Acne is one of the most common skin conditions, and one of the most misunderstood. This article explains what is happening in the skin, which popular beliefs do not hold up, how long treatments normally take and when it is time to ask a pharmacist or GP.
What is actually happening in the skin?
According to the NHS, acne develops when hair follicles become blocked with excess oil and dead skin cells. Bacteria can then grow in the blocked follicle, which causes inflammation and, sometimes, pus. The result ranges from a few spots to deep, painful lumps under the skin. It most often affects the face, chest and back.
The British Association of Dermatologists (BAD) describes the same sequence in three steps. The oil glands near the skin surface become overly sensitive to hormones, even at normal hormone levels, and produce too much oil, known as sebum. The linings of the pores thicken and dead skin cells block them, forming blackheads and whiteheads. Bacteria then multiply in the oily environment and cause inflammation, producing red, swollen or pus-filled spots.
Understanding this sequence explains a good deal of the practical advice. Acne is not a sign of dirt on the surface of the skin. It is a process that starts inside the follicle.
What can make acne more likely?
No single cause explains every case. The BAD says genetics, hormones and lifestyle factors, such as stress, skincare products and smoking, combine to cause most acne. It can run in families, although many people with acne have no relatives who are affected.
The two organisations list a number of other contributors:
- Hormone changes. The NHS links acne to life stages such as puberty, periods, menopause and pregnancy.
- Other conditions. These include polycystic ovary syndrome (PCOS) and rosacea, according to the NHS.
- Certain medicines. The BAD names some hormonal contraceptives, high-dose steroids, anabolic steroids and some other medications.
- Greasy products. Both bodies mention oily skincare, greasy moisturisers and hair products. The BAD also lists oily substances encountered at work.
That last point matters for anyone building a routine. The NHS recommends choosing products described as non-comedogenic, which means they are formulated not to clog pores. The BAD suggests the same labelling, or oil-free products, and says non-comedogenic make-up is reasonable if it helps your confidence. Reading a label properly is a skill in its own right, and our guide to cosmetics labels, ingredients and allergies covers what the terms do and do not tell you.
Does poor washing cause acne?
No. The BAD puts it plainly: “Remember blackheads are not due to poor washing.” Scrubbing harder is therefore the wrong response. Both the NHS and the BAD warn that scrubbing can irritate the skin and make acne worse.
The NHS advice is more modest and more practical:
- Wash twice a day with a gentle cleanser.
- Remove make-up at the end of the day.
- Do not pick or squeeze spots, because this can cause scars. The BAD adds that it can also worsen acne and lead to infection.
The theme is gentleness. Irritated skin is not cleaner skin, and an aggressive routine tends to add a second problem to the first.
Does what you eat matter?
Diet is the subject of more confident claims than almost any other aspect of acne. The BAD’s position is cautious: “There is not enough evidence to support specific diets for treating acne.” It advises a healthy, well-balanced diet in general.
That does not mean the question is closed for ever, only that, as of the BAD’s current patient information, there is no evidence-based diet to follow for acne. Anyone considering a restrictive eating plan because of their skin should speak to a GP or pharmacist first, particularly if the plan cuts out whole food groups.
How long do treatments take?
Patience is the most underrated part of treating acne. The BAD states that most over-the-counter treatments take two to four months to produce their full effect. The treatments it lists for mild acne, available with advice from a pharmacist, include benzoyl peroxide, azelaic acid, nicotinamide and salicylic acid. The NHS also names salicylic acid and benzoyl peroxide, and notes that a pharmacist can recommend skin treatments and supplements such as zinc, niacinamide and vitamin A.
A product swapped every fortnight has not been given a fair trial. The table below sets out the timings published by the BAD for the main treatment routes.
| Route | Who prescribes or advises | Timing noted by the BAD |
|---|---|---|
| Over-the-counter treatments | Pharmacist advice | Most take 2 to 4 months for full effect |
| Topical retinoids | Prescription | May worsen acne for a few weeks before it improves |
| Oral antibiotics | Prescription | Not normally continued for more than 6 months, because of antibiotic resistance |
| Isotretinoin | Dermatology supervision | Most courses last around 6 months |
Why can treatment seem to make things worse first?
