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Acne and Your Face

Location, location, location! A comprehensive look at what is causing those acne breakouts on each part of your face.

In this photo: a visual aid depicting the various regions of the face that acne breakouts can occur and the reasons for breakouts in each of the corresponding regions.

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When you fall victim to yet another aggravating acne breakout on your face, I bet many of you never stop to consider how the part of your face that has broken out might be indicative of its cause. If you have gone through life telling yourself that a pimple is a pimple, regardless of where it is, I’m here to let you know that not all acne breakouts are created equally. It just so happens that the areas where your breakouts keep occurring may be clues as to how to treat them.

While your acne breakouts and the areas they occur may implicate different causes, the one thing that remains the same is why a pimple forms in the first place. All acne, regardless of where the breakout happens, is the result of your pores becoming clogged by an excess of oil, dirt, debris and dead skin cells. Eventually, once it becomes bad enough, that clog then develops into what is known as a comedone. Comedones are the skin-coloured, small bumps (also known as papules) frequently found on the forehead and chin of those with acne. A single lesion is a comedo. Open comedones are blackheads; black because of surface pigment (melanin), rather than dirt.

Photograph of a person's face which shows the difference between a blackhead and a whitehead.

 

Closed comedones are whiteheads; the follicle is completely blocked. Now, should bacteria find its way into the comedone, the result can be the formation of a papule (a “reddish'' colored pimple) or a pustule (a papule that is full of pus). And then we have the two most severe forms of acne, nodular and cystic acne, which manifest below the dermal surface and have a tendency to leave behind scarring at varying levels of severity. 

illustration showing the various types of pimples.

If your acne has ever gotten bad enough, then you’re likely no stranger to the types of scarring your pimples have likely left behind. The three types of scars associated with acne breakouts are referred to as atrophic, hypertrophic, and keloid scars. 

 

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Types of Acne ScarsIllustration depicting the different types of acne scars.

Acne scarring is typically the result of inflammatory acne, which is the kind of acne that is large and pink, or cyst-like. This type of acne is quite serious and painful, and occurs when a follicle or pore becomes clogged with excess oil, make-up, dead skin cells, and bacteria. What can happen is that this clogged pore can sometimes rupture beneath the dermal surface, which can result in injury to the skin and inflammation. Scarring happens during the wound healing process after the inflammation, which results in the subsequent excessive collagen growth and/or degradation that will later become the scar you are left with. Acne scars vary in appearance, ranging from shallow, mottled depression, sometimes called rolling scars, to deep and narrow indentations, or depressions, in the skin. 

At first glance, it can be quite difficult even for your dermatologist to distinguish the difference between hyperpigmentation (which occurs from inflammation when you experience an acne breakout) and what is a true, or “real”, scar. If it is flat and brown, purple or red, then what you are looking at is hyperpigmentation. However, an acne scar is permanent collagen damage that has caused the formation of a depressed (autotrophic) or raised (hypertrophic) scar. If you are someone suffering from cystic acne (the most severe form of acne, which occurs deep within the skin), then you likely already know that you are far more prone to scarring than most, and are far more likely to experience it, as a result of your condition. The unfortunate reality for those that suffer for most forms of acne, is that 95% of patients will experience some form of scarring as a result of breakouts. This is where having an experienced dermatologist comes in handy. They will need to properly identify the type of scarring you have in order to effectively treat it. This is because optimal treatments currently available for each type of scarring are oftentimes different and specific to the types of scars they are meant to treat. It is also not entirely uncommon for doctors to have to treat multiple types of scarring in patients at the same time depending on the severity of the acne and how long the patient has been dealing with it. 

While the depressions acne scars create may be skin colored, they tend to be much darker or even much pinker than our normal skin tone, causing them to stand out on our faces. In this section, let’s take a look at the various types of scarring acne can cause. 

