Acne

in Health Care (IQWiG, Germany)

Table of contents

Overview 3
Introduction 3
Symptoms 3
Causes 3
Risk factors 4
Prevalence 5
Outlook 5
Effects 5
Treatment 5
Everyday life 5
Further information 6
Sources 6

Glossary 8

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Overview

Introduction

(Adem Demir / Hemera / Thinkstock)

Most teenagers will have pimples at some point. Some only have a few small pimples that soon go away
again. Others develop persistent and clearly visible acne. This can be very distressing, particularly in puberty.

But there are a number of things that can be done about acne, although patience is needed. This
information is about acne in teenagers and young adults, known as “common” acne or acne vulgaris.

Symptoms

The severity of acne can vary quite a bit. Doctors distinguish between mild, moderate and severe forms of
acne. There are also inflammatory and non-inflammatory types of acne. Non-inflammatory acne is a milder
type, which most people would refer to as “pimples” or “blackheads” rather than “acne.”

Unlike normal pimples, acne develops over a longer period of time and stays longer. It sometimes leaves
small red marks or scars behind. “Normal” pimples usually form quickly and then go away again soon
afterwards.

 Mild acne: People with mild acne have comedones (blackheads or whiteheads). These are clogged pores
in the skin. The dark color of blackheads has nothing to do with dirt: They look dark because this kind of
blackhead is “open” and the skin pigment melanin reacts with oxygen in the air. Whiteheads are closed,
and have a white or yellowish head. The more oil builds up, the more likely it is that bacteria will multiply
and lead to inflammatory acne. Acne is described as mild if there are only a few acne pimples, or none at
all.
 Moderate acne: People who have moderate acne have noticeably more acne pimples. Inflamed pimples
are called “papules” (small bumps) or “pustules” (filled with yellow pus).
 Severe acne: People who have severe forms of acne have a lot of papules and pustules, as well as
nodules on their skin. These nodules are often reddish and painful. The acne may lead to scarring.

Causes

During puberty, a child’s body changes to the body of an adult. This change is regulated by hormones such
as androgen. Androgen is a male sex hormone which is made in larger amounts during puberty – in girls too.
One thing that it does is cause your skin to produce more oil.

The oil that is made in the skin is called sebum, and it is produced in oil glands called sebaceous glands.
Sebum protects the skin and helps to keep it moisturized. But if a layer of dead cells blocks the opening of a
pore, the sebum can't leave the pore. It builds up in the sebaceous gland, and a blackhead or whitehead

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develops. If this becomes inflamed, it turns into a pimple (also called a zit or spot). Acne mostly develops on
areas of skin that have more oil glands, like the face, chest, back and shoulders.

The main reason teenagers get acne is because their bodies make more androgen hormones during
puberty. Once their hormone levels have settled down – typically by their early twenties – acne usually goes
away on its own. But not all teenagers have acne. For this reason, it is believed that other things play a role
too, such as genetic factors and the immune system. 

Risk factors

There are a lot of theories about what might make acne more likely. Some of these ideas are supported by
scientific proof, but many aren't. For instance, people sometimes say that not washing properly gives you
acne or makes it worse. There is no scientific proof that this is true. But claims like this can make teenagers
feel guilty because they believe they are to blame for their acne.

Some people think that their acne gets worse if they eat particular foods, like chocolate, meat or dairy
products. A number of scientific studies have looked into the effect of diet on acne, but they mostly didn't
find any connection between what people eat and the likelihood of developing acne. Eating a lot of
carbohydrates that cause the sugar levels in the blood to rise quickly could possibly play a role. These
carbohydrates include very sugary foods, potatoes and white bread. But it's not yet clear whether they
really play a role here.

Certain skin care products, such as moisturizing creams or oils that might block skin pores, can make acne
worse. That's also true for rubbing your skin too hard or squeezing blackheads.

Some people report that their acne gets worse when they are stressed. Scientific studies also suggest that
there is a link here. It is not clear whether there might be a connection between smoking and acne.

Hormones are not only produced by the body. They are sometimes found in medications and other products
too. For instance, some hormone treatments can cause acne or make it worse. These include anabolic
substances (for building muscles) and medications such as steroids, as well as some drugs for treating
epilepsy.

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Prevalence

Acne is the most common skin condition in teenagers. Most people will have acne to some degree during
puberty. About 15 to 30 out of 100 teenagers have moderate to severe acne. It is much more common in
boys than in girls.

