Acne is a skin condition that affects areas containing the largest oil glands, including the nose, forehead, cheeks, chin, back, and trunk. It is caused by a disorder of the oil glands that results in clogged pores and outbreaks of lesions commonly known as pimples. Acne affects between 17 million and 45 million people, making it the most common skin disease in the United States. While it tends to last longer in females, males are more likely to get acne and tend to have more severe cases than do females. Some infants may develop acne, but it is most common in adolescents and it generally disappears by age 30. Although it is not a serious health threat, severe acne can be painful and may cause permanent scarring, which can be upsetting for people who suffer from the condition. An estimated $100 million is spent annually on over-the-counter products to treat acne and reduce the pain, scarring, and emotional distress that can be associated with it.

There are various types of acne lesions:

• Comedone — general term for an enlarged hair follicle plugged with oil and bacteria. This is the first and smallest type of lesion. It is often referred to as a microcomendone because it cannot be seen by the naked eye.
• Open comedone (blackhead) — a plugged follicle that reaches the surface of the skin. Although dark in appearance, blackheads do not indicate the presence of dirt.
• Closed comedone (whitehead) — a clogged follicle that stays beneath the skin. Whiteheads usually appear on the skin as round, white bumps roughly 1 to 2 mm in diameter.
• Papules — inflamed lesions that appear as small, pink bumps on the skin
• Pustules (pimples) — inflamed pus-filled lesions that are red at the base
• Cysts and nodules — large, inflamed, pus-filled lesions that are lodged deep and can drain, causing pain and scarring

Lesions can cause scars ranging from small, depressed pits to large elevated blemishes, depending on the severity of the condition and the individual's skin type.

Acne is a disorder of the skin's oil glands. Oil glands make an substance called sebum that normally rises up through a hair-containing canal called a follicle and empties onto the skin surface. The precise cause of acne in newborns is not known, but some researchers speculate that it may be due to the transfer through the placenta of hormones from the mother or of acne-causing medication (such as lithium and phenytoin) that the mother may have been taking. During adolescence, rising hormone levels are thought to increase the number of oil glands and the amount of sebum they produce. The increased production of sebum causes blockage of hair follicles, leading to the formation of small bacteria-filled cysts called comedones. If these comedones remain intact and no not rupture, they can progress into open comedones (whiteheads) or closed comedones (blackheads). When comedones rupture, an inflammatory reaction occurs and can spread into the surrounding tissue. Papules, pustules, cysts, and nodules are all forms of inflammatory lesions.

The following may cause or worsen acne:

• Family history of acne
• Greasy/oily cosmetic or hair products containing vegetable or animal fats
• Hormonal changes associated with adolescence, pregnancy, or menstruation (acne tends to flare up 2 to 7 days before menstruation begins)
• Certain medications such as corticosteroids, androgens, oral contraceptives, lithium, halogens, isoniazid, phenytoin, phenobarbital, and high levels of iodine (such as from kelp)
• Environmental irritants such as industrial cutting oils, tar, wood preservatives, sealing compounds, and other pollutants
• Sweating and friction, such as from headbands, back packs, bicycle helmets, or tight collars
• High levels of humidity
• Squeezing and picking comedones

Although still controversial, some researchers believe that stress and sun exposure can also cause or aggravate existing acne. This may be due to the use of oily sunscreens however, as some people with acne actually experience improvement in symptoms with exposure to the sun.

Acne has a characteristic appearance and is not difficult to diagnose. General practitioners, pediatricians, and internists can treat most individuals with mild and moderate forms of acne. People with more severe cases of acne however, are often referred to a dermatologist or a skin disease specialist. The practitioner will take a complete medical history that includes questions about skin care, cosmetic use, and diet; factors that trigger flare-ups; medication use; occupational and environmental exposures; and prior treatment. The practitioner will also examine the face, chest, back, and other areas for blemishes, lesions, and scars. Several factors, including the size of the blemishes and whether or not they are inflamed, help a practitioner determine the most appropriate treatment.

The main goals of acne treatment are to prevent scarring, reduce the number of painful lesions, and minimize the stress and embarrassment related to the condition. The basic principle of skin care is to wash the affected area no more than one to two times per day with a mild, nondrying soap. Frequent washing and the use of harsh soaps can actually make the condition worse. Healthcare practitioners will often recommend topical medications as their first choice for treating acne (generally either benzoyl peroxide or a class of drugs known as retinoids). These are designed to wear away the top layer of skin (exfoliate) as well as to reduce abnormal clumping of cells in the follicles, oil and bacteria production, and inflammation. Additionally, facial steaming with accompanying manual extraction of the comedones (such as by a professional aesthetician) is valuable for exfoliation as well. Although more research is needed to investigate the safety and effectiveness of alternative remedies for acne, people with mild cases of acne may experience an improvement in symptoms from herbs, Ayurveda, or homeopathy. Mind/body techniques such as biofeedback or hypnosis may also help to alleviate feelings of anxiety and depression that some individuals experience with this skin condition. Expect to use medications and/or complementary and alternative remedies for at least 6 to 8 weeks before seeing a noticeable improvement in symptoms. Seek medical care if infantile acne does not improve within three months.

