Acne: causes, types of pimples, and what really works

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Acne is one of the most widespread skin conditions in the world and is characterized by the formation of spots, blackheads, and other blemishes. It can appear on the chest and back, but it mainly affects the face.

Acne is often accompanied by significant emotional distress and psychological effects. That is why understanding its causes and management strategies can make a real difference.

An important premise: acne is a dermatological condition, not merely a cosmetic concern. In mild cases, a well-designed skincare routine can significantly improve the situation; in moderate and severe cases, a dermatologist is needed, as they can prescribe treatments that a cosmetic product cannot replace. This article explains the mechanisms and what cosmetics can do — it is not a treatment protocol.

What is acne?

Acne results from the blockage of hair follicles by sebum, dead skin cells, and bacteria. This is how comedones form: open comedones, or blackheads, occur when the pore remains open and its contents oxidize on contact with the air; closed comedones, or whiteheads, occur when the pore is completely blocked and the material remains trapped beneath the surface.

Comedone formation is a physiological process, but certain factors can amplify it. Increased sebum production may result from hormonal changes — puberty above all — or from endocrine imbalances.

Acne or just spots?

The distinction is more practical than academic. An isolated spot that appears before your period or after a difficult week is an occasional blemish. We speak of acne when lesions are numerous, recurring, and present simultaneously at different stages — comedones, papules, and pustules together — on skin that tends to have clogged pores. This distinction matters because it changes the appropriate response: with an occasional blemish, it is enough not to make it worse; acne requires a consistent strategy.

What are the causes?

The factors are multiple, and there is rarely a single cause.

Hormonal changes are the main driving force, which is why acne is associated with adolescence. But it does not only affect that stage: adult acne is increasingly common, especially among women.

Certain medications, such as corticosteroids and androgens, can disrupt hormonal balance and promote the appearance of acne.

Genetics influences predisposition and severity: people with parents or siblings who have a history of acne are more likely to develop it, due to variations that make the skin more susceptible to clogging and inflammation.

Diet and stress also matter: a diet rich in sugar and refined products raises insulin levels and may stimulate sebum production, while stress triggers hormonal imbalances and inflammation.

Finally, seasonality has a greater impact than you might think: many people notice an improvement in summer followed by a worsening in September. This is not a coincidence, but a specific phenomenon that we explored in depth in the article on sun, acne and the late-summer rebound effect.

How many types of acne are there?

• Comedonal acne: whiteheads and blackheads.
• Papulopustular acne: papules and pustules on the face, chest and shoulders.
• Nodulocystic acne: the most severe form, with deep nodules and cysts.

Comedonal acne

Whiteheads form when pores become clogged, trapping sebum, bacteria and dead skin cells beneath the surface and creating small flesh-colored bumps.

Blackheads are similar, but appear dark due to oxidation: contrary to popular belief, they are not caused by dirt. They are concentrated on the nose, chin and forehead—the T-zone, where sebum production is higher.

Papulopustular acne

These are inflammatory forms. Papules are small, red, tender bumps that form when the pore walls rupture due to inflammation. Pustules are inflamed lesions containing pus, with a whitish center.

The most important rule: do not squeeze. Manipulation worsens inflammation, spreads the contents into the surrounding layers and significantly increases the risk of permanent scarring. It is the single behavior that causes the most long-term damage.

Nodulocystic acne

Nodules are large, solid lesions that develop deep beneath the skin; they are hard to the touch and persistent. Cysts are similar but contain fluid and are often larger and more painful.

In both cases, the risk of scarring is high and a dermatologist is needed: these forms require medical treatments, either topical or systemic, and no cosmetic product can manage them.

Where acne appears and what it suggests

The distribution of lesions can provide useful clues, but it should not be turned into the maps circulating online that associate each area with an organ: those have no scientific basis.

• T-zone (forehead, nose, chin): this area has the most sebaceous glands, so it is the most prone to comedones at any age;
• Jawline, chin and neck: the typical distribution of hormonal acne, common in adults and often cyclical;
• Cheeks: this is the area most affected by external factors, from phones and pillows to products that are too occlusive;
• Forehead with small, uniform lesions: this may be caused by hair products, hats, or bangs.

The impact on the skin over time

In addition to immediate effects — redness, swelling, and pain — poorly managed acne can leave lasting marks: scars of varying depth and post-inflammatory hyperpigmentation, meaning the dark spots that remain after the lesion heals.

