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How to Know Which Acne Treatment Is Best For You: The 5 Underlying Mechanisms of Acne

Updated: Jan 21, 2021

Having acne is rough, and the world of acne treatments is a damn minefield. Even when a friend recommends something that worked fabulously for them, you find it doesn't give you the same miraculous results. You've already worked out that airbrushed advertisements don't always deliver on their promises. So, how do you figure out where to start? Your skin is a huge, intricate and complex organ that interacts with every system in your body. Your acne will not be the same as someone else's because your genetics, diet, stress levels and other lifestyle factors are not the same. There are five major biological processes happening in the skin that create pimples and blackheads. Some acne sufferers will have all of these underlying drivers present; others might only have 2 or 3. If you can understand and identify what is going on in your skin, it will help direct you to the appropriate types of acne treatments to explore.

Acne vulgaris is a condition involving chronic inflammation of the pilosebaceous follicles (the hair follicles which also have a sebum/oil gland). Most of these follicles are on the face, chest, shoulders and back so this is where acne will most likely occur. Acne can present as pustules, papules, oily skin, redness, pain and discomfort in the skin, blackheads and whiteheads and over time, scarring. These are the five major problems occurring within the skin, that lead to the formation of acne: 1. Proliferation of Keratinocytes These are the cells that make up 90% of the epidermis - the outer section of the skin. Keratinocytes start out as plump, lively little skin cells at the basal layer of the epidermis. As the move closer to the surface, they change and die in a process called apoptosis. By the time they reach the surface, they should be anuclear (their nucleus has dissolved), flat, dead cells that are ready to protect the rest of the skin from the outer world. In a normal, healthy skin it takes about 28 days for the keratinocytes to move from the basal layer of the epidermis up to the surface. In acneous skin, the production of these cells may occur at an increased rate, leading the cells to reach the surface in a shorter space of time. This may mean that the cells are not quite developed normally when they reach the surface, and it can also cause more blocking of the pores. Signs that this is a problem for you:

  • Fast growing hair

  • Fast growing nails (hair and nails are also made of keratin)

  • Blackheads and clogged pores

If you have a blood sugar or insulin imbalance, you are more likely to have an increased production of keratinocytes. This can be caused by many different factors, one being a diet high in sugar, starchy foods (bread, potatoes, oats, rice etc) and refined foods. 2. Incomplete Separation of Corneocytes Corneocytes are the very same keratinocytes we just talked about, but we call them corneocytes once they reach the surface layer of the skin. If these cells don't separate properly and are clumped together, they may clog the pores. Clogged pores result in inflammation, pain and possibly infection. Blood sugar imbalances, insulin resistance and high levels of insulin-like growth factor 1 (IGF-1) also affect the incomplete separation of corneocytes. Hormonal conditions like polycystic ovarian syndrome can lead to insulin imbalances. Some of the signs of blood sugar imbalances include:

  • Hungry all the time, always thinking about food

  • Excessive appetite, binge eating, huge portions

  • Sugar and carb cravings (even for healthy foods like rice, potatoes, oats, fruit)

  • Urinary frequency (feeling the need to pee all the time, even if you just went)

  • Thirsty all the time or drink a lot of water

  • Pot belly that you can't shift with exercise or eating less

  • Acne

3. Increased sebum production Sebum is the oil produced by your skin. This mechanism basically results in oily skin. You'll know if you have it. Not all acne sufferers do. The excessive production of oil causes more plugging of the pores because the skin cells get easily trapped. Aside from the quantity of oil, quality can also be a problem. If you eat lots of baked or fried foods with damaged fats or trans-fats, or you don't eat enough healthy fats, you can have an unhealthy quality of oil being produced in the skin, which can be more sticky and oxidised, resulting in more clogging and inflammation. So, why do you have oily skin? Some possible causes:

  • Excessive circulating androgens (testosterone and other hormones)

  • Blood sugar, insulin and IGF-1 imbalances

  • Polycystic ovarian syndrome (PCOS) which often involves high levels of androgens and blood sugar imbalances

  • Poor liver detoxification (Your liver is responsible for processing and clearing out hormones. If it it overburderned or underfunctioning, this can cause hormonal imbalances.)

  • Stress (Can create imbalance between oestrogen and testosterone, influence blood sugar levels and increase cortisol levels.)

