While I have been around many friends growing up who have suffered from acne (including my brothers), it wasn't until my mom developed acne in her 30s after her third baby (she'd barely had a pimple before then) that I realized chronic breakouts aren't just a teenage issue. A recent post on THE/THIRTY, our wellness Facebook group, confirmed it. When one member relayed her adult acne experience, the thread exploded with commenters who had also suffered the same fate as a grown-up. But that leaves me wondering why.
While most people assume that acne only occurs in teens and young adults, David Lortscher, MD, CEO at Curology, assured us that it can affect women (and men) later in life too. In fact, a Harvard study of acne in women revealed that although acne peaked in the teenage years, 45% of women aged 21 to 30, 26% aged 31 to 40, and 12% aged 41 to 50 were affected. "The characteristics of acne differed over the years, with younger women having more inflamed pimples, and older women having more comedones (clogged pores)," he told MyDomaine. And no one really knows why. "Acne breakouts wax and wane," he explained. "Sometimes you will have breakouts despite treatment, as no medication is a cure." According to Lortscher, the closest thing we have to a cure is Isotretinoin, formerly known as Accutane, but it has side effects.
As anyone who has suffered can attest, acne is a serious confidence drainer too. "We recently conducted a survey on acne that confirmed dealing with any form of acne can take a toll on someone, both emotionally and physically," he said. "In fact, 36% of women admitted to feeling nervous or anxious going into a job interview or big presentation because of their acne." So what can be done about it? We asked Lortscher to give us the rundown once and for all, from the common causes to the triggers, foods to avoid, and the best treatments for acne, so you can work out a prevention plan to keep the breakouts at bay.
MYDOMAINE: What are your top foods to avoid/remove from our diet to prevent adult acne?
DAVID LORTSCHER: Milk contains precursors to testosterone and other androgens, which influence the hormone receptors in the skin to turn on the process that causes acne. The likely link involves insulin-like growth factor-1 (IGF-1) as a general stimulant, synergized by the steroid hormones present in milk. The 5-alpha-reduced compound 5-alpha-pregnanedione (5-alpha-P) present in milk is a direct precursor of dihydrotestosterone. IGF-1 is present even in organic milk.
Carbohydrates that have a high glycemic index (like white bread) increase blood sugar and studies show that these foods may trigger acne. Foods that are low GI (meaning "smart carbs" that do not make our blood glucose levels rise very high), such as high-fiber, unprocessed foods are better choices than "empty" carbs or sugary snacks. Examples of high-GI foods: white bread, white rice, cornflakes, pretzels, bagels, and most desserts. Examples of "smart carbs": whole grains, seeds, legumes, veggies, and many fruits (such as peaches, strawberries, and mangoes).
Whey protein has been identified as particularly likely to cause acne (and casein is likely similar, as they're both milk-derived).
MD: How much does stress play a part in acne? Why/why not?
DL: Although stress does not directly cause acne, stressors may trigger acne. During periods of stress, hormones that stimulate the oil glands are released, beginning a process that may lead to acne. Some of us go through some very rough patches in life, and simple aphorisms don't apply. But for many of us dealing with every-day less-than-major stressors, some yoga, and/or meditation, modest exercise and a good night's sleep can go a long way toward happy skin.
"It is possible that cheese, ice cream, and yogurt may be associated with acne, but the link appears to be stronger with milk."
MD: What are the common environmental factors that contribute?
DL: Chronic sun exposure over years may lead to large pores and blackheads/whiteheads (called solar or senile comedones). This happens slowly and gradually over years. Solar comedones associated with elastosis (yellowish thickening and furrows) is called Favre-Racouchot syndrome.
MD: There are so many creams, potions, and lotions out there that claim to help acne, but how do we know what really works so we aren't wasting our money or making it worse?
DL: We recommend checking your cosmetics, sunscreens, moisturizers, etc., and use only products labeled with terms such as "noncomedogenic," "non-acnegenic," "does not clog pores," or "won't cause breakouts." A good way to double check your skin care products is to use CosDNA.com.
The label "noncomedogenic" (or similar) indicates that the manufacturer considers the product to be designed for people with oily or acne prone skin and is less likely to cause acne. It is not a guarantee, but can be a useful guideline.
