If you’ve ever struggled with acne, you’ve probably been told to do everything except understand it.

Wash your face more. 

Stop eating chocolate. 

Dry it out. 

Scrub harder. 

Use this acid. 

But this cleanser. 

Try this spot treatment. 

Don’t moisturize because it’ll clog your pores. 

The list goes on. 

And when none of that works? 

Somehow, it starts to feel like you’re doing something wrong. 

This is what I was told for the over 4 years I struggled with acne, and trust me when I say I understand what it feels like when you want to light everyone on fire trying to give you “advice.” 

Acne is one of the most common skin conditions in the world, and somehow it’s still surrounded by an incredible amount of misinformation. Are we shocked? Not at all. 

So before we talk about treating acne, I want to do something I think skincare should do much more often: 

Understand the biology first. 

Because acne isn’t simply a collection of pimples appearing on the surface of your skin. 

What you’re seeing in the mirror is the end result of a much more complicated process happening inside the pilosebaceous unit – the microscopic structure containing the hair follicle and its associated sebaceous gland. 

And once you understand what’s happening inside that follicle, acne starts making a lot more sense. 

So the next time someone tells you to “drink more water,” well thanks to me you can just send them this article! 

First things first: what actually is acne?

Acne vulgaris is a chronic inflammatory disorder of the pilosebaceous unit. 

That’s the clinical definition. 

In normal language? 

Acne develops within structures we commonly call pores, where hair follicles and sebaceous glands interact. 

Several biological processes contribute to its development, particularly: 

• Increased or altered sebum production 

• Abnormal shedding and accumulation of keratinocytes within the follicle 

• Formation of a follicular plug, or microcomedone 

• Activity of Cutibacterium acnes 

• Inflammation 

Hormones, genetics, certain medications, skincare practices, environmental factors, and other influences can modify these processes. 

That’s already very different from: 

“You have acne because your face is dirty.” 

And if you still believe that, the door is that way. 

Acne begins before you can see it 

This might be one of the most important things to understand about acne. 

That pimple you woke up with this morning? 

It didn’t start this morning. 

Long before an acne lesion becomes visible, changes are already happening microscopically within the follicle. 

One of the earlier acne lesions is called a microcomedone. 

You can’t necessarily see it. 

Inside the follicle, keratinocytes that would normally shed are accumulating and becoming increasingly cohesive. 

At the same time, sebum contributes to the environment within the follicle. 

Eventually, the follicular opening becomes obstructed. 

And now we have the beginning of a comedone. 

This is why effective acne treatment isn’t just about attacking individual pimples after they appear. 

Ideally, we’re interrupting the processes that create them in the first place. 

Let’s talk about keratinization 

Breathe, this word sounds much scarier than it is. 

Hyperkeratinization refers to abnormal accumulation and shedding of keratin-containing cells. 

Within acne-prone follicles, keratinocytes don’t separate and shed normally. 

Instead, they become increasingly cohesive and accumulate within the follicular canal. 

Mix those cells with sebum and you begin forming a plug. 

That plug becomes the foundation of a comedone. 

This is one of the reasons ingredients such as retinoids and salicylic acid can be useful in acne treatment. We’re not simply “drying out pimples.” We’re trying to influence what’s happening inside the follicle. 

Then there’s sebum 

Sebum gets blamed for almost everything. 

But sebum itself isn’t bad. 

Your sebaceous glands produce sebum because your skin actually uses it. 

Sebum contributes to lubrication of the skin and hair and interacts with the skin’s surface environment. 

The problem in acne isn’t simply: Oil exists. 

Sebaceous activity can be increased by androgen signaling, and acne-prone skin often produces greater amounts of sebum. Differences in sebum composition may also contribute to the follicular environment and inflammatory processes associated with acne. 

So yes, oil matters. 

But removing every trace of oil from the surface isn’t the solution. 

Because surface oil isn’t the entire disease process. 

Meet Cutibacterium acnes 

You’ve probably heard people say acne is caused by bacteria. 

That’s true… 

And also way too simple. 

One microorganism associated with acne is Cutibacterium acnes, commonly abbreviated C. acnes. 

But here’s the interesting part: 

C. acnes normally live on human skin. 

Even people without acne have it. 

So acne isn’t simply an infection where a foreign bacterium arrives and starts causing pimples. Instead, changes within the follicular environment can favor particular C. acnes strains and interactions that contribute to inflammatory signaling. 

This distinction matters: 

Because healthy skin isn’t sterile skin. 

We’ve already learned that from the microbiome. 

The goal isn’t to wage war against every bacterium on your face. It’s to influence the environment and biological processes contributing to acne. 

And then inflammation enters the conversation

Acne is an inflammatory condition. 

And inflammation may begin earlier in lesion development than we once appreciated. 

