As long as people have had acne, they’ve tried to find something to blame for the condition — including dirt, diet, stress, makeup, and sex. Although dermatologists and researchers still aren’t 100 percent sure about what causes acne, we’ve come a long way in recent decades, and most doctors agree that hormones and heredity are the fundamental sources that lead to the development of acne.

In here, I explore the role that stress and diet play in causing acne or making existing acne worse. I also review some of the medications and “tripwires” that have been implicated as causing or worsening acne. I end with an appraisal of the relationship between makeup and acne.

I also looks at some of the historical misconceptions that have persisted about acne. For example, you’ve probably been warned not to eat too much chocolate. And you may have heard “The Big Bang Theory,” that is, keep your hair away from your skin. Not true.

These types of myths are passed down from one family member to another, told to you by a friend, and occasionally published in beauty magazines. Myths die hard and often there is some underlying truth that can be found to explain where and how some of them got started; other times they’re just based on silly folklore.

Debunking Dirt and Grease Theories

The appearance of acne — the black color of blackheads and facial oiliness — suggests that if only you rubbed and scrubbed your face really hard and often, you could get your acne to go away.

Not so — in fact, before all of the effective acne treatments became available to us, that was how acne was often treated — and unsuccessfully I might add. What may look like dirt inside your blackheads is actually melanin, the pigment that provides the natural color of your skin.

Despite what you may have seen or heard in commercials, your pores don’t get blocked from the top down; instead, most of the action of acne formation takes place on the inside of your skin in your hair follicle. Think about it.

If dirt was a major reason that some people get acne, we’d probably see gazillions of blackheads, whiteheads, and pimples on the faces of folks who do a lot of manual labor such as coal miners, ditch diggers, construction workers, and gardeners.

But it so happens that office workers, teachers, and doctors — even alas, dermatologists and their kids — get acne. As for the oil, although there is a connection between how severe acne is and the amount of oil a person’s skin produces, not all people with oily skin have acne and not all people with acne have oily skin.

It so happens that some people with dry skin also have it. Scrubbing and rubbing a face that has acne will only serve to irritate and redden an already inflamed complexion. Instead, the face should be washed daily (twice a day at the most!) with a gentle cleanser.

Dismissing the Diet

We aren’t always what we eat. Despite occasional personal anecdotes and persistent cultural myths, acne is probably not significantly influenced by diet. In fact, there have been studies in which people were actually paid to eat chocolate. Yum! The conclusion: The chocolate-eating subjects’ acne didn’t get worse.

Furthermore, several substances found in chocolate have been identified as being mood-lifters that apparently increase your brain’s endorphins (chemicals that decrease pain and elevate your mood). So chocolate isn’t bad for your blemishes; your stress level may diminish and so may your pimples!

However, your waistline may get wider. Currently, there is some disagreement about the link between diet and acne; several researchers are suggesting that there may be a degree of truth behind some dietary factors having an influence on acne.

For example, certain dairy products and refined sugars that are found in our Western diet are now being evaluated as possible acne triggers. The jury is still out on this issue. In the meantime, if you’re absolutely convinced that a certain food type is making your acne worse — avoid it!

But if your acne is being treated properly, you probably don’t need to worry about food affecting it. Take a skeptical approach with any acne “cure” books that hype a special diet, such as salmon, as one of the fundamental treatment components.

Frying up an acne fable

To prevent pimples, you may have been told to avoid junk food because it contains so much fat and grease that it’ll make your skin greasy too and you’ll get whopper-sized McPimples!

According to studies to date, it’s the oil in your sebaceous glands that causes you problems and not the oil in your French fries or in your stomach. Sure, it makes sense to follow a healthy diet, which involves avoiding greasy foods, but avoiding such foods doesn’t guarantee a clear complexion.

Here’s the beef — and the milk

Many cattle are fed androgens to help them build muscle. And as you may have read, your body’s androgens are often what kick-starts the overproduction of oil. Some researchers are looking into whether we also get androgenic stimulation and acne when we eat beef.

On the other hand, the androgens may be degraded by cooking before they get to our acne-prone, androgensensitive hair follicles. And there are some investigators (a small minority, mind you) who believe that milk, particularly skim milk, and some other dairy products may worsen — or even cause — acne.

They claim that the androgenic hormones that are injected into our cows to make them produce more milk get into our bodies and give us pimples. But it’s questionable whether the hormones in milk could survive the high levels of gastric acidity (our stomach acid) and be absorbed into our bodies.

My take on this debate is simple: I’ve seen many vegetarians who choose not to eat any flesh foods (fish, chicken, beef), and a few vegans (pronounced vee-guns), people that totally avoid eating any animal products including dairy and eggs.

Guess what — both vegans and vegetarians still get acne like the rest of us! (And by the way, when was the last time you saw a cow with pimples?)

