clogs

Keep going with your Step 1 routine. Benzoyl peroxide in particular stays an essential part of managing combination acne.
Add salicylic acid or a retinoid for the blackheads and whiteheads that remain, using it on alternate nights with benzoyl peroxide.
Glycolic or lactic acid can be used instead of salicylic acid or a retinoid, if they suit your skin better.
Introduce one new product at a time, two to three nights a week at first.
Keep supporting your barrier every day.

Supporting acne-prone skin

Whatever type of acne you have, your skin barrier needs support, both while you manage breakouts and after they clear. Acne ingredients like acids and retinoids work by changing how your skin sheds, and a strong barrier is what lets your skin tolerate them without stinging, peeling or redness.

Support your barrier with a hydrating serum and a moisturizer every day, even if your skin is oily. Skin that is dry or dehydrated can respond by producing more oil, and more oil means more material for the traffic jam. Many moisturizers made for acne-prone skin say non-comedogenic on the packaging, which means they were formulated not to clog pores.

A dropper releasing a drop of clear serum beside an open jar of light gel-cream and water droplets on stone. — A hydrating serum and a moisturizer help your skin tolerate acne ingredients without stinging or peeling.

Wear sunscreen every morning and reapply it through the day. Retinoids and exfoliating acids make your skin more sensitive to the sun, and UV darkens the marks that breakouts leave behind.

Acne is controlled, not cured

The tendency to clog comes from your genes, which means it is still there when your skin looks clear. That is why it is important to keep your routine going after your breakouts are gone.

Clogs begin forming deep in the pore long before you see them, and it can take around 90 days for one to reach the surface. When you start a routine, you are clearing the clogs that are already on their way up as well as preventing new ones. If you stop, the clogs that form in the meantime start surfacing again about three months later.

Once your skin has stayed clear for around three months, you may be able to use your acne products fewer nights a week. Keep the routine itself going, and if breakouts start to return, go back to your original frequency.

What is skin purging?

Purging is a temporary increase in breakouts when you start an ingredient that speeds up how fast your skin sheds, such as a retinoid, salicylic acid, glycolic acid or lactic acid. These ingredients bring the clogs that were already forming up to the surface sooner, and there is roughly ninety days of congestion in your skin at any time.

A purge tends to show up in the areas where you usually break out, as small bumps, whiteheads or blackheads, and it can take three to six months to settle. Around weeks three to four, many people decide the product is making things worse and stop. That is usually the moment to keep going, because stopping does not stop the clogs that are already on their way up.

A purge is different from a reaction. Breakouts in areas where you do not usually break out, burning, itching, or new bumps that are still appearing after six months are signs the product does not suit your skin barrier, and you should stop using it.

Omega supplements and acne

Supplements can help manage acne from the inside, and omega fatty acids are one of the options with research behind them. Omega-3 fats, found in fish oil, and gamma-linolenic acid, an omega-6 fat found in borage and evening primrose oil, both help calm inflammation in the body. They are also thought to change the makeup of the oil your skin produces, making it thinner and less likely to clog.

In a ten-week controlled trial of 45 people with mild to moderate acne, those taking 2,000 mg of omega-3 or 400 mg of gamma-linolenic acid a day had fewer inflamed and non-inflamed breakouts, while the group taking nothing saw no change.

There are few large trials on omega supplements and acne for a simple reason. Large clinical trials cost millions of dollars and are usually funded by pharmaceutical companies that can patent the molecule they are testing. Fish oil and borage oil are natural and cannot be patented, so there is little financial incentive to fund a 1,000-person, multi-year acne trial.

In our clinic, we see an enormous difference in acne-prone skin when we recommend Face Reality Clear Skin Balance supplements alongside an acne routine.

Supplements work alongside skincare rather than replacing it. Speak to your doctor before starting one, especially if you take blood thinners or other medication, or if you are pregnant or breastfeeding.

