The 4 Factors We Consider When Treating Acne

Understanding what is happening beneath the breakout

When we talk about acne, it's very easy to focus entirely on what we can see. A blocked pore, an inflamed breakout, congestion across the forehead or a cluster of breakouts along the jawline. Naturally, we want to know what we can put on that breakout to make it disappear, but acne starts well before the point where we can see it on the surface.

One of the things I spend quite a bit of time explaining during acne consultations is that acne isn't caused by one single thing. There are several biological processes involved in its development, and they interact with each other. Understanding those processes gives us a much better framework for deciding what someone's skin actually needs rather than simply reaching for products labelled “for acne”.

There are four main factors we consider when we're thinking about acne from a skin perspective: altered follicular keratinisation, sebum, Cutibacterium acnes and inflammation. You definitely don't need to remember all of those terms, but understanding what they mean can completely change the way you think about treating your skin.

01. How skin cells are shedding within the follicle

Our skin is constantly renewing itself. New cells are produced, move through the epidermis and are eventually shed from the surface. Within an acne-prone follicle, the way cells are produced and shed can become altered, contributing to an accumulation of cells within the follicle and the formation of a blockage.

This process is known as follicular hyperkeratinisation, and the very early blockage that forms is called a microcomedone. You won't necessarily see a microcomedone when you look in the mirror, but it can eventually develop into the congestion, blackheads, closed comedones or inflammatory breakouts that you do see.

This is one reason ingredients and treatments that help regulate keratinisation and cellular turnover can be useful within acne management. Depending on the individual skin, that might include appropriately selected exfoliating ingredients or Vitamin A.

Where things become complicated is when we assume that because altered keratinisation contributes to acne, we should simply exfoliate the skin as much as possible. If someone is already using an exfoliating cleanser, an acid serum, a retinoid and another exfoliant a few nights a week, adding even more exfoliation isn't automatically going to give us a better result.

We want to support more normal functioning of the skin without creating unnecessary irritation in the process.

02. Sebum is more complicated than simply having oily skin

The second factor is sebum. Sebum is produced by our sebaceous glands and plays a normal role within the skin, but sebaceous activity is also closely involved in acne. Hormonal signalling, particularly androgens, can influence sebaceous glands, which is one of the reasons hormones are relevant when we're talking about acne, particularly adult female acne.

It's very easy to translate this into oil = bad, but I don't think that's a particularly useful way to look at it. The conversation isn't only about how oily somebody looks. Sebum production and composition, the environment within the pilosebaceous follicle and how all of that interacts with the other processes involved in acne are more important than simply trying to remove as much oil as possible.

This matters because one of the most common things we see clinically is someone who has spent years trying to dry their acne out. They're cleansing aggressively, avoiding moisturiser because they're worried it will clog their pores and choosing products specifically because they make the skin feel squeaky clean. They may still produce plenty of oil, but underneath that they're also dehydrated, irritated and uncomfortable.

Having acne doesn't mean your skin doesn't need hydration, lipids or appropriate moisturisation. We're not trying to eliminate everything the skin naturally produces. We're trying to create an environment where it can function more normally.

03. C. acnes isn't simply “bad bacteria”

The third factor is Cutibacterium acnes, commonly shortened to C. acnes. This is where acne education can become a little misleading because people often hear the word bacteria and understandably assume acne is an infection caused by having bacteria on the skin.

C. acnes actually forms part of the normal skin microbiome. Having it on your skin doesn't mean your skin is dirty, and the goal isn't to sterilise your face.

What matters is what is happening within the follicular environment and the complex interaction between C. acnes, the skin's immune response, sebum and inflammation. Our understanding of this has also become more nuanced over time, including recognition that different strains of C. acnes may behave differently within acne-prone skin.

For clients, the practical takeaway is quite simple: acne is not happening because you aren't cleaning your skin well enough. In fact, excessively cleansing or repeatedly trying to “kill bacteria” can create another problem if we're also increasing irritation and disrupting the skin barrier along the way.

Cleanse appropriately, absolutely. But your face doesn't need to feel stripped to be clean.

04. Inflammation is involved earlier than you might think

When most people think about inflammation and acne, they picture the obvious red, sore breakout. But inflammatory processes are involved much earlier in acne development than the point where a lesion becomes visibly angry on the surface.