Atrophic acne scars are the result of a loss of collagen and elastic fibers deeping in the skin. They appear as small indentations in the skin, and typically occur while cystic acne is being healed. Atrophic scarring is caused by the destruction (or loss, as mentioned above) of collagen in the skin when it does not produce enough fibroblasts (those elastic fibers we just mentioned) in the midst of trying to heal itself. Our fibroblast cells play a critical role in the wound healing process, as well as the synthesis of collagen within the body. These types of scars are described as being flat, shallow, depressions (like a crater) that heal below the skin’s surface. Atrophic scars are the most commonly seen acne scars and are classified into three different subtypes: rolling (broad depressions with sloped, non-distinct edges), boxcar (broad depressions with sharply defined edges and a flat bottom), and icepick (which have an opening that is wider than the deeper region, forming a “V” or ice-pick shape).

Hypertrophic scars are described as being thickened, wide, oftentimes raised scars that develop where the skin has sustained an injury. While scars aren't uncommon during the healing process, hypertrophic scars are different because they are the result of an abnormal response to a trauma or injury. These types of scars tend to be larger than the original acne lesion and they look thick, firm, and are raised above the level of your skin. With regard to coloration, they tend to vary, ranging from flesh-colored to pink, and they will sometimes itch and feel tender or tight. 

 

In some people, their body cells, called myofibroblasts, produce too much collagen during the healing process. The formation of hypertrophic scars has a lot to do with a person’s skin type, as well as their healing tendencies. Typically, it is when a wound has become infected and inflamed, especially when that wound is subjected to significant amounts of motions or tensions (for examples, when the wound is over a joint), or when a wound is left to heal without stitches, that we see this overproduction of collagen. Hypertrophic scars are similar to keloid scars but tend to be milder and don’t grow beyond the boundaries of the original skin injury.

Oftentimes being more of a cosmetic issue, and despite their tendency to sometimes be a bit itchy and painful, hypertrophic scars are not life-threatening or dangerous. While no official treatment or regimen exists for the scars, many do exist that can help diminish their appearance. Without getting into too much detail, the list of medical treatments currently available to lessen the appearance of hypertrophic scarring are: 

Corticosteroid treatments: Corticosteroid injections are considered a first-line treatment for hypertrophic scars. Injecting a steroid into the scar every six weeks may help flatten and soften the scar. There’s a limit to the number of times this can be performed, however, as the steroids may also weaken normal tissue around the scar.

Laser therapy: Laser therapy is more effective in newly formed scars than in older scars. The lasers work by burning and flattening elevated scars. They also target the red and pink pigments in the scars to lighten them. 

Bleomycin: Bleomycin is a metabolite of a strain of soil bacteria. It’s shown promising results when injected directly into a hypertrophic scar. It may help improve the scar's appearance and relieve itching and pain. More clinical trials are needed to confirm its efficacy.

Cryotherapy: In cryotherapy, a doctor or dermatologist freezes the scar tissue with liquid nitrogen to help flatten it. Cryotherapy has been shown to be successful, safe, nontoxic, and well-tolerated in a number of small studies.

Surgery: After waiting at least a year, a hypertrophic scar can be excised, or cut out, and closed again with stitches. This treatment tries to re-heal the injury while eliminating the issues that may have caused the scar in the first place, such as infection, inflammation, or tension.

Call and make an appointment to speak with your dermatologist if you are interested in available treatment options for minimizing the appearance of your acne related hypertrophic scarring. 

However, if seeing a dermatologist just isn’t in the cards for you at the moment, there are a number of non-prescription treatment options you can explore for yourself at home. The following home treatment options have been found effective at reducing the appearance of hypertrophic scarring. I am providing this information solely to share with you what others have stated has worked for them. Personally, I have never had to combat this issue in my lifetime. Because of such, and given that I am not a dermatologist, nor am I a licensed skin care professional of any kind, I cannot personally guarantee their effectiveness of the treatments listed below.

Remember, every person’s body and healing tendencies are uniquely specific to them, so what may have worked for one person, may not necessarily work for you. Don’t give up or become discouraged. You will find the treatment options best suited to you as long as you keep trying. 