Topical

Topical medications (those applied directly to the skin) are available in many forms including gels, lotions, creams, soaps, or pads. The most commonly used topical medications for acne include:

• Benzoyl peroxide — works by killing bacteria and unclogging pores. This medication comes in prescription and over-the-counter preparations. Benzoyl peroxide should not be applied at the same time of day as topical retinoids. To avoid adverse reactions, apply to small area on forearm and observe the area for two to three days. If no reaction occurs, application to the face should be safe.
• Retinoids — work by unclogging pores and reducing inflammation. These medications come in prescription form only. Commonly prescribed retinoids include tretinoin, adapalene, and tazarotene. They are intended for individuals with significant numbers of both open and closed comedones as well as papules and pustules. Side effects may include redness, peeling, and photosensitivity (high risk of sunburn). Most retinoids are applied at night and should not be applied at the same time as benzoyl peroxide (with the exception of adapalene). Topical retinoids should not be used during pregnancy as they may cause harm to the fetus.
• Antibiotics — work by killing bacteria and reducing inflammation. Topical antibiotics such as clindamycin or erythromycin are available in prescription form. They may be used to treat mild to moderate acne.

In some cases, healthcare practitioners may recommend a combination of topical medications, such as benzoyl peroxide and clindamycin. Other topical acne medications available by prescription include sodium sulfacetamide and azelaic acid.

Oral

Healthcare practitioners may prescribe oral (taken by mouth) antibiotics either alone or in addition to topical medications for individuals with moderate to severe acne. For those with severe, inflammatory acne that does not improve with other medications, healthcare practitioners may prescribe an oral retinoid called isotretinoin. Further information about these medications is discussed below:

• Antibiotics—work by killing bacteria and reducing inflammation. Commonly prescribed oral antibiotics include doxycycline, minocycline, and tetracycline. Oral antibiotics should not be used during pregnancy or by those under 9 years of age.
• Isotretinoin—works by reducing the size of oil glands and lowering sebum production. It is usually prescribed by a dermatologist for individuals with severe, inflammatory acne that does not improve with other medications. Isotretinoin is taken twice a day for 20 weeks. It should not be used by pregnant women as it may cause harm to the fetus. 

In some cases, healthcare practitioners may also prescribe certain oral contraceptives in addition to acne medications.

Individuals with severe acne scars may require surgery or other procedures to improve the appearance of their skin. Dermatologists can perform skin resurfacing techniques such as dermabrasion (a procedure that uses a rapidly rotating brush to remove acne scars or pits) or chemical peeling (a chemical solution is applied to the skin that causes it to blister and eventually peel off). Dermatologic surgeons can also perform scar excisions (a technique in which the scar is removed and the surrounding healthy skin is joined together) and punch grafting (a method in which the surgeon punches a hole in the skin, removes the scar, and replaces it with a small plug of new skin) to correct deep acne scars.

Diet

Some people with acne report that certain drinks and foods (particularly nuts) worsen their symptoms. Studies have yet to confirm a scientific link between diet and acne, but people with this skin condition should avoid substances that appear to aggravate their symptoms.

Zinc

Studies indicate that the mineral zinc may be an effective treatment for inflammatory acne. In two studies of about 60 people with inflammatory acne, those who took zinc gluconate daily for roughly two months had a significant reduction in the number and severity of inflammatory lesions compared to those who took placebo for the same period of time. Despite these promising findings, differences in the type of zinc preparations as well as variations in the amount and duration of treatment, make it difficult to draw definitive conclusions from these two studies. In addition, certain topical medications such as erythromycin ointment may contain zinc oxide. It is possible, but not entirely clear, that the zinc contained in the ointment may contribute to the effectiveness of the product.

L-carnitine

Researchers in Greece showed that a large group of people who had side effects from isotretinoin got better when taking L-carnitine compared to those who took a placebo.

