Acne 101: Treating Pimples

We all want clear skin, especially if you have been suffering from acne. Pimples, blemishes, zits… no matter what you call them, you don’t want to have them on your face. But do you feel like you’re piling pimple cream on to your face and the only result is dry, flaky skin that happens to have even more zits?

If you want clear skin, you need to take a systematic approach to treating pimples. First, make sure you have read the basics of how pimples form, because it will make the treatment approach much easier to understand!

How to Treat Acne

When choosing products to treat your acne, it is best to target acne via different routes. Most dermatologists think of including these product types in an entire regimen:

1. Exfoliant
The cells within the hair follicles aren’t sloughing properly and they’re clogging the pore. Exfoliating the surface will help to clear some of them out.

2. Antimicrobial
P. acnes is the main bacteria involved in the development of acne. We don’t fully understand the role this bacteria plays in acne, but it much more likely to be found on the skin of those with acne and in higher numbers. It certainly plays a role in inflammation of pimples. As well, reducing the amount of bacteria has been found to decrease acne.

The main issue with treating P. acnes is bacterial resistance. Up to 60% of people have a strain that easily becomes resistant to the most commonly used antibiotics for acne. Combining the antibiotic with another agent, such as benzoyl peroxide, can prevent the resistance from becoming an issue.

3. Retinoid
There are a lot of caveats to using a retinoid (they’re not pregnancy safe, they can be very irritating to the skin), but retinoids will help blemishes many ways. For example, they regulate the skin cell sloughing. More below.

4. Anti-Inflammatory
Obviously if you’ve ever had a big pimple then you will know that they are full of pus. Which is from all of that inflammation. And this will make the pimple much worse as well, making it harder to remove everything from the blemish, and clean up the mess. The inflammation also makes scarring and post-pimple hyperpigmentation much more likely.

Retinoids in Acne Treatment

The first way to treat acne is to start up at the very beginning of that acne circle of death. The skin cells that are sloughed off have 2 reasons they are sticky and clog things up. The first is that they have slightly different charges on their cell surface, think of them as a bunch of little magnets. Little positive and negative areas line up and keep the cells close together. Once this has happened, an enzyme (transglutaminase) creates little cross bridge connections holding the cells together.

Retinoids will actually treat both of those issues. First, they help to normalize the rate at which the skin cells slough off. The cells that do slough off (at their newly improved rate) will have reduced charges and overall the levels of transglutaminase (and therefore cross bridges) are reduced as well. Blemishes under retinoid treatment are less cohesive and looser. You’re less likely to have the whole follicle plug up and create the blemish, and then when it does the decrease in compactness means that other treatments will be able to penetrate into the blemish more easily. It’s a win-win all around.

Antibiotics and Antimicrobials in Treating Pimples

So, remember when I said that bacteria will infiltrate into the whole sebum-white cell-sloughed skin cell mess? It only makes sense that getting rid of the bacteria will help to stop the downward spiral of a pimple. Less bacteria=less inflammation=less pus, etc.

There are 2 main ways to treat the bacteria. The first is with Benzoyl Peroxide. Benzoyl Peroxide will create free radicals (read more about that in my antioxidants in skin care post), and those will directly attack and kill the bacteria. Keep in mind that due to the free radicals you’ll see damage also to the area’s skin cells, so there is a potential for speeding up aging.

The second way to treat the bacteria is obviously with antibiotics! Usually Clindamycin or Erythromycin are used. Both work equally well, though there’s more risk of bacteria becoming resistant with Erythromycin. When used in combination with Benzoyl Peroxide the risk of resistance is lower. Both of these anti-biotics also work as anti-inflammatories. Both of these antibiotics need to be prescribed.

Finally, you’ll sometimes see Sulfur (or Sodium sulfacetamide) used as the anti-biotic in over the counter meds. Sulfur can also work on the rate of skin cell sloughing, though it won’t affect the charges and enzyme levels like a retinoid.

Clear Out Your Pores

So, obviously cleaning the junk out of the pimple is a good thing. You should not do this by popping the pimple. That follicle won’t only push everything out the pore, but it will likely also rupture back into the skin, spreading the inflammation and bacteria, resulting in an even bigger mess. Extractions can be performed by those trained to do it properly (such as an esthetician), or you could remove things from your pores using a mask like the Gelatin Mask to pull everything out. I’m also a big fan of a mud mask.

Alpha and Beta Hydroxy Acids are also great for helping to clear out the hair follicle. BHAs like Salicylic Acid are more effective because they are lipid soluble, so can penetrate into the sebum clogging the follicle much more easily. Note that Salicylic Acid is also anti-inflammatory.

Decrease Inflammation

I’m sure we’ve all seen in magazines the recommendations to head to your dermatologist for a steroid injection if you get a big blemish the day of an event. It really does work. Bringing down the inflammation makes the swelling go away, the redness is gone, and while that little plug of sebum and sloughed cells is still present, the blemish is much less apparent. If only it was always this easy!

There are a few ways to bring down inflammation to help acne. The first way is obviously steroids, but this should be avoided at all costs. You can have thinning of the skin from steroid use (steroid atrophy), but use of topical steroids can even cause “steroid acne”. So, definitely no steroids! Instead, take advantage of the anti-inflammatory side effects of some of the other treatments, such as topical antibiotics and Salicylic Acid.

Reduce Oil Production

To help decrease sebum production you can use Retinoids (oral and topical both decrease oil production), or a hormonal treatment such as a birth control pill. There aren’t any other ways to really decrease oil production, but you should also remember to not do things that increase oil production. Over washing of the skin will increase oil production quite a bit, so definitely stick to 2x a day at most.

Give It Time

You may have noticed something about all of the above Acne treatments. Very few of them work on blemishes that you already have. Instead, they work on changing the way your skin acts, so they prevent future blemishes. Which means that rather than seeing results quickly, you’ll need to wait about 6-8 weeks to really see a result.

If you want to see immediate results, you should look for Salicylic Acid, Benzoyl Peroxide and steroids (with your physician). I’ve also had results using heat, with either a warm compress or my Tanda Zap.

Medical Help

Keep in mind that not everything that looks like acne, is actually acne. If you’ve tried the typical over the counter treatments without any effect, then it is definitely time to head to your doctor. There’s a huge list of alternative diagnoses, but they include things like Pityrosporum folliculitis, Rosacea, and Seborrheic dermatitis.

So, that’s acne and acne treatment made super simple. Obviously there’s a lot more to this than I’ve explained (I’m but a simple pediatric intensivist, not a dermatologist), and when in doubt I recommend seeing your doctor. Most primary care doctors do treat a lot of derm issues (we did a lot of rashes and acne back in my general peds days), and if needed they’ll refer you on to a dermatologist.