Golden omega softgel capsules in a slate blue dish beside walnuts and flaxseeds. — Omega supplements are thought to make skin oil thinner and less likely to clog, and they help calm inflammation.

Common questions

Does acne mean my skin is dirty?

No. Acne starts inside the pore, with dead cells and oil sticking together, which is why it affects people who wash their face carefully every day. Washing too often or scrubbing hard can make acne worse by irritating the skin.

How long until I see results?

Most acne routines take three to six months to show a clear difference, because clogs take around 90 days to reach the surface. Photograph your skin on day one, in the same spot and natural daylight, and again every four weeks, which lets you see the change side by side.

Can I pop a pimple?

No. Squeezing pushes the contents of the pore deeper into the skin, which makes the breakout last longer and raises the chance of a dark mark or a scar. Sulfur applied only to the breakout dries it out and reduces bacteria, without the risk of scarring that squeezing carries.

Will sunscreen and makeup make my acne worse?

Not usually, as long as you choose formulas made for acne-prone skin and remove them fully every night. Look for non-comedogenic on the packaging. Skipping sunscreen is the bigger risk, because sun darkens the marks breakouts leave behind.

Which acne ingredients can I use during pregnancy?

Azelaic acid is usually recommended during pregnancy and breastfeeding, and glycolic acid and niacinamide are among the safest options. Salicylic acid at around 0.5 to 1 percent is often considered acceptable, although not every doctor agrees, and benzoyl peroxide at 5 percent or less is used in some cases, depending on your OB-GYN. The same applies while breastfeeding. Skincare ingredients are almost never tested on pregnant people.

Most retinoids are avoided. Very little is absorbed from a cream, and some may be acceptable depending on the retinoid, which is a decision for your doctor. Check any product with your OB, midwife or doctor before you use it.

Can I use salicylic acid if I am allergic to aspirin?

Not until you have checked with your doctor. Salicylic acid is closely related to aspirin, and people with an aspirin allergy are usually advised to avoid it.

How to use it

Identify your acne type before choosing your ingredients.
Introduce one acne ingredient at a time, two to three nights a week at first, and use it more often as your skin allows.
Apply your acne products to clean, dry skin, then follow with a hydrating serum and moisturizer.
Wear sunscreen every morning, and reapply it through the day.
Change your pillowcase two to three times a week.
Keep your routine going after your skin clears.

Good to know

Stinging above a mild tingle, or lingering redness, means you are using an ingredient too often or at too high a strength for your skin barrier.
Do not apply acids, retinoids, benzoyl peroxide or sulfur to broken, picked or sunburned skin.
Benzoyl peroxide bleaches fabric, so use white towels and pillowcases, and let it dry fully before getting dressed.
Keep acne products away from your eyes, lips and the corners of your nose.
Introduce exfoliating acids and retinoids one at a time, and keep your weekly scrub on a different night from them.

Acne can feel very personal, and finding the right routine can take some trial and error. Give a new routine three to six months, including any purging, before deciding it is not working. With the right ingredients for your type of acne and some patience, your acne can be kept under control.

If you would like help working out your acne type and the routine that suits it, we would love to take a look at your skin together, whether that is a virtual consultation or a visit to our New York City LAZ Clinic.

Book a consultation

If a product causes swelling, real burning, or a rash that spreads, stop using it and see a doctor. If you have any difficulty breathing, swelling of the face, lips or throat, or you feel faint, treat that as an emergency and seek medical care immediately. Once your skin has settled, we are happy to look at your routine with you and work out what to adjust.

A mole that changes shape, color or size, or a spot that bleeds and does not heal, is something to show your doctor.

Everything here is general education rather than personal advice. If a doctor is treating you or you use prescription skincare, check with them before changing your routine.

Products and supplements mentioned here are not intended to diagnose, treat, cure or prevent any disease, and these statements have not been evaluated by the Food and Drug Administration.