As the follicular environment changes, interactions between sebum, keratinocytes, microorganisms, and the immune system can activate inflammatory pathways. 

Eventually, the follicular wall may become increasingly stressed or rupture, releasing material into the surrounding dermis. 

The immune system responds. 

Now we may begin seeing the red, swollen, tender lesions people typically associate with “inflamed acne.” 

This is where acne can progress beyond simple comedones into papules, pustules, nodules, and deeper inflammatory lesions. 

So what are the different types of acne lesions? 

Acne doesn’t look one single way. 

You can have multiple lesion types at the same time. 

Broadly, we can divide acne lesions into non-inflammatory and inflammatory categories. 

Closed comedones 

These are commonly called whiteheads. 

The follicle is obstructed, but the opening remains covered by a thin layer of epidermis. 

They often appear as small, skin-colored bumps. 

Open comedomes

These are blackheads. 

And no – the black color isn’t dirt. 

The follicular opening is exposed to air, and material within the comedone comedone undergoes oxidation, contributing to its darker appearance. 

Scrubbing harder will not “wash the dirt out.” 

Because dirt was never the problem. 

Papules

Papules are small, inflamed, raised lesions without an obvious collection of pus at the surface. 

Think of the classic red, tender bump. 

Pustules

Pustules are inflammatory lesions containing visible purulent material. 

These are what many people think of when they hear the word “pimple.” 

Nodules 

Nodules are deeper inflammatory lesions that develop within the skin and may be painful. 

They deserve more caution because deeper inflammation increases the risk of lasting tissue changes and scarring. 

Cyst-like lesions 

People often use the phrase “cystic acne” for any large pimple. 

True acne pathology is a little more complicated, and deep inflammatory lesions can include nodule and pseudocystic lesions. 

We’ll dedicate an entire Skin Journal to understanding nodular and severe inflammatory acne, because deeper acne deserves much more attention than a paragraph here. 

Acne severity isn’t determined by how much it bothers you 

This is an important distinction. 

Clinically, acne can be classified based on factors such as lesion type, lesion number, inflammation, distribution, and presence of scarring. 

But someone’s emotional experience doesn’t always correlate with clinical severity. 

A person with five persistent lesions may feel significantly affected by them. 

Another person with widespread acne may feel differently. 

Both experiences matter. 

Skin conditions exist on a person – not a textbook diagram. 

That’s something I never want to forget when evaluating skin. 

Hormones and acne 

Hormones play a significant role in acne, particularly androgens. 

Androgens influence sebaceous gland activity and sebum production. This is one reason acne often begins around puberty. 

It’s also why some people experience changes in acne: 

• Around menstruation 

• During pregnancy or postpartum 

• After changing hormonal contraception 

• With certain endocrine conditions 

• During other hormonal transitions 

Hormonal acne is often associated with the lower face and jawline, particularly in adult women, but location alone isn’t enough to diagnose the underlying cause. 

A jawline breakout does not automatically equal “hormonal imbalance.” 

Skin rarely gives us answers that easily. 

Genetics matter too

If acne runs in your family, that matters. 

Genetics can influence things such as sebaceous activity, inflammatory responses, follicular behavior, and overall susceptibility to acne. 

This doesn’t mean your acne is inevitable or untreatable. 

It means two people can follow identical skincare routines and have completely different skin. 

Which is why comparing your skin to someone else’s routine can be so misleading. 

Your friends may sleep in makeup and somehow have perfectly clear skin. 

Annoying? 

Absolutely. 

Evidence that you should do the same? Absolutely not. 

Is acne caused by dirty skin? 

No. 

And I want to make this very clear because the belief can create some incredibly damaging skincare habits.

Acne isn’t a hygiene failure. 

Washing your face six times a day doesn’t wash away the biological mechanisms causing acne. 

Instead, excessive cleansing can strip barrier lipids, impair barrier function,  increase irritation, and make an already inflamed situation even harder to manage. 

Acne-prone skin still deserves gentle care. You don’t need to punish it for breaking out. 

Oily acne-prone skin still needs moisturizer

This one is near and dear to my heart. 

People with acne are constantly told to dry their skin out. 

Oil-free everything. 

No moisturizer. 

Strong cleanser. 

Acid. 

Another acid. 

Spot treatment. 

Repeat. 

But remember what we’ve already learned: 

SEBUM is not HYDRATION. 

Acne-prone skin can be oily and dehydrated simultaneously. 

ANd many effective acne treatments – including retinoids and benzoyl peroxide – can increase irritation and dryness, especially if the skin barrier is already struggling. 

A well-formulated moisturizer can help support barrier function and improve treatment tolerability. 

Moisturizer isn’t automatically the enemy of acne. 

The formulation simply needs to be appropriate for the individual skin. 

What about diet? 