Some common pore-clogging ingredients to watch out for include myrisitic acid, isopropyl palmitate, isostearyl isostearate, isopropyl myristate, glyceryl stearate SE, sodium laureth sulfate, sodium lauryl sulfate, myristyl myristate, laureth-4, potassium chloride and ethylhexyl palmitate.
MD: What are some of the things that can make acne flare up or worsen? Why?
DL: Although stress doesn't directly cause acne, it may trigger breakouts; during stress, hormones that stimulate the oil glands are released, beginning a process that leads to acne. Some foods (especially sugars/carbohydrates, milk, and ice cream) can cause a lot of acne and increased oil in certain people.
6 Common Causes of Adult Acne
While no one really knows why women are seeing more breakouts and acne cases in adulthood, Lortscher does have theories. Here he outlines the most common causes. Some you can control, but others (like genetics) are simply unavoidable.
This is one factor that is out of your control. Acne in adult women is more common when there is a history of acne in their family.
Hair and skincare products
For facial products, look for the label "noncomedogenic"—it's not a guarantee, as there are no regulations around a company’s use of the term, but it's a place to start. Haircare products aren't labeled as far as comedogenicity, since they are not intended to be applied to the face. But they can be culprits, especially if you have acne around the hairline or on the back, which is exposed to hair products as you shower. Some people break out more when they use products containing sodium lauryl sulfate. Products without these ingredients won't tend to lather well, so they can take some getting used to.
Women often experience acne due to hormonal influences, especially:
- After discontinuing (or starting) birth control pills
- Around their periods
- During pregnancy, perimenopause, and menopause
Life stressors, such as work deadlines or relationship issues, don’t exactly cause breakouts but can trigger them, perhaps more so in adolescent males but also in adult females. Even "good" stress, such as preparing for a vacation or a wedding, can cause acne at the most inconvenient times. This is because our bodies are complex. Stress can lead to hormonal and inflammatory changes in those predisposed to acne.
It's easy to assume that acne and oily skin go hand in hand. But dry skin is more common as the years go on—and the disruption of the skin barrier that may occur in very dry skin can predispose you to inflammation, which can initiate acne.
How to Treat Acne
Treating acne is different for everyone, but Lortscher says the best way is to take the five steps below.
1. Speed up the life cycle of the cells that line the pores so the cells are shed properly and do not accumulate inside the pore.
The Fix: Tretinoin works here.
2. Decrease oil production.
The Fix: Avoiding dairy. For women, certain birth control pills and/or a pill called spironolactone can help. This is the main way that isotretinoin (Accutane) works but spironolactone is a lower-cost option.
3. Fight Propionibacterium acnes to prevent overpopulation and stimulation of the body's defense system.
The Fix: Clindamycin, zinc, and azelaic acid do this.
How to Treat a Breakout
Despite all our best efforts to eat well and look after ourselves, sometimes breakouts just happen to good people. It can be emotionally debilitating, but Lortscher says don't stress, it will only make it worse. The best way to treat a mild breakout is to start with benzoyl peroxide acid, salicylic acid, and/or a retinoid. "All good over-the-counter ingredients for acne-prone skin (will work)," he says. "Don't feel that there is 'magic' in using products solely from one line—take into account your personal preferences and affordability when you choose. Mixing it up does not mess it up."
If these over-the-counter measures don't take care of your breakout, then Lortscher advises you to see a dermatologist for a prescription treatment. "A prescription treatment is expected to work much better than over-the-counter options," he said. For help in finding a local dermatologist so that you can be seen in-person, visit the American Academy of Dermatology Association site or see a dermatology provider conveniently online at Curology.
Try This 4-Step Skincare Regimen to Curb Acne
One of the reasons acne and breakouts can extend way beyond our teens and into adulthood is due to our lifestyle. Lortscher says this plays a huge role and that we should all consider a healthy diet, regular exercise, and sleep to prevent breakouts. Oh, and "never smoke." Here he outlines a simple four-step skincare regimen to take care of your skin and keep it healthy to reduce the occurrence (and severity) of breakouts.