Outlook

Acne often clears up on its own by the age of 20, but some people still have acne when they're over 30. It
may leave scars or red marks (brownish marks on darker skin).

Effects

Acne can lead to scarring, especially if it is severe. Scars sometimes form when wounds heal. The wounds
caused by acne are found in the deeper layers of skin. They heal in very different ways: While some people
only have small, flat scars that are hardly noticeable, others have clearly visible indented scars (“pock marks”)
on their face. Acne scars can be divided into the following categories:

 Atrophic scars: If an acne wound doesn't heal properly, not enough connective tissue is made. The scar
then forms beneath the surrounding tissue, creating a dent in the skin.
 Hypertrophic scars: These raised scars can form on your chest, back or shoulders, particularly in people
who have severe acne. They develop if too much connective tissue is produced while the wound is
healing. This type of acne scar is less common.
 Keloid scars: Keloid scars also form when too much connective tissue is made. Unlike hypertrophic scars,
though, they're bigger than the original inflamed area. This is a very rare type of acne scarring.

Regularly squeezing blackheads and pustules can increase the likelihood of scarring.

Treatment

People with acne often try out different things to improve the appearance of their skin. There are a lot of
different recommendations when it comes to acne, involving things like facial toners, sunlight and specific
diets. But not all of them have been proven to work.

Oil-in-water emulsions (lotions) or moisturizing gels (hydrogels) are recommended for skin care. Greasy
creams can clog the pores in your skin even more. Soap-free cleansing products that have a similar pH to
skin (5.5) are a good idea too. It's important not to overdo it, though, because too much skin care can irritate
the skin even more.

There are also a number of medications for acne, to be applied to the skin or swallowed. Some treatment
approaches and medications have been proven to effectively reduce acne, while others have not. Examples
of effective treatments include benzoyl peroxide, antibiotics and retinoids.

Acne treatment usually requires patience: Most products have to be used for a long time before there is a
noticeable improvement. The treatment may take months or even years. Every treatment can have side
effects, too.

Everyday life

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Puberty is a difficult time of life. Many teenagers feel less self-confident, and may be very negative about
themselves and their appearance. This is especially true of teenagers who have acne, who often feel
unattractive or might be embarrassed about how they look. Comments people make about their skin
condition can be very upsetting, and difficulties finding a boyfriend or girlfriend might be hard to take. But
self-esteem issues and mood swings are a normal part of puberty, even in teenagers who don't have acne.
So it would be wrong to blame all puberty-related problems on acne.

The severity of someone’s acne doesn't always directly determine how much it bothers them. Moderate
acne can be just as distressing as severe acne.

How people cope with acne varies greatly. Some teenagers are less bothered by it or can deal with it in a
more self-confident way, but for others it can be a major problem. Anxiety, depressive thoughts and low
self-esteem are generally more common in people who have acne. Teenagers with acne are more likely to
become withdrawn and have conflicts with their friends and family.

If having acne makes teenagers feel less self-confident around others, supportive friends and family are
particularly important. But they don't want to be constantly reminded of the issue, either. Things like
foundation and concealer, sunglasses, long shirts or a haircut with bangs can make it easier to cope with
acne in everyday life and feel more confident in public.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. Read about how
to find the right doctor, how to prepare for the appointment and what to remember.

Updated September 26th 2019
Created January 16th 2013
Next update: 2022

Sources

Cao H, Yang G, Wang Y, Liu JP, Smith CA, Luo H et al. Complementary therapies for acne vulgaris. Cochrane Database Syst Rev 2015; (1):
CD009436.

Degitz K, Ochsendorf F. Acne. J Dtsch Dermatol Ges 2017; 15(7): 709-722.

Deutsche Dermatologische Gesellschaft (DDG). Behandlung der Akne (S2k-Leitlinie). AWMF-Registernr.: 013-017. October 2011.

Magin P, Adams J, Heading G, Pond D, Smith W. Experiences of appearance-related teasing and bullying in skin diseases and their
psychological sequelae: results of a qualitative study. Scand J Caring Sci 2008; 22(3): 430-436.

Magin P, Adams J, Heading G, Pond D, Smith W. Psychological sequelae of acne vulgaris: results of a qualitative study. Can Fam
Physician 2006; 52: 978-979.

Nast A, Dreno B, Bettoli V, Bukvic Mokos Z, Degitz K, Dressler C et al. European evidence-based (S3) guideline for the treatment of acne
- update 2016 - short version. J Eur Acad Dermatol Venereol 2016; 30(8): 1261-1268.