The following herbs have anti-inflammatory properties that may be helpful in the treatment of skin conditions including acne:

• Calendula (Calendula officinalis) 
• German chamomile (Matricaria recutita) 
• Witch hazel (Hamamelis virginiana) 
• Licorice root (Glycyrrhiza glabra) 
• Flaxseed (Linum usitatissimum) and flaxseed oil 

Tea Tree Oil

Some plants contain antimicrobial substances that may help eliminate Propionibacterium acnes (the bacterial strain associated with acne), thereby potentially reducing inflammation associated with the skin condition. Preliminary evidence suggests that tea tree oil (Melaleuca alternafolia) may have antimicrobial effects. One study compared the effectiveness of tea tree oil gel with benzoyl peroxide lotion in 119 people with mild to moderate acne. Individuals in both treatment groups showed a significant reduction in the number of inflamed and noninflamed lesions over a 3-month period. Seventy-nine percent of the benzoyl peroxide group compared to 44% of the tea tree oil group reported side effects included stinging, itching, burning, and dryness. A laboratory study also found that tea tree oil as well as certain active components of tea tree oil effectively slows the growth of P. acnes.

While there have been no well-designed studies evaluating the use of acupuncture for acne, there have been several reports in the medical literature that auricular (acupuncture applied to the ear) and electroacupuncture therapies may reduce the symptoms of acne.

There have been few studies examining the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for acne based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Belladonna— for people who experience flushes of heat to the face or who have inflamed pustular acne that improves with cold applications
• Calendula— for skin conditions involving pustules or blisters
• Hepar sulphur— for painful, pus-filled acne
• Kali bromatum— for deep acne, especially on the forehead, in persons who are chilled and nervous
• Silicea— for pustules or pit-forming acne

Biofeedback and Cognitive Imagery

Emotional stress can worsen acne, so it is possible that relaxation therapies such as biofeedback together with cognitive imagery may improve acne symptoms. Biofeedback is a technique in which an individual is trained to control certain internal bodily processes that normally occur involuntarily, such as heart rate (measured by an EKG) and muscle tension (measured by an EMG). During biofeedback training, an individual participates in a relaxation technique, such as guided imagery, while hooked up to an EKG or an EMG. Guided imagery involves the formation of mental pictures to promote a variety of favorable physical and emotional effects. This combination of biofeedback and cognitive imagery allows the person to visualize and understand the bodily changes that occur when he or she changes from being tense to being relaxed. In a study of 30 individuals with acne, those who participated in EMG feedback and guided imagery demonstrated a significant improvement in acne symptoms compared to those who did not receive these treatments.

Hypnosis

Hypnosis may enhance the effectiveness of treatments for a variety of skin conditions including acne. It is not entirely clear how hypnosis improves symptoms of acne, however. Some researchers speculate that it can help an individual become more relaxed and, as a result, may positively influence the activity of hormones and the immune system (which may contribute to reduced inflammation).

In one well-designed trial, 82 people with moderate acne were randomly assigned to receive either placebo or one of four Ayurvedic preparations. Only one formulation, Sunder Vati, significantly reduced the number of both inflammatory and non-inflammatory lesions. The herbs in the Sunder Vati preparation include:

• Ginger (Zingiber officinale)
• Holarrhena antidysenterica
• Embelia ribes

Some healthcare practitioners have reported that Keigai-rengyo-to (TJ-50), a Japanese Kampo medicine, may be effective in the treatment of acne. Researchers speculate that the therapeutic effects of this medication may be due to the antibacterial and anti-inflammatory activity of its components. The formulation contains 17 herbs, including:

• Skullcap root (Scutellaria lateriflora)
• Licorice root (Glycyrrhiza glabra)
• Mint (Mentha arvensis)
• Angelica root (Angelica archangelica)
• Peony root (Paeonia lactiflora)

Pregnant women should avoid all retinoids (oral and topical), isotretinoin, and the antibiotics tetracycline, minocycline, doxycycline because they can be harmful to the fetus. The antibiotic erythromycin (in both topical and oral forms) is safe to use during pregnancy.

Acne is not a serious health threat, but severe acne can be painful, emotionally upsetting, and may cause permanent scarring. Squeezing lesions can rupture comedones and cause inflammation. Infants with acne have an increased risk of developing acne in adolescence. Symptoms generally diminish after adolescence and disappear by age 30. However, the incidence of adult acne, especially in women, seems to be increasing and is not unusual in women in their 30s and 40s.

Akamatsu H, Asada Y, Horio T. Effect of keigai-rengyo-to, a Japanese Kampo medicine, on neutrophil functions: a possible mechanism of action of keigai-rengyo-to in acne. J Int Med Res. 1997;25:255-265.

American Academy of Dermatology (ADD). Acne. 1987. Accessed at http://www.aad.org/pamphlets/acnepamp.html on October 12, 2001.

