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All Your Gross Acne Questions, Answered

Breakouts are like annoying coworkers: Almost everyone has them, and it takes tons of effort to avoid them. But, maybe, life would be a bit easier if we could actually understand them.

Since acne is the most common skin condition in the U.S., we’re guessing you’ve had at least a run-in or two with the frustrating spots — and you probably have some questions. So, we got some of the best dermatologists in the breakout biz to share the real facts, including the correct way to pop a pimple, the reason your butt breaks out, and what causes scars.

Read on for some mighty useful acne info.

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Why don’t all my breakouts look the same?
Because they’re not the same. There are two broad categories of acne: inflammatory and non-inflammatory. But, they do have some things in common. Blemishes have three basic causes: oil, bacteria, and skin cells, all of which clog pores, explains Neal Schultz, MD, assistant clinical professor of dermatology at Mount Sinai medical school in New York City. If you have more bacteria in your pores, you’re prone to inflammatory acne. If you just have thick sebum or an excess of skin cells, then you have more non-inflammatory bumps.

Non-inflammatory acne includes blackheads and whiteheads, also called comedones. Whiteheads are little white bumps, and blackheads look like tiny specks of dirt on your face. These don’t feel red or sore, and don’t change in size. Inflammatory acne includes papules and pustules. Both kinds are larger, painful red bumps, but pustules contain, you guessed it, pus.

Cysts are technically inflammatory, but they belong in their own category. These are the largest blemishes, and extend far beneath the surface of the skin. Glands under the skin become inflamed and irritated, and fill with blood, which causes the painful bumps.

What’s in the bumps?
This is where it gets even grosser. Your pores are lined with skin cells called follicle keratinocytes, says Richard Fried, MD, a dermatologist in Yardley, Pennsylvania. Some people tend to have stickier keratinocytes than others, and sometimes hormones cause the cells to clog up pores. When there's an excess of these sticky skin cells and sebum, they form a semi-solid plug. Those plugs are what fills whiteheads and blackheads.

Whiteheads have a layer of skin, sealing the pore. But, blackheads are open and exposed to oxygen. So, when the debris in the pore is oxidized, it turns black, hence its name.

Cysts, pustules, and papules are filled with blood, pus, and clear fluid called blood serum. “The reason inflammatory acne is swollen is because the body is enlisting your immune system to fight the irritation in your pores,” Dr. Fried says.

That immune response means the blood vessels dilate to bring white cells that can neutralize a foreign body. The added blood flow and presence of immune fluid causes swelling and soreness, he explains. The yellow pus is actually sebum, skin, and dead bacteria rising to the surface.

Can I squeeze them?
Any dermatologist or aesthetician will adamantly warn you to keep your hands off. But, any dermatologist or aesthetician who understands human nature will also give you some advice on safely squeezing a pimple.

“Don’t squeeze a pimple that’s not ready,” says Joshua Zeichner, MD, director of cosmetic and clinical research for dermatology at Mount Sinai medical school. “If the center is white or yellow, then you can try to pop it.”

Dr. Zeichner says to treat the process like a surgical procedure, because it technically is, and clean your hands, clip your nails, and wash your face. Ideally, use two cotton swabs rather than your hands. Gently push down — do NOT squeeze sideways. Squeezing pushes the pus and blood further down into the skin, which can cause the glands to burst and spread the infection. So, you end up with a larger zit that lasts even longer.

Once you dislodge the pus, quit pushing. If blood or clear fluid comes out, the pimple isn’t ready. Use light pressure and hold a clean tissue to your pimple until the blood stops. Here’s an animated (meaning non-gross) video demonstrating the proper technique.

“The urge to pop is a way to feel like you have more control over what’s happening to you with acne,” says Amy Wechsler, MD, a dermatologist and psychiatrist in New York City. “Most people just make it worse when they pop or pick.” She counsels her patients to walk away from the mirror, and get rid of any magnifying mirror, rather than try to pop pimples.

What really works if I have an emergency and need to shrink a zit?
See your dermatologist for a cortisone shot, says Dennis Gross, MD, a dermatologist in New York City. “Your doctor can inject you with cortisone in a way that targets the inflammation and can reduce the size dramatically.”

Do you have a cyst that’s lasted for two weeks or longer? You’re at a standoff and could use some professional intervention. If making it to your doctor isn’t an option, Dr. Zeichner says icing the cyst and applying topical hydrocortisone can help with the redness. Since cysts are so deep in the skin, using a spot treatment isn’t likely to be very effective. Your best bet is to completely leave it alone, or you’ll cause more irritation and make the cyst look even worse.

Do I break out because I touch my face too much?
That’s complicated. The germs on your hands aren’t the same germs that cause breakouts, but the various dirts and oils you touch may be a problem. “Think about all the things we touch in a day without thinking about it — food, hair, doorknobs, pets,” says Papri Sarkar, MD, a dermatologist in Boston. “You’re always transferring something onto your face.”

