So, what causes acne, anyway?
When there’s an issue that we don’t like, it’s best to get to the root cause of the issue, right? That way, the issue can be stopped altogether. That’s why we want to talk about the root cause of acne to start with rather than talking about the treatments that can help stop merely the symptoms (we all know stories like…I got off my birth control, then my acne came back in a rage). Acne can be a complex issue, but understanding how your skin works can only help in addressing acne in a more profound way. This is our effort to shed some insight into acne that might potentially help you think about dealing with your acne in a different way, especially if you’re not finding a good solution or confused about what to do. Throughout the month, we will discuss ways to combat the root cause of acne, so we wanted to start with first creating the framework that we’ll use for the rest of the month: identify the root cause and eradicate that. So, let’s get dig in together.
Surface-level cause of acne:
Let’s first look at what happens in your skin when there’s a breakout. We can talk about the root cause of this chain of events right after. For the benefit of everyone – including those totally new to skincare – let’s break down the skin structure as this is key to understanding what happens when acne forms. The surface of your skin, your stratum corneum, is basically comprised of dead cells that are protein-packed, called keratin. Keratin (yes, the same thing that makes up the structure of your hair and nails) is a good protective physical barrier for the deeper layers of your skin. Keratin is basically embedded in a mix of fatty acids, ceramides, and cholesterol. Sitting on top of the stratum corneum is a cocktail of sebum and sweat that help form your acid mantle, which is a chemical barrier to keep out the bad guys (harsh chemicals, bacteria, pollutants, etc.) from skin.
Further below the stratum corneum is a layer of living skin cells called the stratum spinosum or the spiny layer, which has a spiny look from all the little protruding cell processes that join the cells together. Moving further down the epidermis, which is the outermost layer of the skin, there’s a layer called the stratum germinativum or the basal layer as most of the cells here are basal cells, which is a precursor to the keratinocytes found in the epidermis. Basal cells basically grow and divide and move toward the surface of the skin as they mature and eventually become dead skin cells. This process of basal cells maturing and dying and forming dead skin cells is called keratinization.
Moving onto pores
Our skin has pores, whether they appear to be very invisible or not. These pores are also called follicles, which isn’t just referencing small hair follicles. Some follicles have hair, some don’t. The follicle/pore is essentially a tube that starts in the dermis (inner layer of skin that’s made up on collagen and elastin and has blood vessels, nerves, sebaceous glands, etc.) and goes all the way straight out to the surface of the skin. This follicle has sebacous glands attached to them that produce sebum/oil.
A “functional” pore:
When there are no issues with your pores, the sebum that’s produced by your pore simply flows nicely to the top of your pore and is secreted from your skin.
A “dysfunctional pore” – and this is where the acne story begins:
As we just discussed, the keratinization process occurs to form the dead skin cells. A natural process called desquamation or exfoliation allows the keratins/dead skin cells to easily be shed from the skin and carried out by the flow of sebum. Importantly, keratins also line the inside of your pores. When all is good, the keratin in your pores are easily exfoliated. However, when retention hyperkeratosis the keratins that line your pores basically don’t exfoliate easily and get stuck. When that mixes with sebum (since sebum is secreted through the pores, this mixing is inevitable), the pore becomes super sticky like a sticky glue trap for everything, including impurities. Now, you have a clogged pore.
The chain of events that happen from a clogged pore:
With a clogged pore, it doesn’t take much time for bacteria to form – and grow exponentially – which creates more inflammation within the pore and ultimately even in the skin around the pore. The bacteria breaks down the sebum into fatty acids that leads to oxidative stress (i.e. free radicals/bad guys beat out the antioxidants that defends our cells) in the surrounding cells.
Oxidative stress can beget more oxidative stress.
Oxidative stress basically leads to molecules called transcription factors being triggered. One of these transcription factors when triggered causes cells to produce proinflammatory proteins called cytokines that essentially turn on inflammation. One kind of cytokine can actually leak out of the cell where they trigger more oxidative stress. All this leads to even stickier keratinocytes leading to the beginning of acne, a microcomedo.
From microcomedone to a visible pimple:
It starts with that pesky “dysfunctional” pore (or rather, dysfunctional exfoliation process) and forms at first a microcomedo (you can’t even see it with your eye), which is a clogged pore. Then, it evolves into a comedo that’s open (blackhead – turns black as the oil meets oxygen and oxidizes) or closed (whitehead). Usually, this is accompanied by just low-grade inflammation. At this point, if the comedones are able to drain itself, the issue may be resolved. However, if it remains clogged, further inflammation can happen and comedones can grow and form into visible acne. Inflammation that sits closer to the top of the skin results in pustules, a bit deeper, you’ll see papules (aka pimples), deeper yet and you’ll see nodules which are solid lesions, and also, cysts, which are pus-filled lesions. To sum up, we can see that the retention hyperkeratosis, or the insufficient shedding of the keratins in your pores, can lead to acne.
But the question is – what causes this chain of events where pores get clogged?
It’s easy to chalk up clogged pores to excess sebum production. And while that’s, in part, a culprit, it doesn’t explain why some folks with very oily skin don’t have acne and why some people with very dry skin (lacking sebum production) struggle with acne. When it comes to acne, Dr. Perricone, is one of my favorite dermatologists, because he seeks to get to the root cause of acne – that is, the foundational cause for why pores get clogged. We discussed above the inflammation-causing cytokines that also lead to keratinocytes getting sticky and ultimately a clogged pore. Dr. Perricone discusses this specific cytokine, interleukin-1, as the specific inflammation-inducing protein molecule that causes retention hyperkeratosis (pores don’t shed dead skin cells and get clogged).
The next logical question is then how do you combat this proinflammatory interleukin-1?
When we take a close look at premature aging, various ailments, even cancer – similar to acne, inflammation is often one of the core culprits. To get to the root of acne then, it’s helpful to understand what triggers inflammation and the different ways to fight inflammation.
With inflammation identified as the beginning of acne, this month, for our Clear Complexion month, we’ll be doing a deep-dive into all the anti-inflammatory essentials: what we eat, levels of stress, sleep patterns, workout routines, and of course, the right anti-inflammatory and pore-clearing skincare routine to help combat acne. You may be surprised at how a holistic and systematic approach to acne may just help you break out of the acne cycle – for good. We’ll help build a program this month to help you try out this approach and make it as easy and straightforward as possible.
Alicia Yoon is the founder and CEO of Peach & Lily, a trusted Korean beauty expert, a licensed esthetician and is known for her proprietary facial and massage techniques that result in an inner glow even without the use of devices.