Silicone sheets: Silicone elastomer sheets are noninvasive and can be applied as soon the skin heals after an injury. They’re also considered a first-line treatment for hypertrophic scars. Many silicone products are available, including sheets, gels, sprays, and foams. Many are available over the counter (OTC). A sheet must be worn over the scar for 12 to 24 hours per day for 2 to 3 months. You have to apply the gel multiple times per day.

Pressure and massage: One of the cheapest and most effective ways to help heal the scar is to apply pressure and massage to the area. You can use bandages or tape to apply pressure. Over time, it can help weaken the scar tissue and improve the appearance of the scar.

Onion extract creams: Another OTC option is a topical gel made of onion extract. This product is commonly marketed as Mederma. However, limited clinical data shows its effectiveness in reducing the appearance of hypertrophic scars.

Bio Oil: Bio Oil is marketed as a treatment for all different types of scars. It can be purchased at many beauty supply stores. Clinical trials for Bio Oil showed positive results. However, the sample sizes were small. More research is needed to confirm that Bio Oil can effectively reduce the appearance of hypertrophic scars.

Before your doctor can begin treating you for hypertrophic scarring, it is important that they have first taken the time to differentiate it from another similar type of acne scar known as a keloid. Keloid scars appear as smooth, hard, benign growths that form the same way as hypertrophic scars do (when scar tissue grows excessively). While the two may be so similar that even your doctor may have issues telling them apart, it is important that they distinguish which type of acne scar they are dealing with ahead of time, as the treatment for one may be different from the treatment for the other. Here is a side by side comparison of hypertrophic and keloid scars, to give you an idea of their differences and similarities: 

In general, hypertrophic scars:
  • Are raised, but rarely more than 4 millimeters above the skin
  • Are red or pink in color
  • Can develop anywhere on the body
  • Do not grow beyond the boundaries of the original skin injury
On the other hand, keloids usually:
  • Are raised more than 4 millimeters from the skin
  • Grow beyond the boundaries of the original skin injury
  • Are pink to purple in color
  • Evolve and grow over time
  • Form on the earlobes, shoulders, cheeks, and chest above the sternum

 

Research has found that both types of scarring appear to be most common in darker skin types, with hypertrophic scarring typically being much easier to treat than keloids, which have a high recurrence rate even with routine treatment.

 

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When we talk about key factors influencing most acne breakouts, we have to consider all of the environmental, behavioral, as well as internal variables which can make us more susceptible to breakouts in specific areas of our faces. Next, we will take more of an in-depth look at the primary areas where facial acne tends to occur, and discuss what it is that might be causing it.

Forehead Acne

Photograph of a girls forehead with an acne breakout in progress.

If you have particularly oily skin, then you’ve likely experienced a breakout here a time or two. But your oily skin might not be solely to blame for acne that occurs on this part of your face. The real issue might just be your trendy hairstyle, especially for anyone with hair that tends to hang down over their forehead. It isn’t uncommon for people to opt for a hairstyle with bangs because they are insecure about their forehead scene. What many haven’t taken into consideration, is how those adorable bangs of theirs have a tendency of trapping dirt, oil, and hair products in the forehead area, which only serves to exacerbate the issue by causing more frequent breakouts. 

Another culprit worth taking into consideration if you suffer from forehead acne, is yeast! Yeast thrives in warm, moist places. So for those of you that love to sleep with wet hair, this might be something you especially might want to take into consideration. If yeast has developed on your scalp, it can then fall from the scalp and become trapped in the pores along the hairline when sweat and oil accumulate in that area. When this happens, the subsequent fungal acne (which, in all honesty, isn’t technically acne at all) that develops likely won’t become inflamed. What it will do, however, is make the skin on your forehead feel rough and bumpy.

Image displaying the forehead of a woman suffering from a fungal acne outbreak.