The distinction between the two matters: a blemish is flat, affects only the color, and in most cases fades over time, especially with consistent use of sunscreen. A scar is an alteration in the skin's surface, either depressed or raised, and cannot be resolved with a cosmetic product: medical treatments are the appropriate option.

Acne-prone skin also tends to thicken and appear asphyxiated and dull due to persistent inflammation.

The routine for acne-prone skin

If you are looking for specific advice for men's skin, which has different needs due to its thickness, sebum production, and shaving, you can find everything in the guide to acne and men's oily skin. For the complete protocol for enlarged pores, see the routine for oily skin.

Cleansing and exfoliation

Cleansing removes excess sebum, impurities, and residue that can clog pores. Regular exfoliation removes dead cells that accumulate in the stratum corneum.

The most suitable exfoliants are beta hydroxy acids (BHAs), particularly salicylic acid: because it is oil-soluble, it penetrates sebum and works inside the pore, with comedolytic action.

Cleansing Active Mousse contains 0.5% salicylic acid, together with tea tree oil, burdock, and betaine.

Hydration, which should not be skipped

Many people with acne-prone skin worry that moisturizing will make the situation worse. The opposite is true: skin deprived of its lipids compensates by producing more sebum. Lightweight, non-comedogenic creams are preferable, with humectants such as panthenol — soothing and repairing — or betaine.

Active ingredients that help

Azelaic acid is one of the most studied active ingredients for acne-prone skin: it acts simultaneously on follicular keratinization, inflammation, and post-inflammatory hyperpigmentation. In cosmetic formulations, it is often used in the derivative form of azeloglycine, which is water-soluble and better tolerated with comparable efficacy.

Zincidone combines zinc and L-pyrrolidone carboxylic acid: the former helps regulate sebum, while the latter strengthens the skin barrier.

Niacinamide helps reduce residual marks and redness and helps regulate sebum production. Its synergy with salicylic acid is among the most studied combinations for blemish-prone skin.

The complete line protocol is described in the article on teenage acne and the Acnerebal protocol.

Mistakes that worsen acne

1. Over-cleansing: cleansing more than twice a day with harsh products has the opposite effect, because the skin reacts by producing more sebum;
2. Drying out the skin at all costs: alcohol and degreasing formulas provide immediate relief, followed by worsening several weeks later;
3. Changing products every ten days: no active ingredient shows its true effect before a month;
4. Layering too many active ingredients: acids, retinoids, and antibacterial ingredients used together irritate the skin barrier, increasing inflammation;
5. Skipping sunscreen: the sun lightens lesions for a few weeks, then causes them to return worse than before, while also darkening residual marks.

Lifestyle

A balanced diet rich in fruit, vegetables, and whole grains supports skin health. Regular physical activity helps manage stress, which is one of the factors that worsen the condition. And even with acne-prone skin, sunscreen should be used: in this regard, it is helpful to know how to prevent a flare-up after summer.

Patience is also essential: results on blemished skin take weeks, not days, and changing products too quickly is the best way to never see any improvement.

Frequently asked questions about acne

How long does acne take to improve with a proper routine?

The first differences in texture and comedones become noticeable after three or four weeks. A significant change requires two or three months, because it corresponds to several complete skin-renewal cycles. Anyone evaluating a product after ten days is measuring chance, not its effect.

Does diet really affect acne?

The strongest evidence concerns high-glycemic-index foods—sugars and refined flours—which several studies have associated with a worsening of the condition. There is also some evidence regarding milk, particularly skimmed milk. Chocolate itself is much less implicated than tradition would have us believe: it is the sugar that accompanies it that matters.

Do you need to remove makeup even if you are not wearing makeup?

Yes. Oxidized sebum, particulate matter, sunscreen residue, and hair products settle on the skin. Evening cleansing does not remove makeup; it removes the day.

Does makeup make acne worse?

Not in itself, provided the formulas are non-comedogenic and makeup is thoroughly removed in the evening. Wearing makeup is often what makes it possible to leave the house confidently during a difficult period, and there is no reason to give it up.

When is it time to see a dermatologist?

When painful nodules or cysts appear, when scars remain, when acne extends to the back and chest, or when three months of a correct skincare routine have made no difference. Also when it affects your mood and social life: that is as legitimate a criterion as any other.

Is adult acne treated like teenage acne?

No, and treating it the same way is the most common mistake. Adult skin is thinner, often more reactive and dehydrated: harsh degreasing products designed for teenage skin damage it. The details are in the article on adult acne.