Acne 101: Acne Causes

Episode #121 / Nov 11, 2009

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You recognize acne breakouts as pus pimples, cysts, red bumps, whiteheads, blackheads, but what are they? What’s going on here? What’s broken? In order for me to explain this to you, I need to use a diagram of your skin. Your skin has three parts—it has an upper layer, which is the epidermis, which isn’t much of a problem here, it has a middle layer, which is the dermis, where all of the equipment, where all of the machinery in your skin is, and that’s exactly where the problem is, and then it has the bottom layer, or the fat or the subcutaneous tissue. But what we’re really focused on here is this long, club-like organ in the dermis, in the middle layer, and this is the hair follicle, and the hair follicle has the hair bulb and the hair shaft that comes up through this canal and comes out through the skin. The troublemaker is this little bulge on the side of the bottom of the hair follicle. That’s the oil gland which is also called a sebaceous gland, and that’s where you make your oil. When the oil gland makes its oil, through a little duct, it conducts the oil into the shaft of the hair follicle, comes up the shaft and onto the skin. So what’s going on here? The real problem in acne is oil, because if you don’t have any oil, and if the oil gland isn’t working, you can never have acne, that’s why Accutane cures acne, Accutane stops oil. But when you do have oil, oil combined with bacteria will cause inflammatory acne down here and inflammatory acne is pus pimples and red tender pimples and cysts, and oil up here with dead cells from the lining of the hair follicle, will cause non-inflammatory acne which is whiteheads and blackheads.
So let’s come back here to the bottom where the bacteria are. Why are there bacteria down here at some times and not at other times? We really don’t understand, but we do know that, with the hormonal changes that occur in adolescence, those hormones cause you to make much more oil and once the oil is working, you are set up for acne. The bacteria, which tend to live down here, take the normal oil, which is called triglycerides, and it splits triglycerides into a couple of things but one of them is called a free fatty acid. Free fatty acids are very irritating to the skin, to the inside of the skin, almost like a splinter is irritating to the inside of the skin and, just the way a splinter will often cause a pus bump or a pus pimple, free fatty acids are so irritating, they cause an accumulation of pus and that accumulation of pus down here is where your red tender pimple, your pus pimple, and your cysts come from. On the other hand, having nothing to do with bacteria, the lining of the hair follicle and the hair shaft has dead cells just like on the surface of your skin and they fall off, and as they fall off, they are conducted out with the oil, as the oil flows up, and they get carried out. Well, what happens if those dead cells and the oil forms a mix like cement and gives you a clog? That clog over here doesn’t know that there is more oil being made, and the body doesn’t know that there is a clog, so you make more oil behind the clog and that’s how you get a blackhead or a whitehead.
So now that we understand what’s going on with whether it’s inflammatory acne or non-inflammatory acne, we can understand why treatment works. Antibiotics kill bacteria. If antibiotics kill bacteria that ‘s acting on the oil, you won’t get pus pimples or cysts. If you use exfoliants which take dead cells away or dissolve dead cells in clogs, those exfoliants can get into the channel here and dissolve the clog and allow the oil to flow. That’s why the exfoliants help treat non-inflammatory acne like whiteheads and blackheads. So the next time you see a pimple, at least you’ll understand what it is but, more importantly, why your treatment works.

We can all recognize acne: white heads, black heads and cysts. But do you know what causes acne? Or what treats acne? Or why acne treatments work? Dr. Schultz answers all of these questions in Acne 101.

COMMENTS (8)

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Adam Goldstein on November 19, 2009 at 9:35pm

First of all, I would just thank you for responding to all of my posts. I love this website.

I have 2 questions pertaining to this subject. As you now know, i have been complaining about dry skin post-accutane.

First question, I still get some whiteheads from time to time now. Does this mean that my oil glands are still active? Because i thought i might just still be getting these whiteheads post-accutane because I apply so many thick moisturizers and oils to my skin to combat the dryness.

Second question, what is the difference between a pus pimple and a whitehead.? As you explained, the pus pimples are inflamed and the whiteheads are not inflamed. The reason I ask is because i'm curious to know that if my pimple eventually forms a head, but started off as a little painful bump under the skin, is that inflamed or not inflamed. I still get these very seldom but used to get them a lot before accutane. So just to say that again incase i made that confusing. Are pimples that start out as bumps, slightly painful, under the skin and take a little while to come to the surface, are these inflamed?