This conversation deserves nuance. 

The old claim that chocolate or greasy food simply “causes acne” is overly simplistic. 

However, nutrition and acne aren’t completely unrelated either. Your gut, skin, and mind are all very much connected. 

Research suggests that high-glycemic dietary patterns may influence acne in some individuals, potentially through hormonal and metabolic pathways. 

Dairy – particularly certain milk consumption patterns – has also been associated with acne in some observational research, although the relationship isn’t straightforward and doesn’t mean everyone with acne  needs to eliminate dairy. 

My approach? 

Don’t turn your diet into a punishment. 

If we suspect a dietary factor is influencing someone’s acne, I want to look at patterns thoughtfully rather than creating an unnecessarily restrictive list of “bad foods.” 

Acne is already stressful enough. 

Stress isn’t imaginary either 

Stress doesn’t magically create a clogged pore out of nowhere. 

But stress influences hormones, inflammatory signaling, immune function, sleep, behavior, and potentially sebaceous activity. 

So yes – stress can contribute to acne severity in some people. 

That doesn’t mean telling someone with acne to “just stress less.” 

If only biology worked that way. 

It simply means the skin is connected to the rest of the body. 

Something we’re going to come back to constantly throughout these journals. 

Why picking acne makes everything more complicated. 

I understand the temptation, I myself suffer from dermatillomania and know this topic all too well. 

You see something in the mirror. 

It looks like it could come out. 

And suddenly you’re performing bathroom surgery at 11:30 p.m. 

We’ve all been there. 

But squeezing, picking and manipulating acne can increase inflammation and cause additional trauma to the surrounding tissue. 

That increases the risk of: 

• Post-inflammatory hyperpigmentation 

• Post-inflammatory erythema 

• Prolonged healing 

• Secondary infection 

• Scarring 

And deep inflammatory lesions are particularly dangerous to manipulate aggressively. 

Sometimes the fastest way to make a pimple last longer is trying to desperately make it disappear tonight. 

Acne marks aren’t always acne scars 

This distinction is incredibly important. 

After acne heals, it may heave behind discoloration. 

That doesn't necessarily mean the skin is scarred. 

Post-inflammatory hyperpigmentation (PIH) creates brown or gray-brown discoloration due to increased melanin production following inflammation. 

Post-inflammatory erythema (PIE) refers to persistent pink, red, or purplish vascular changes after inflammation, particularly noticeable in lighter skin tones. 

 A true acne scar involves structural alteration of the skin. 

And treating all three as “acne scars” leads to a lot of confusion. 

We’ll break each one down individually later. 

How is acne actually treated? 

Because acne develops through multiple biological pathways, treatment often works best when we target more than one of them. 

Depending on the type and severity of acne, approaches may include: 

• Topical retinoids 

• Bezoyl peroxide

• Salicylic acid 

• Azelaic acid 

• Topical antibiotics when medically appropriate 

• Oral antibiotics in selected cases 

• Hormonal therapies 

• Spironolactone for appropriate patients 

• Combined oral contraceptives 

• Isotetinion 

• Professional procedures as adjective care 

• Barrier-supportive skincare 

Not every person needs every treatment. 

And throwing everything at acne simultaneously isn’t automatically better. 

The treatment plan should match the acne in front of us. 

Why retinoids are such an important acne treatment

If you’ve read my Retinoids Ingredient Note, you already know I love talking about these. 

Retinoids can help normalize follicular keratinization and reduce the formation of microcomedones – the microscopic lesions where acne begins. 

That’s important because we’re not just spot-treating today’s breakout. 

We’re intervening earlier in the acne cycle. 

This is also why retinoids require consistency. 

We’re influencing the process that creates future lesions. 

Not magically erasing everything already visibly overnight. 

Benzoyl peroxide works differently

Benzoyl peroxide has antimicrobial activity against C. acnes and can also help reduce inflammatory acne. 

One particularly valuable feature is that bacterial resistance does not develop to benzoyl peroxide in the same way it can with antibiotics. 

This is why it’s frequently incorporated alongside topical or oral antibiotics in acne management. 

But benzoyl peroxide can also be drying and irritating. 

Once again: 

Effective doesn’t mean we need to use as much as physically possible. 

The goal is treatment the skin can tolerate consistently. 

Salicylic acid and the follicle 

Salicylic acid is a beta-hydrocy acid with properties that make it particularly useful for oily and acne-prone skin. 

It can help reduce follicular plugging and improve comedonal acne by promoting more normalized shedding within the follicular environment. 

But adding salicylic acid to a routine already containing multiple irritating acne treatments requires thought. 

Because acne treatment stops being helpful when the surrounding skin becomes too inflamed to tolerate it. 

And then there’s azelaic acid 

Azelaic acid is one of my favorite multitasking ingredients because it can influence several concerns relevant to acne-prone skin. 

