For most people, acne is an inherited condition of the pores. When someone is prone to acne, their pores clog with dead skin cells much faster than normal. Healthy pores shed about one layer of dead skin cells per day inside the pore, but acne-prone pores shed up to five layers of dead skin cells per day. The body just can’t keep up with keeping the pore clear. Technically, this is called “retention hyperkeratosis” — dead skin cells shedding more quickly than the pore can expel them.
This first picture is of a normal healthy pore.
As the dead skin cells begin to accumulate inside the pore, the cells become sticky and get stuck inside the pore and form a plug. Medically, this is called a “microcomedone” – essentially the precursor to all acne. As you can see in this picture, there are more dead skin cells shedding inside the pore. Hormonal fluctuations trigger more oil production inside the pore. Normally, this isn’t a problem because the dead skin cells don’t get trapped. But with acne prone-skin, when the dead skin cells shed more quickly and form a blockage, the perfect environment for the P. Acnes bacteria is created. The oil is a nutrient for the bacteria, so the bacteria proliferates. So you see, bacteria is not the “cause” of acne, it is the effect of too many dead skin cells. This is an important distinction to remember.
But, some people don’t get inflamed lesions — inflammation is also an inherited tendency. If the dead skin cells and the oil that form the plug don’t become inflamed, the plug becomes a whitehead; that is, a non-inflamed lesion under the skin, also called a “closed comedone”.
Or the plug can become a blackhead, which is a noninflamed acne lesion where the pore remains open, also known as an “open comedone”. In the case of a blackhead, the tip of the plug darkens as it is exposed to oxygen in the environment. As the oil in the pore builds up, inflammation can develop in the cells surrounding the pore. Blackheads can be infected or not depending on whether the P. acnes bacteria have affected the cells around the pore.
As the oil and the dead skin cells build up, they put pressure on the cells surrounding the pore. With enough pressure, the sides of the pore rupture and the contents of the pore leak into the surrounding skin. Because this sebaceous material contains a lot of P. acnes bacteria, the surrounding skin now becomes infected, creating a red bump that we know as a pimple. The medical term for this red bump is an inflammatory papule.
This next drawing shows an inflammatory pustule, which is different from a pimple only in that it contains white blood cells. When the immune system fights off the P. acnes infection, white blood cells, which are soldiers of the immune system — pile up, creating pus in the pore.
Now another, deeper inflamed lesion can form called a nodule or cyst. It is a solid dome-shaped lesion that extends below the surface, deep into the layers of the skin. Scarring is common with nodules and can sometimes leave an impaction behind, which can flare again and again. When a group of pustules cluster together under the skin, they form a cyst. An acne cyst can appear similar to a nodule, but is pus-filled, and can have a diameter of 5mm or more across. They are usually very painful and scarring is common with cysts.
So you see, acne is primarily an inherited dead skin cell problem. Most acne, no matter what form it takes, starts with microcomedones. This means the solution lies in products that penetrate the pore and prevent dead skin cells from building up. That’s why your home care routine is so crucial — it’s all about preventing the microcomedones (the beginning of acne) from forming at all. This is the best way to get rid of acne.