Thank you Dr. Schultz once again!

Neal Schultz, M.D. on November 20, 2009 at 5:33pm

@Adam: Thank you for your kind words about DermTV! Your questions show that you clearly have a very good understanding of the physiology of your skin. Below I will answer both:

Regarding question #1 - While post Accutane everyone's oil glands still function a little, I think your whitehead issue is strictly external occlusion from the "many thick moisturizers and oils" you have used in pursuit of fighting your skin's dryness. While glycolics are my treatment of choice for the condition you describe, because of your dry and sensitive skin, I would instead recommend gentle extrusion by either a professional facialist or dermatologist.

Regarding question #2 - A "pus pimple" contains pus which is yellowish. Given a few days it forms a crust and then heals leaving a red/pink flat mark for days to weeks. Pus is composed of white blood cells (and debris) which are one of the mediators of inflammation in the body, hence these are "inflammatory" lesions. On the other hand, a "whitehead" is a tiny collection of sebum/oil (from your oil gland or from skincare products) sometimes mixed with a few dead skin cells (from the lining of the follicle). There's no pus and no white cells and hence considered a non inflammatory pimple. Also, whiteheads tend to be very stable and usually just hang around until they gets popped or picked. So, the evolving painful pimples you are describing are most likely regular inflammatory acne lesions. On an interesting note, they are also an unwelcome confirmation that even post Accutane, oil glands retain some sebum synthesis ability.

magaly on November 21, 2009 at 5:28am

I'm sixteen so obviously I'm dealing with acne. However when I break out its normally one to two huge inflammatory pimples that sometimes take months to go away! Right at this moment Ive be been dealing with a pimple right on the tip of my nose and im already on topical acne medication and plan to see the dermatologist soon. However, I really want to know a way to get rid of these pimples in a safe way with out scarring. And this one on my nose is popped but its still very inflammed and seems to have blood underneath the surface but also a scab has already formed. I need help urgently!

Neal Schultz, M.D. on December 10, 2009 at 6:27pm

@magaly: Pimples on the nose are the toughest to deal with because the top and tip of the nose scar so easily (because there is no fat underneath). There are really only two options for healing:

(1) Get the body to take away the pus that is causing the pimple. To do this, make a warm compresses (washcloth soaked in warm but not hot water) and apply it to the pimple area for three-to-four minutes four times per day. In addition, topical meds like over-the-counter cortisone and products containing salicylic acid and sulfur or resourcinol can help. It usually takes two-to-five days.

(2) Physically remove the pus that is causing the pimple. On the nose in particular, physical removal must be done by a dermatologist because of the risk of scarring if too large of an opening in the skin is made when draining the pimple.

If it takes a long time for occasional pimples to go away, preventing them might be a better way to go (i.e., option #1).

Your first sentence "I'm sixteen so obviously I'm dealing with acne" is refreshingly calm and realistic. Good luck!

AGesss on April 10, 2010 at 5:29am

Does Tea tree oil work for pimples?

Neal Schultz, M.D. on June 1, 2010 at 1:04am

@AGesss: Tea tree oil has antibacterial properties and therefore is helpful for acne. Unfortunately at higher, more effective doses it can have an unpleasant odor.

Jennifer on June 27, 2010 at 11:43pm

Hello Dr. Schultz!
I will try to make this short, but have a long history with acne so bear with me! I am 18 years old, and have dealt with acne since I was 11. I had cystic acne and was prescribed accutane when I was 14, But it dried my skin out so horribly that it cracked. I honestly feel as though I have tried everything. although my acne is no longer severe, it is still a huge annoyance to me, and really effects my self esteem, I am on tri-cyclen lo now, and also take prozac for the depression the acne has caused. I have been on oral antibiotics, prescribed creams, I've tried proactiv, I recently ordered a skincare regimen for $300 that made my acne worse. I am really really fed up, I don't know what else to do. Are there any new treatments for acne? or should I try laser? Sorry for so many questions.. Thank you for your time!

Neal Schultz, M.D. on July 15, 2010 at 7:05pm

@Jennifer: The two options I would consider at this point are laser treatments(as you mentioned) or intense topical treatments involving weekly visits to a dermatologist who does superficial glycolic exfoliation treatments and extracts clogs and pus pimples (since it sounds like while your acne is persistent, it's not as cystic as before your accutane). To find a dermatologist specializing in acne visit The American Academy of Dermatology.

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