This is an important part of the way we assess acne at Curated because I'm interested not only in the number of breakouts someone has, but in the overall inflammatory state of their skin.

Is there diffuse redness around the acne? Does everything sting? Is the skin reactive? How long do inflammatory lesions take to settle? Is someone picking because the breakouts feel uncomfortable? Are they left with significant redness or pigmentation afterwards?

We also want to understand whether anything within the current routine may be adding additional irritation on top of an already inflammatory condition. A product can be designed to treat acne and still be too much for a particular skin at a particular point in time.

This is why calming inflammation can sometimes become part of the early plan rather than immediately trying to stimulate or exfoliate the skin harder.

Where does the skin barrier fit into all of this?

This is something I want to make really clear because we talk about barrier health a lot at Curated.

A compromised skin barrier isn't one of the classic four primary factors that causes acne, and I don't want to oversimplify acne by saying that repairing your barrier will somehow clear every breakout. That isn't how acne works.

What we do need to consider is the condition of the skin we're treating.

Someone can have acne alongside dehydration, irritation and barrier dysfunction. Some acne treatments can also be irritating, particularly when several are being combined or introduced too quickly. If we're not paying attention to the surrounding skin, we can end up with someone who still has acne but now also has significant sensitivity and discomfort.

That's why we might temporarily spend more time strengthening and normalising the skin before progressing further with targeted treatment. We're not pretending the barrier caused the acne. We're making sure the skin is in a better position for us to manage the acne appropriately.

So where do hormones fit?

Hormones are incredibly relevant to acne, but I don't think they need to become a mysterious fifth box that we blame everything on.

Androgens can influence sebaceous gland activity and other processes involved in acne, which is why hormonal changes can affect the skin. Adult women may notice acne appearing or changing around their menstrual cycle, after stopping or starting hormonal contraception, during pregnancy or postpartum, or at other points where hormonal signalling is changing.

But seeing acne on someone's jawline doesn't tell me what their hormone levels are.

This is where I think we need to distinguish between recognising a pattern and making a diagnosis. Your skin history can give us reasons to ask more questions. It can tell us that further investigation may be worthwhile. It cannot tell us exactly what is happening internally without appropriate assessment.

If someone has other symptoms or a history that suggests further medical investigation would be appropriate, we can recommend discussing that with their GP or another suitably qualified practitioner.

The skin gives us part of the picture. Sometimes we need other professionals to help us understand the rest.

This is why there isn't one acne routine

Once you understand that several processes are involved in acne, it becomes easier to see why I don't believe every person with acne should leave a consultation with exactly the same routine.

One person may have significant non-inflammatory congestion and tolerate active ingredients beautifully. Another may have predominantly inflammatory acne with considerable sensitivity and dehydration. Someone else may already be using appropriate topical acne treatment but have a history that makes medical investigation worthwhile.

The end goal might be similar, but the order in which we approach things can be completely different.

At Curated, we're considering the acne itself, but we're also looking at the surrounding skin, what you've already tried, what your skin can tolerate and whether there are factors outside our scope that need to become part of the conversation.

This is also why sometimes we begin with more targeted acne management and other times we spend a period strengthening and normalising first. There isn't one correct starting point for every person. There is the starting point that makes sense for your skin.

Treating acne is about understanding the whole environment

I think the biggest shift I want clients to make is moving away from seeing acne as individual breakouts that need to be removed and towards understanding the environment in which those breakouts are developing.

We're thinking about how cells are behaving within the follicle. We're thinking about sebum. We're considering C. acnes and the microbiological environment. We're looking at inflammation. And then we're placing all of that within the context of the actual person sitting in front of us.

What is their skin barrier doing? What are they using at home? What have they previously tried? How does their acne behave over time? Are there hormonal patterns or other health factors worth investigating? And most importantly, what should we actually address first?

That's why treating acne well isn't necessarily about finding the most powerful acne treatment available. It's about understanding which part of the picture we need to influence, choosing an appropriate way of doing it and giving the skin enough time and consistency to respond.

Because the breakout you can see is only one part of what's happening. Understanding what's underneath it is where the plan really begins.

— Shae
Founder & Dermal Clinician
Curated Skin Aesthetics