Prior J, Khadaroo A. 'I sort of balance it out'. Living with facial acne in emerging adulthood. J Health Psychol 2015; 20(9): 1154-1165.

Romano M, Dellavalle RP, Naldi L. Acne vulgaris. In: Williams H (Ed). Evidence-based dermatology. London: BMJ Publishing Group; 2014.

Tan JK, Vasey K, Fung KY. Beliefs and perceptions of patients with acne. J Am Acad Dermatol 2001; 44(3): 439-445.

Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet 2012; 379(9813): 361-372.

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IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main
treatment options and health care services.
Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The
suitability of any of the described options in an individual case can be determined by talking to a doctor. We do not offer individual
consultations.
Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and
editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated
in our methods.

Labels: Acne, Glands and hormones, L70, Pimples, Skin and hair

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Glossary

acupuncture

Acupuncture is a complementary form of therapy used in traditional Chinese medicine. A doctor inserts thin
needles at precisely defined points on the body. This is supposed to loosen what are thought to be
blockages in the body or to stimulate or calm different organs.

antibiotics

Antibiotics are medicines that can be used for bacterial and some fungal infections. Antibiotics do not work
against viruses. Well-known antibiotics include penicillin, tetracycline and chloramphenicole.

bacteria

Bacteria are micro-organisms that, unlike viruses, can exist on their own. Viruses, on the other hand, can only
exist inside a living cell. Most bacteria are not harmful to people, and some are actually beneficial. Bowel
bacteria support bowel health. However if they get into the urinary system, they can cause an infection
there. Doctors prescribe antibiotics for illnesses where bacteria need to be stopped or killed off.
Immunisation is also possible against some bacterial infections, such as diphtheria, tetanus or whooping
cough.

Cochrane Collaboration

The Cochrane Collaboration is an international network of thousands of researchers and others. They work
together in teams called Cochrane Review Groups to answer questions about health care by doing
systematic reviews of evidence. To achieve this, the members of the Collaboration have developed systems
and methods for systematically finding and analysing the results of trials of health care interventions. The
goal of the Cochrane Collaboration is to help patients, health care practitioners and others make more
informed decisions about health care. You can read more about the Cochrane Collaboration at their website.

eczema

Eczema is a collective term referring to all non-infectious acute or chronic inflammations of the skin with
itching. The symptoms can occur locally on the skin or on the entire body and may include redness,
blistering, nodules or crusting.

evidence

Evidence is what we call scientific proof from well-conducted, good-quality scientific trials that have been
carefully designed to answer specific questions. Depending on the types of questions, different scientific
research methods (types of study) are most appropriate to find reliable answers to these questions.
Randomized controlled trials (RCTs), for example, are the best way to get reliable evidence on the
effectiveness of medical treatments (interventions). This type of study, however, is not the best form of
evidence for all possible questions, and does not provide the best answers to all kinds of questions, either.
Epidemiological studies, for example, are very suitable for establishing well-founded proof for the
spreading of a disease in the population.

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hormones

“Hormones” is the collective term for different types of messenger substances in the body. They are
produced in different organs or tissues and released into the blood or the lymphatic system to be
distributed throughout the body. Hormones only have an effect on those parts of the organism that have a
corresponding docking site. This is how hormones can have such specific effects. Insulin, estrogens,
vasopressin and thyroxine are some well-known hormones. Many medical ingredients imitate the effect of
hormones.

infection

In medicine, we speak of an infection when a person has caught a germ (an infectious agent). This germ can
be a bacterium, a virus, a fungus or a worm. The germ multiplies and then either spreads throughout the
body or only attacks one particular organ. As long as there are no signs of a disease, this is called an
asymptomatic infection. When the body shows a reaction to the germ in the form of symptoms, this is called
a symptomatic infection (an infectious disease). The period between the moment the germs enter the body
and the moment the first symptoms of the disease appear, is called the incubation period. It may last a few
hours or days, or even many years. An infection does not necessarily have to lead to the onset of a disease.

inflammation

An inflammation is a (defense) reaction of the body to an injury, irritation or infection. More blood is
brought to the respective body part to protect the body. This is why this body part feels warmer, becomes
swollen and red and is usually more sensitive. If the inflammation affects the mucous membranes, they
secrete more fluid than usual. This helps to wash out the germs that have entered.

virus

Viruses are germs that enter living cells (plant, animal or human cells) to multiply. Viruses cause illnesses and
diseases such as smallpox, influenza, colds, hepatitis, herpes and AIDS.

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