“Most oil-based, or thick, greasy products can clog pores,” Dr. Sarkar says. The oil closes the pore, she explains. “With the sealed-off pore and extra oil, the bacteria that cause breakouts have plenty of food and can multiply with abandon.” She says pulling your hair away from your face when you sleep and looking for oil-free, silicone-free hair and skin products can help prevent more breakouts. And, no, you shouldn’t touch your face! Anytime you disturb the oil glands and hair follicles, you’re risking irritation and inflammation.

Another common question about acne causes? Whether the foods you eat have caused your breakouts to get worse. That depends. If you polished off a pint of gelato, then yes. “One of the strongest links between what we eat and acne is glycemic index,” says Whitney Bowe, MD, a dermatologist in Briarcliff Manor, New York. “Low-glycemic foods seem to have a beneficial effect on acne, while high-glycemic foods — carbs and sugars — cause a spike in blood sugar that leads to acne flares.”

There’s also some research that suggests dairy products, especially skim milk, may play a role in breakouts. Dr. Bowe says research indicates that the high levels of whey protein and casein stimulate hormones that cause acne.

The one exception to the dairy rule: yogurt, says Dr. Bowe. “Probiotics seem to have a role in controlling breakouts, so yogurt is great, as long as it’s low-sugar.” Eating healthy fats can also calm breakouts. Omega-3 fatty acids have anti-inflammatory benefits that can help with the chain reaction that causes acne inflammation, Dr. Bowe says.

Why do I only have acne on my hairline?
Either your hairstyle or your workouts are to blame. “Anything that touches or rubs the hair follicle, and prevents oil from reaching the surface, increases the chance of a clog,” says Dr. Schultz. That means hats or headbands could be causing your breakouts. Repeated friction could also cause the follicles to narrow, which increases the odds of zits, he explains. Also, take a look at your hair products — especially if you have bangs. Oil from your hair and any stylers could also be clogging your pores.

Sweat could contribute, too. “Perspiration is...salt in the wound and irritates hair follicles,” Dr. Fried says. For someone with a SoulCycle habit, this could lead to an unfair side effect. “Working out on a bench or mat can also cause breakouts, because the sweat and oils are coming into direct contact with your skin.” The fix is to wipe down any equipment your skin touches and wash your face with an alpha-hydroxy-acid (AHA) wash. Look for one with glycolic or salicylic acid.

What’s with the cysts on my chin, jaw, and neck?
This is due to some bizarre hormonal trick, usually. “As we get older, acne tends to surface lower on the face or jawline,” says Dr. Fried. But, you should also pay attention to where you’re holding your phone. Too much friction there could also be clogging pores.

For hormonal acne, the answer could be birth-control pills that help to balance testosterone levels. If your phone is the problem, switch to a headset and wash with an AHA cleanser.

But, you don’t want to be too aggressive with your acne-fighting routine. “Many people think that acne is an oil-quantity issue, when, in reality, it’s an oil-quality issue,” Dr. Gross says. “When acne occurs, the oil is too thick and waxy, so it becomes blocked and forms a plug.”

So, washing and scrubbing the surface isn’t helping stop those cysts. In fact, he explains that adult acne is often linked to dry skin — using aggressively harsh treatments will only cause more dryness and dead skin to clog pores.

Why is my butt breaking out?
“Technically, the spots some people develop on their buttocks aren't acne,” Dr. Sarkar says. “It’s called folliculitis and is an inflammation of the hair follicles.” Sometimes, it's caused by an infection, or it could be a result of injury or irritation.

The likely culprit is your workout clothes. “Tight clothing and sweat can occlude pores, so that the dead skin cells and oil become trapped and cause painful inflammation,” says Dr. Sarkar. Change out of your gym clothes as soon as possible and use an AHA body wash or benzoyl peroxide to help calm the irritation.

What causes scars?
In a word, inflammation. When the immune system senses a threat, it sends blood and T-cells to attack the intruder. But, that response causes inflammation that damages surrounding tissue.

Acne scars happen because the immune-system response is so severe that the body creates a fibrous wall of collagen around the follicle to prevent the rest of the skin from infection, Dr. Fried says. That collagen fiber tugs at the follicles surrounding it and creates a depression. Unfortunately, there’s not much you can do once these scars are formed. But, there are laser and surgical methods to help minimize them.

The brown spots that remain after a breakout heals are also due to inflammation. The pigment is a response to the injury of a breakout, Dr. Schultz says. Much like your skin tans after sun exposure, it also sends melanin to the site of a pimple to help defend your skin from damage. The marks usually fade over time, but ingredients like vitamin C, retinoids, and hydroquinone can help speed up the process.

Am I cursed to have acne forever?
No. “Acne is 100% controllable,” Dr. Schultz says. “There’s no reason in 2014 that anyone has to suffer from acne.”

Dermatologists have an arsenal of options to treat your acne, including antibiotics, topical retinoids, birth-control pills, and isotretinoin, also known as Accutane. The drug has a scary reputation, and has serious potential side effects (liver damage, birth defects, depression), but it’s also one of the most effective options for anyone with severe, cystic acne. “Isotretinoin is one of the few miracle drugs of the 20th century,” Dr. Schultz says.

Regardless of the method you choose, all the experts we spoke to said that with a little intervention, you can bring acne under control.

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