The BAD notes that some topical treatments, such as retinoids, can lead to acne getting worse for a few weeks before it gets better. It says the same of isotretinoin, which may cause a slight worsening before improvement. This is a common reason people give up early.
The BAD’s advice on irritation is practical. If a topical treatment causes redness or irritation, stop for a few days, then restart less often and build up gradually. Our explainer on starting retinol slowly sets out the same principle for cosmetic products.
What can a GP or dermatologist offer that a pharmacy cannot?
The NHS lists the prescription options. Applied to the skin, these are retinoids (tretinoin and adapalene) and antibiotics (clindamycin and erythromycin). Taken by mouth, they are antibiotics (doxycycline and lymecycline), the combined pill, which can help manage hormone levels, and isotretinoin, a retinoid.
Two points deserve emphasis.
First, the BAD says oral antibiotics are normally limited to no more than six months because of concerns about antibiotic resistance. That is a reason for treatment to be reviewed, not left running.
Second, isotretinoin carries strict conditions. The BAD says it can only be prescribed under dermatology supervision, and that contraception must be used for at least four weeks before treatment, during treatment and for at least four weeks after. It also says people should tell their doctor about any personal or family history of mental health conditions before starting, and may be referred to a mental health professional first. These are matters for a specialist consultation, not for self-directed decisions.
The BAD also notes that spironolactone is used off-licence for acne in women, often those with raised androgen levels or PCOS, and that light and laser therapy has had mixed results and is usually ineffective for severe acne.
When should you see a GP?
The NHS gives four situations in which it recommends seeing a GP:
- You have tried treating acne yourself and it is not improving.
- You have lots of spots, or spots that are deep, painful or causing scars.
- You have signs of a skin infection, such as hot, swollen, red skin. The NHS notes that redness is harder to see on brown and black skin.
- Acne is affecting your mental health.
The BAD adds two more: acne that develops or suddenly worsens, in which case it suggests discussing whether a medicine could be the cause, and spots that look unusual, because not all spots are acne.
The mental health point is not a footnote. The NHS says acne can cause anxiety, depression and low self-esteem, and the BAD says it can significantly affect mental health. If acne is affecting your mood, that is a legitimate reason to seek help on its own, whatever the skin looks like.
What about scarring and marks left behind?
Scarring is the reason the BAD stresses early action: acting early helps to avoid permanent scarring. It describes scars that are raised (hypertrophic or keloid) or indented (pitted or atrophic), and notes that acne can also leave red, darker or lighter discolouration.
The BAD says scar treatments such as steroid injections, chemical peels, microneedling and subcision are not routinely available on the NHS, and that laser resurfacing should not be done for at least a year after isotretinoin. It describes skin camouflage as an inexpensive option for changes in pigmentation.
Sun exposure is worth a thought here, since sunlight can make some treatments harder on the skin. Our guide to SPF and UVA star ratings explains how to read sunscreen labels, and a pharmacist can say whether a particular treatment calls for extra sun care.
A calm routine, and when to ask for more
Put together, the published advice is unglamorous. Wash gently twice a day, remove make-up at night, choose non-comedogenic products, leave spots alone and give any single treatment two to four months before judging it. Ask a pharmacist about over-the-counter options. See a GP if the acne is painful, scarring, worsening, unexplained or affecting how you feel.
Acne is a medical condition with a range of established treatments, not a failure of hygiene or willpower, and nobody needs to wait for it to become severe before asking for advice.
This article is general information, not medical advice. For personal advice about acne, treatments or medicines, speak to a pharmacist, GP or dermatologist.
Sources: NHS (Acne); NHS (Acne: treatment); British Association of Dermatologists (Acne patient information leaflet)