"Cleanse gently, with a product that suits your skin. For some product recommendations and tips, visit Curology."
"Exfoliation is an option, not a necessity. A BHA (beta-hydroxy acid) and/or an AHA (alpha-hydroxy acid) product may be used one to two times every week, gradually increasing the frequency as tolerated. These can help dull, dry, or flaky skin and clogged pores. Sensitive-skinned folk should proceed with caution."
"Keep in mind exfoliation is easy to overdo. A shiny but not oily appearance, redness, tightness, and dryness may be signs that you are overdoing it."
"Über-moisturize if your skin is dry and tired, especially when dry, cold winter air and central heating have robbed your skin of moisture. Try a thick cream containing hyaluronic acid or glycerin, which draws in water. If your skin is sensitive, look for products with ceramides, which are naturally occurring lipids (fats) in the skin. Ceramides support barrier function, protecting sensitive skin from outside insults. But, depending on your age, skin type, and the environment, you may not need a moisturizer. Don't feel you have to use one. Use your judgment here—it's okay to be a minimalist."
"Hydration is key for well-nourished, soft, and glowing skin. If you're doing three things: making water your main choice of drink, drinking water when thirsty, and drinking water with meals, you won't need to worry about dehydration."
Zeichner JA, Baldwin HE, Cook-Bolden FE, Eichenfield LF, Friedlander SF, Rodriguez DA. Emerging Issues in Adult Female Acne. J Clin Aesthet Dermatol. 2017;10(1):37-46.
Vallerand IA, Lewinson RT, Farris MS, et al. Efficacy and Adverse Events of Oral Isotretinoin for Acne: A Systematic Review. Br J Dermatol. 2018;178(1):76-85. doi:10.1111/bjd.15668.
Katta R, Desai SP. Diet and Dermatology: The Role of Dietary Intervention in Skin Disease. J Clin Aesthet Dermatol. 2014;7(7):46-51.
Zamil DH, Perez-Sanchez A, Katta R. Acne Related to Dietary Supplements. Dermatol Online J. 2020 Aug 15;26(8):13030/qt9rp7t2p2.
Zari S, Alrahmani D. The Association Between Stress and Acne Among Female Medical Students in Jeddah, Saudi Arabia. Clin Cosmet Investig Dermatol. 2017;10:503-506. doi:10.2147/CCID.S148499
Zeichner JA, Baldwin HE, Cook-Bolden FE, Eichenfield LF, Fallon-Friedlander S, Rodriguez DA. Emerging Issues in Adult Female Acne. J Clin Aesthet Dermatol. 2017;10(1):37-46.
Prakash C, Bhargava P, Tiwari S, Majumdar B, Bhargava RK. Skin Surface pH in Acne Vulgaris: Insights from an Observational Study and Review of the Literature. J Clin Aesthet Dermatol. 2017;10(7):33-39.
Bagatin E, Freitas THP, Rivitti-Machado MC, et al. Adult Female Acne: A Guide to Clinical Practice. An Bras Dermatol. 2019;94(1):62-75. doi:10.1590/abd1806-4841.20198203
Skroza N, Tolino E, Mambrin A, et al. Adult Acne Versus Adolescent Acne: A Retrospective Study of 1,167 Patients. J Clin Aesthet Dermatol. 2018;11(1):21-25.
Schmidt N, Gans EH. Tretinoin: A Review of Its Anti-inflammatory Properties in the Treatment of Acne. J Clin Aesthet Dermatol. 2011;4(11):22-29.
Trivedi MK, Shinkai K, Murase JE. A Review of Hormone-Based Therapies to Treat Adult Acne Vulgaris in Women. International Journal of Women’s Dermatology. 2017;3(1):44-52. doi:10.1016/j.ijwd.2017.02.018
McLaughlin J, Watterson S, Layton AM, Bjourson AJ, Barnard E, McDowell A. Propionibacterium acnes and Acne Vulgaris: New Insights from the Integration of Population Genetic, Multi-Omic, Biochemical and Host-Microbe Studies. Microorganisms. 2019;7(5):128. doi:10.3390/microorganisms7050128
Acne: Diagnosis and Treatment. American Academy of Dermatology Association.