Fungal acne tends to respond best to a sulfur-based face wash called sodium sulfacetamide, which you can obtain from your dermatologist with a prescription. Additionally, if you aren’t able to see a doctor, many people have reported successful results treating their fungal acne with dandruff shampoo from the drugstore (like Selsun Blue), which contains the active ingredient selenium sulfide. Selenium sulfide is effective in the treatment of fungal acne for the same reason it is so effective at treating dandruff: it helps with cell turnover and reduces inflammation. 

If you suffer from frequent forehead acne breakouts, try finding lighter hair products to replace what you are currently using, taking special care to avoid using heavier products such as pomades or styling creams, and always make sure that you are washing your hats to keep them clean (especially if you are someone that likes to wear a hat during workout sessions). 

Nose Acne

Image showing acne occurring on the nose.

Now, if you have extremely oily skin, then you probably know a thing or two about nose acne. Breakouts of this variety tend to be on the smaller side of things, and don’t become inflamed. While you tend to see larger, cystic acne lesions on other parts of the face and body, they are not common on the nose. Here, you tend to see more blackheads than anything else. This time, your oily skin likely is to blame for your troubles. The areas around the nose contain more sebaceous glands than any other part of your face, which is why if you already have oily skin at baseline (or even if you don’t), you can attest to the fact that this part of your face can have a tendency of becoming especially oily. 

The best advice dermatologists can offer in the case of nose acne, is to resist the urge to touch or mess with the blackheads when they occur. For those of you out there that love to pop  your pimples, this one is likely going to be especially difficult for you. But the more you mess with the pores on your nose, the more you are going to provoke them to dilate, and in doing so, accumulate even more dirt, oil, dead skin, and bacteria, causing them to become inflamed. You might want to, instead, try using a mild, gentle exfoliant with active ingredients like salicylic acid, lactic acid, or even glycolic acid, to slowly and gently clear everything out of your pores. 

If that doesn’t help resolve matters for you, then perhaps it might be time to consider using a retinoid or consulting with a dermatologist to see if a chemical peel is right for you. A chemical peel can reduce the appearance of breakouts and the residual scars they can leave behind on your nose. 

If you are someone that wears glasses, double-check to make sure that they aren’t too tight or resting too heavily on the bridge of your nose, as unnecessary pressure tends to trap dead skin and keep it from shedding normally. When this happens, the dead skin becomes trappy in your pores which will trigger....can you guess?...that’s right...another breakout!

Cheek Acne

Image of acne occurring on the cheek.

Ah, the elusive cheek acne. Experts aren’t entirely certain what actually causes breakout in this portion of the face, but they do have some ideas as to where we can start looking to place the blame. It’s suspected that genetics may actually play a large role in the prevalence of cheek acne, but then again, it could also just be that that is where your skin happens to be more likely to develop it in the first place. 

More than likely, though, it could also have something to do with your day-to-day habits. Think about all the things that make contact with our cheeks on any given day, and there is a list of possible suspects right there. Anything that gets pressed against your skin for an extended period of time runs the risk of creating a buildup of oil, bacteria, and dead skin cells, which, as we know, causes breakouts. So that means your cell phone, the pillow you sleep on every night, your sheets, and even your hands for those of you that simply cannot help but touch your face repeatedly throughout the day. All of these things could be contributing factors when it comes to your cheek acne. 

Thankfully, the remedy for this issue is one that is as simple as it is straightforward: Keep all items that make contact with your cheek every day clean and avoid touching your face as much as you possibly can throughout the day. This alone should reduce the amount of bacteria and oil introduced to your skin, and in doing so, also reduce the amount of breakouts your experience. 

For those of you who suffer from rosacea, which causes small, red, acne-like bumps that oftentimes also show up on the cheeks, is also sometimes confused with cheek acne. If you find that your efforts to tackle acne on this part of your face have proven unsuccessful, or if you find that your skin also appears to be flushed and your skin tends to feel sensitive around the cheek area, it might be worth the trip to see your doctor to see if something else, like rosacea, might be going on. 

