More Frequently Asked Questions About Acne

I have been using topical benzoyl peroxide and an oral antibiotic for my acne and have noticed blue-black and brown marks developing on my face and some discoloration on my body. The marks are especially noticeable around acne scars and recently healed lesions. Is this a side effect of medication and is it permanent?

Answer: It is not possible to make general statements about side effects of medications that apply to individual cases. A dermatologist should be consulted. The facial marks and body discoloration described by the patient in this case do fall within the range of side effects of some antibiotics.

Unique patterns of pigmentation are sometimes seen in acne patients treated with certain oral antibiotics—particularly minocycline. The pigmentation patterns that appear may include:

• Localized blue-black or brown marks in and around acne scars and in areas of previous acne inflammation

• A "muddy skin" appearance that may cover much of the body

• Diffuse brownish pigmentation of the feet and lower legs.

The pigmentation side effect gradually disappears after the therapy 
is discontinued.

Any side effect of a medication should be noted by the patient and brought to the attention of the physician. While most side effects are temporary they should be discussed with the physician and monitored.

My doctor is prescribing a topical retinoid for my acne. He said a retinoid is a substance related to vitamin A. If the drug is related to vitamin A, shouldn’t vitamin A dietary supplements be helpful in getting rid of acne?

Answer: Dietary vitamin A is essential to good health, especially vision. It has healthful effects in the skin. Large doses of vitamin A for the treatment of acne is not recommended on grounds of safety. The retinoids and retinoid-like substances used as topical treatments for acne are prepared especially for their potent effect on the shedding of cell lining in the sebaceous follicle. Their use should be monitored by a dermatologist.

Dietary vitamin A has multiple health effects in the human body. Vitamin A is essential for good vision. Extreme vitamin A deficiency can result in blindness, usually accompanied by dry, scaly skin. Vitamin A overdose that far exceeds the Recommended Dietary Allowance (RDA) of 5,000 IU can have effects nearly as catastrophic. Extreme vitamin A overdose can cause the skin to blister and peel—an effect first seen in early North Pole explorers who nearly died after eating polar bear liver that has an extraordinarily high vitamin A content.

Topical retinoids are usually prescribed as a treatment for moderate to severe acne. Side effects are chiefly dermatologic, including redness, scaling and dryness of the skin, itching and burning. These side effects can usually be managed by adjustment of the amount and timing of retinoid applied to the skin. Dose adjustment must be discussed with the dermatologist who prescribed the treatment.

Are there any acne treatments specifically for people with dark skin? Are there any treatments specifically harmful to dark skin?

Answer: There are no acne treatments specifically for use on dark skin. Acne treatments are generally as safe and effective on dark skin as on light skin. Some treatments for acne scars may cause temporary lightening of dark skin.

Acne is a common skin disease that has the same causes and follows the same course in all colors of skin.

Very dark or black skin may be less well-moisturized than lighter skin. Topical anti-acne agents such as benzoyl peroxide that have a drying effect on the skin should be used under the supervision of a dermatologist. Benzoyl peroxide also is a strong bleach and therefore must be applied carefully to avoid inadvertent decolorization of a patch of hair, towels or clothing.

Darker skin has a tendency to develop post-inflammatory hyperpigmentation (excessive skin darkening at places where the skin was inflamed). Severe inflammatory acne may result in dark spots. The spots resolve over time; a dermatologist may be able to recommend cosmetic measures to make the spots less apparent until they resolve. Some acne treatments, such as topical retinoids and azelaic acid, may also help fade the discoloration.

Removal of acne scars by dermabrasion or chemical peeling may cause temporary lightening or darkening of dark skin in the areas of treatment. Scar treatment should be discussed with a dermatologist or dermatologic surgeon before it is undertaken.

Alterations of melanin (dark pigments that give the skin its color) pigmentation such as vitiligo and melasma are not related to acne, but they may be present simultaneously with acne. The diagnosis and treatment of melanin pigmentation disorders such as vitiligo requires a dermatologist with knowledge and experience in treating these conditions.

Is acne that appears for the first time in adulthood different from acne that appears in adolescence?