It has: 

• Antimicrobial activity 

• Anti-inflammatory effects 

• Effects on abnormal keratinization 

• Activity relevant to pigmentation pathways 

That makes it particularly interesting when we’re dealing with both active acne and the post-inflammatory pigmentation it leaves behind. 

We’ll give azelaic acid its own Ingredient Note because it deserves much more attention than it gets. 

Sometimes skincare isn’t enough 

This is one of the most important things I can say as an aesthetician. 

There are situations where acne needs a dermatologist. 

Particularly when we’re seeing: 

• Deep nodules 

• Significant pain 

• Rapidly worsening acne 

• Scarring 

• Extensive inflammatory acne 

• Acne that isn’t responding to appropriate topical management 

• Signs of an underlying hormonal or medical condition 

I don’t believe good aesthetics means trying to treat everything ourselves. 

Good aesthetics means recognizing when someone’s skin needs a different level of care that doesn’t lie within our scope of practice. 

Early medical intervention can sometimes prevent years of inflammation and permanent scarring. 

Referral isn’t failure. 

It’s good treatment planning. 

Why acne treatment takes time

Acne is one of those conditions where patience is incredibly frustrating – but incredibly necessary. 

Remember: 

The lesion you see today began developing before you could see it. 

So when we start a new routine, we’re not only treating visibly acne. 

We’re trying to influence lesions already developing microscopically while preventing future ones from forming. 

That’s why I don’t want someone changing their entire routine every ten days because” 

“It’s not working.” 

Skin needs time. 

Treatment needs consistency. 

And we need enough time to actually evaluate the response. 

Constantly changing variables makes that almost impossible. 

Why this matters as a provider 

When someone comes to me with acne, I’m not simply counting pimples. 

I’m looking at the entire picture. 

What type of lesions are present? 

Where are they occurring? 

How inflamed is the skin? 

Is there scarring? 

Is there PIH or PIE? 

How oily is the skin? 

What does the barrier look and feel like? 

What medications are being used? 

What skincare is being used? 

How frequently? 

What has already been tried? 

What happens around their menstrual cycle? 

What does family history show me?

How long has the acne been present? 

Has anything recently changed? 

Because “I have acne” isn’t enough information to build an intelligent treatment plan. 

Acne has patterns. 

And my job is to start understanding the pattern before I start throwing products at it. 

Acne doesn’t mean unhealthy skin everywhere

This is something I want people struggling with acne to understand. 

Acne is a skin condition. 

It isn’t evidence that you're dirty. 

It isn’t proof that you’ve failed at skincare. 

And it doesn't mean every aspect of your skin is unhealthy. 

You can have acne and a healthy barrier. 

You can have acne and beautiful hydration. 

You can have acne while doing everything “right.” 

Our job isn’t to become angry at the skin for developing acne. 

Our job is to understand the processes contributing to it and intervene thoughtfully. 

I think that’s a much healthier – and much more effective – way to approach treatment. 

Final Thoughts 

Acne looks simple from the outside. 

A pore gets clogged.

A pimple appears. 

Get rid of it. 

But when we look underneath the surface, we find an incredibly complex interaction between follicular keratinization, sebum, microorganisms, hormones, inflammation, genetics, and the immune system. 

And suddenly, the idea that we can simply “dry acne out” doesn’t make much sense anymore. 

That’s what I hope you take away from this guide. 

Acne isn’t something we need to aggressively fight until the skin finally gives up. 

It’s something we need to understand well enough to interrupt intelligently. 

Sometimes that means a retinoid. 

Sometimes benzoyl peroxide. 

Sometimes hormonal treatment. 

Sometimes professional intervention. 

Sometimes simplifying the routine. 

And sometimes it means recognizing that the person sitting in front of me needs a dermatologist – not another facial. 

The treatment changes. 

The philosophy doesn’t: Understand the biology first. 

Then decide what the skin actually needs. 

Journal Note 

Acne is probably one of the clearest examples of why I became so passionate about skin education. 

Because when you don’t understand what’s happening underneath the surface, acne feels personal. 

Why is my skin doing this? 

Why isn’t anything working? 

Why does everyone else’s skin seem fine? 

Trust me, those three sentences haunted my brain for years as I struggled with acne. 

Then I learned what’s actually happening inside one tiny follicle. 

Keratinocytes are accumulating. 

Sevum is changing the environment. 

Microorganisms are interacting with the immune system. 

Inflammatory pathways are activating. 

Hormones may be influencing the entire process. 

And suddenly… 

It’s not your skin “being bad,” it’s biology. 

Biology we can study. 

Biology we can influence. 

And biology that deserves a little more thought than simply trying to dry it into submission. 

That’s where good acne treatment starts.