Chin Acne

Acne on a person's chin.

And finally, the scourge of all acne, the dreaded breakouts that occur around the mouth, chin, and jawline area. Some dermatologists refer to this type of acne as “the beard distribution”. Breakouts that occur in this region are usually a sign of fluctuations, or changes, in a person’s hormone levels. 

Because of such, contraception tends to be the most widely turned to treatment option for this particular type of acne issue. To date, birth control pills, of which there exists three different varieties the FDA has specifically approved for the treatment of acne, has proven to be the most effective treatment option available for breakouts of this nature. So if your doctor suspects that there may be a hormonal component to blame for your acne breakouts, it is highly likely that they will refer you to see your ob-gyn for a prescription of this kind.  

Birth control aside, spironolactone is also one of the preferred treatment options to manage jawline acne breakouts. Normally, doctors would prescribe this in an effort to treat high blood pressure, but have found that it also blocks androgens, which are male hormones that can contribute to the development of acne related breakouts along the chin and jawline area of the face. 

Despite the fact that the drive force behind acne formation in the region of the face being that of a hormonal nature, you should still remain consistent with all of your other acne-prevention and skin care strategies so as to help prevent future breakouts in this, and other, areas. Clean regularly, exfoliate, and always remember to keep your phone, pillowcases and sheets clean!

 

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Prevention: A Vital Part of Your Daily Routine

It doesn’t matter where acne decides to pop up on your face, because with the help of a few basic steps you might just be able to prevent a breakout from happening in the first place. 

Consistency and dedication are going to play a big role in your acne-prevention strategy. Stick with your usual skin care regimen. Don’t forget to cleanse regularly, moisturize (even if you have oily skin), and especially do not forget to protect your skin from the sun by using your SPF. Doing so will keep your face happy, healthy, and free of breakouts. Never forget to always make sure you are using the right products for your skin type. If you have oily skin, you should be choosing products that are noncomedogenic so that they don’t clog your pores.  

Exfoliate regularly—but go easy. For many of us, exfoliating one to three times a week is sufficient enough to keep our skin clear of those acne causing buildups of dead skin cells, oil, and excess makeup or skin-care products. Generally speaking, dermatologists recommend using gentler chemical exfoliants over scrubs or brushes, but there’s no harm in exploring a few different options to find the one that is best suited to your skin. However, if you notice your skin is feeling dry, irritated, or sensitive, it may be time to reign things in a little. These things are all signs that you just might be over exfoliating, which means it may be time to dial back the number of times you are doing so each week.

It is also possible that you are using products that are too harsh for your skin. I would, again, start with cutting down on the number of times you exfoliate each week, and if you still notice that you are experiencing issues with your skin after doing so, then I would start looking into alternatives to replace your current product and see if there is any change after you make the switch. 

Try over-the-counter medications. While cleansing and exfoliating will help you tackle mild to moderate acne that’s caused by your pores becoming clogged with dirt, skin cells, and other gunk, to fight bacteria-driven acne or more severe cases, you’ll need to step things up a little. In this case, you might consider trying benzoyl peroxide (my personal “go-to” product of choice since I was just a kid in high school), which actually kills the bacteria, or an over-the-counter retinoid like retinol or Differin (adapalene), which will speed up the cell turnover process.

Don’t feel like you need to struggle on your own with this. If you have been using these strategies for about eight to 12 weeks, and still haven’t seen any improvement in your skin, then it might be time to consider calling a dermatologist and having them evaluate your skin to help determine what the real issue is, as well as the best course of action to take to remedy it.  Going to see a  board-certified dermatologist can help figure out the exact cause of your acne, and they may recommend that you try a prescription retinoid, birth control (for acne being caused by hormonal changes or fluctuations), spironolactone, or an in-office treatment. Common as it may be, trying to manage stubborn acne can be an intensely trying experience, and there is no reason why you need to try and take it on all on your own.

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