Bassett IB, Pannowits DL, Barneston RSC. A comparative study of tea-tree oil versus benzoyl peroxide in the treatment of acne. Med J Aust. 1990;153:455-458.

Brown DJ, Dattner AM. Phytotherapeutic approaches to common dermatologic conditions. Arch Dermtol. 1998;134:1401-1404.

Dai G. Advances in the acupuncture treatment of acne. J Trad Chinese Med. 1997;17(1):65-72.

Darmstadt GL. Acne vulgaris. In: Behrman RE, Kliefman RM, and Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, PA: W.B. Saunders Company; 2000: 2047-2051.

Dreno B, Amblard P, Agache P, Sirot S, Litoux P. Low doses of zinc gluconate for inflammatory acne. Acta Derm Venereol. 1989;69:541-543.

Dreno B, Trossaert M, Boiteau HL, Litoux P. Zinc salts effects on granulocyte zinc concentration and chemotaxis in acne patients. Acta Dermatol Venereol. 1992;72:250-252.

Ernst E, Huntley A. Tea tree oil: a systematic review of randomized clinical trials. Forsch Komplementärmed. 2000;7:17-20.

Georgala S, Schulpis KH, Georgala C, Michas T. L-carnitine supplementation in patients with cystic acne on isotretinoin therapy. J Eur Acad Dermatol Venereol. 1999;13(3):205-209.

Gfesser M, Worret WI. Seasonal variations in the severity of acne vulgaris. Int J Dermatol. 1996;35(2):116-117.

Higaki S, Morimatsu S, Morohashi M, Yamagishi Y, Hasegawa Y. Susceptibility of Propionibacterium acnes, Staphylococcus aureus and Staphylococcus epidermidis to 10 Kampo formulations. J Int Med Res. 1997;25:318-324.

Hughes H, Brown BW, Lawlis GF, Fulton JE. Treatment of acne vulgaris by biofeedback relaxation and cognitive imagery. J Psychosom Res. 1983;27(3):185-191.

Jansen T, Plewig G. Advances and perspectives in acne therapy. Eur J Med Res. 1997;2:321-334.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 227-230.

Krowchuk DP. Treating acne. A practical guide. Med Clin North Am. 2000;84(4):811-828.

Kubo I, Muroi H, Kubo A. Naturally occurring antiacne agents. J Nat Prod. 1994;57(1):9-17.

Lucky AW, Biro FM, Simbartl LA, Morrison JA, Sorg NW. Predictors of severity of acne vulgaris in young adolescent girls: results from a five-year longitudinal study. J Pediatr. 1997;13(1):5.

Lucky AW, Cullen SI, Jarratt MT. Comparative efficacy and safety of two 0.025% tretinoin gel: results from a multicenter double-blind, parallel study. J Am Acad Dermatol. 1998; 38(4): S17–23.

Meynadier J. Efficacy and safety study of two zinc gluconate regimens in the treatment of inflammatory acne. Eur J Dermatol. 2000;10:269-273.

NIAMS/NIH. Questions and answers about acne. March 1999. Accessed at http://www.niams.nih.gov/hi/topics/acne/acne.htm on October 12, 2001.

Papageorgiou PP, Chu AC. Chloroxylenol and zinc oxide containing cream (Nels cream®) vs. 5% benzoyl peroxide cream in the treatment of acne vulgaris. A double-blind, randomized, controlled trial. Clin and Exp Dermatol. 2000;25:16-20.

Paranjpe P, Kulkarni PH. Comparative efficacy of four Ayurvedic formulations in the treatment of acne vulgaris: a double-blind randomized placebo-controlled clinical evaluation. J Ethnopharm. 1995;49:127-132.

Raman A, Weir U, Bloomfield SF. Antimicrobial effects of tea-tree oil and its major components on Staphylococcus aureus, Staph. epidermidis and Propionibacterium acnes. Letters in Applied Microbiol. 1995;21:242-245.

Shenefelt PD. Hypnosis in dermatology. Arch Dermatol. 2000;136:393-399.

Swerlick RA, Lawley TJ. Eczema, psoriasis, cutaneous infections, acne, and other common skin disorders. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:303-304.

Thiboutot D. New treatments and therapeutic strategies for acne. Arch Fam Med. 2000;9:179-187.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 185-186.

Whang KK, Lee M. The principle of a three-staged operation in the surgery of acne scars. J Am Acad Dermatol. 1999; 40(1): 95–97.

Whitmore, SL. Common problems of the skin. In: Barker LR, Burton JR, Zieve PD. Principals of Ambulatory Medicine. 5th ed. Baltimore, MD: Williams & Wilkins; 1999: 1511.