Answer: Acne has a specific definition as a disease of sebaceous follicles. This definition applies to acne that occurs at any age. However, it may be important to look for an underlying cause of acne that occurs for the first time in adulthood.

Current understanding of the causes of acne vulgaris is described in the Main Text section Why and how acne happens. In brief summary, acne vulgaris develops when excessive sebum production and abnormal growth and death of cells in the sebaceous follicle result in plugging of follicles with a mixture of sebum and cellular debris and formation of comedones (blackheads and whiteheads). Bacteria in the follicles—chiefly Propionibacterium acnes, the most common bacterial colonist of sebaceous follicles—may contribute to the inflammation of acne by release of metabolic products that cause inflammatory reaction. The pathogenic events, which cause disease, in the sebaceous follicle are believed to be due in large degree to changes in levels of androgenic (male) hormones in the body—a circumstance usually associated with growth and development between ages 12 and 21.

Some acne investigators believe that although this understanding is generally correct, there is more yet to be learned about the causes of acne vulgaris. 

Acne that appears after the age of 25-30 years is (1) a recurrence of acne that cleared up after adolescence, (2) a flare-up of acne after a period of relative quiet—for example, during pregnancy, or (3) acne that occurs for the first time in a person who had never previously had acne.

Acne that occurs in adulthood may be difficult to treat if there are multiple recurrences. Some patients with severe recurrent acne have undergone repeated courses of treatment with the potent systemic drug isotretinoin. 

Acne flares in association with pregnancy or menstruation are due to changes in hormonal patterns.

Acne that appears for the first time in adulthood should be investigated for any underlying cause. Drugs that can induce acne include anabolic steroids (sometimes used illegally by athletes to “bulk up”), some anti-epileptic drugs, the anti-tuberculosis drugs isoniazid and rifampin, lithium, and iodine-containing drugs. Chlorinated industrial chemicals may induce the occupational skin disorder known as chloracne. Chronic physical pressure on the skin—for example, by a backpack and its straps, or a violin tucked against the angle of the jaw and chin—may induce so-called acne mechanica. Some metabolic conditions may cause changes in hormonal balance that can induce acne.

Some lesions that appear to be acne may be another skin disorder such as folliculitis—infection and inflammation of hair follicles—that require different treatment than acne. Acne that appears for the first time in adulthood should be examined and treated by a dermatologist.

My 15-year-old daughter has what I would describe as a very mild case of acne. She has made it much worse by constant picking and squeezing. She looks in the mirror for hours, looking for some blackhead or blemish she can pick or squeeze. Does she need psychological counseling?

Answer: Excessive picking and squeezing of otherwise mild acne is a condition called excoriated acne, seen most often in young women. A dermatologist may provide effective counseling.

The typical person with excoriated acne is a person—often a young women—who is so distressed with her appearance due to acne that she literally tries to "squeeze the acne out of existence." The acne is often very mild, but the person’s face may constantly be covered with red marks from squeezing, and open sores where lesions have been picked open.

The word excoriate means to scratch or abrade the skin. Excoriated acne is a medically recognized condition that should be discussed with a dermatologist. Occasionally giving in to a temptation to squeeze a blackhead is not defined as excoriated acne. Hours in front of a mirror, squeezing and picking every blemish, is a definition of excoriated acne. A dermatologist may be able to counsel the patient regarding a course of treatment in which the patient can participate, but keep "hands off."

Can the rate of secretion or the composition of sebum be altered by diet? If it can, shouldn’t alteration of diet be considered a treatment for acne?

Answer: Diet has never been proven to have a role in the cause or treatment of acne. Dietary manipulation may have a role in the treatment of some scaling diseases of the skin, but not in the treatment of acne.

Dietary cause is one of the most persistent myths about acne. Foods, such as chocolate or greasy foods, do not cause acne, but certain foods seem to make some people’s acne worse. The following can bring on or worsen it:

• Hereditary factors

• An increase in male hormones found in both males and females

• Menstruation

• Emotional stress

• Oil and grease from cosmetics, work environment

No food has been shown to be effective in preventing or treating acne. A healthy diet is, of course, necessary for good general health.

An educational program brought to you by the American Academy of Dermatology.