4. Overgrowth of Propionobacterium acnes I put this one at number 4 for a reason! There are so many misconceptions about the role of bacteria in acne. Some acne sufferers, but not all, will have bacterial involvement with their condition. Propionobacterium acnes (P. acnes) is a specific bacteria that has been identified to be involved in many cases of acne, but not all. P. acnes causes oxidative stress on the skin itself, and also breaks down sebum into harmful fatty acids that create more inflammation in the skin. Whenever you see pus in the skin, this is evidence of your immune system sending in an army of white blood cells to fight off infection. Part of what you are seeing is these white blood cells that have died after battling the bacteria. Some ways to tell if your acne is bacterial:

  • Visible pus in your pimples, especially if it is yellow or green

  • Excess redness and inflammation

  • Cystic acne

  • Positive swab results (you can ask for a pathology test to see if you have an overgrowth of this bacteria on the skin. There are also other types of harmful bacteria that can grow on the skin.)

Some possible contributors to bacterial acne:

  • Insulin resistance, high sugar diet, high IGF-1 (Are you seeing a pattern here?)

  • Internal antibiotics and anything else that weakens the immune system such as alcohol, a poor diet, stress, eating foods you are intolerant to and certain medications

  • Harsh cleansers and strong antibiotics (Yep, the very acne treatments that promised to fix your skin might be making it worse.)

Often initially when people first develop mild acne, it isn't bacterial. We all have an entire community of healthy bacteria on the skin that protect it and act as our first line of defence against the world. Antibacterial washes can kill good bacteria on the skin which means there may be no defense system to stop the bad bacteria growing in abundance. They can also break down the fragile acid mantle of oil and water in the skin which can make your skin more sensitive and vulnerable. Internal antibiotics (whether for the skin or for something else) have a similar effect on your gut microbiome, potentially leading to all manner of gut, immune, skin and mental problems as a result. Have you ever taken a hefty or prolonged dose of antibiotics? (A better question might be, who hasn't?) Possible treatment options for this mechanism of acne:

  • Natural antibacterial treatments applied topically only to the spots themselves and not to healthy skin

  • Antibacterial and immune boosting herbs

  • Zinc and vitamin C to boost immunity while also promoting connective tissue repair and addressing stress and hormonal balance

  • Probiotic supplements and fermented foods (sauerkraut, kombucha etc are rich in probiotics, but are not suitable for everyone. Oddly enough people with severe gut issues are most likely to initially struggle with these foods.)

  • Probiotic skincare (you can buy topical sprays and moisturisers that contain specific healthy skin bacteria to repopulate healthy skin microbiome)

  • Gut repair work under naturopathic guidance

5. Excessive Inflammation Inflammation is present in pretty much all cases of acne. Systemic inflammation can potentially cause and maintain acne but acne itself also causes local inflammation. Systemic inflammation may occur due to an inflammatory diet (too much sugar, junk food, additives, alcohol, colours, pesticides, low intake of healthy fats and fruits and vegetables), leaky gut syndrome (can be caused by unidentified food intolerances), stress and the presence of other chronic illnesses. Inflammation in the skin presents as redness, tingling, swelling, pain and even heat. If pores become clogged due to one of the afore-mentioned drivers, this can create pressure and swelling. Inflammation gets a bad rap, but it is actually a natural and vital part of our immune response. Basically, it is just when the blood cells rush to the area to fight pathogens, heal and repair. The problem with inflammation occurs when it is ongoing - as it is for most acne sufferers. It results in persistent redness in the skin, irritation and pain. Which of these acne mechanisms resonated with you? It's important to remember that not every acne sufferer will be experiencing all five mechanisms. And the ones that are relevant for you may change as your skin changes. People with severe acne most likely have all the above drivers present. People with milder forms of acne may only have 2-3 of these mechanisms. When it comes to treating acne, getting the treatment approach right is important. For example, there's no point taking antibacterial treatments for acne if bacteria was never the cause. We first need to identify which mechanisms are occurring and then look deeper to see what is causing it to occur in the first place. There are many herbal and nutritional treatments for acne. A tailored, cause-specific approach is, in most cases, the best way to treat the skin to resolution, while also improving the overall function of the entire body. I hope this gives you a little more understanding about what is happening in your particular skin. If you have questions, please email me If you need further support and a tailored skin treatment plan, you can of course book in a consultation with me.

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