So right now, nobody knows for sure, but for the time being, I think you should listen to the age old parental advice and drink your milk! (Unless you have a milk allergy.) Same with eating that steak. The jury is out on the whole cow-androgen-acne thing.

A disease of Western civilization?

A recent study regarding two societies, the Kitavan Islanders of Papua New Guinea and the Aché hunter gatherers of Paraguay, found absolutely no evidence of acne until these groups were exposed to a Western diet.

The investigators of this article (found in the December 2002 volume of the Archives of Dermatology) suggested that the refined sugar in our Western diets is a possible cause of acne.

Bottom line: Besides diet, there are so many other factors that might be responsible for their lack of acne, such as climate, sun exposure, and less stress in their tropical homeland. And even when American diets were much lower in sweets 30 years ago, teens probably had as much acne as today.

No, it’s the iodides

It has been traditionally believed that overeating foods that are rich in iodides, such as sushi, seaweed, and shellfish, can cause or aggravate acne. Bottom line: As far as I know, there have been no reports of acne epidemics reported so far in Japan or Korea.

Salmon saves the day, or does it?

There are those who advocate eating more fish, most notably, salmon, which is loaded with the anti-inflammatory omega-3 fatty acid. Its fans would have you believe that eating salmon can help you prevent and treat acne.

Eating more salmon is likely a good idea for your general health. However, farmed salmon may contain PCBs and dioxins, two substances that have been linked to various health problems. And wild salmon contains mercury. So don’t eat too much of it.

Stress and Acne

Modern-day living, anxiety in the workplace, too many or too few hormones, nuclear threats, terrorism, inflation, crime, poverty, obesity — it’s enough to give you terminal acne! Most investigators agree that stress doesn’t cause acne; however, most would agree that stress seems to worsen it.

Just ask college students at exam time, teenagers about to go to the prom, or someone going for that first job interview. It’s well known that at times of stress, the body releases excess amounts of glucocorticoids (the body’s natural steroids).

Some people think that the glucocorticoids, having some androgenic properties, cause sebaceous glands to secrete more oil and thus worsen acne or even cause an acnelike eruption. It has been suggested that regular stress-reducing activity (like exercise, knitting, yoga, and so forth) can help minimize the glucocorticoids, and reduce their effect on sebaceous glands.

Some pundits also advise getting extra sleep and meditating. Just like with diet and acne, there is no hard evidence that these measures really do much to help reduce acne. However, they are healthy habits that may reduce stress, so why not?

Addressing some Aggravating Agents

A host of outside agents such as drugs, physical factors such as cosmetics, and even sun exposure have been considered to be triggers and tripwires for acne. I review these agents in the next section.

In particular, certain drugs can be acnegenic (acne producing) or create skin eruptions that look exactly like acne (acneiform reactions). The same drugs can sometimes exacerbate pre-existing acne.

Drugs that can induce acne

Acne reactions caused by medications are usually self-limiting, which means they disappear when the drugs are stopped. If the drug must be taken for an extended period of time, the acne or acne-like lesions can be treated with the same medications that are used to fight most forms of acne.

Corticosteroids

Oral corticosteroids are synthetic derivatives of the natural steroid, cortisol, which is produced by the adrenal glands. They’re prescribed for a large number of serious inflammatory diseases. They’re called “systemic” steroids if taken by mouth or given by injection as opposed to topical corticosteroids, which are applied directly to the skin.

Prednisone, prednisolone, and methylprednisolone are examples. These drugs sometimes produce inflammatory acne lesions consisting of papules or pustules that have a tendency to appear on the chest and/or back (sometimes called steroid folliculitis). They disappear after the medication is stopped.

Comedones (blackheads and whiteheads) are generally absent from steroid-induced acne. The overuse of potent topical corticosteroids (used for many skin conditions) on the face can cause a condition similar to acne. It is known as steroid-induced rosacea.

I realize that this sounds somewhat contradictory, since the oral corticosteroid drugs are anti-inflammatory, and it would appear that they would actually be used to treat acne. If fact, they are used for acne treatment under special circumstances. Sometimes they’re used to treat the nodules and scars of acne by injection.

And on special occasions, we dermatologists prescribe corticosteroids orally for short threeto- five-day, low-dose “bursts” as an “emergency” treatment to wipe out acne for a special occasion (wedding, prom, and so on). They can really wipe out acne fast, but only for short periods of time.

Anabolic-androgenic steroids

Abuse of these hormones can lead to acne and other serious health problems. Besides legitimate medical uses of androgens such as testosterone for hormone deficiencies, widespread use and abuse of these compounds exist, particularly the anabolicandrogenic steroids, as performance-enhancing drugs.

This type of acne is observed in males mainly on their backs, shoulders, and chest, and less often on the face, whereas in female athletes using these drugs, lesions tend to appear on the face as well as on the back and shoulders. An already-existing acne problem may get worse or nonexisting acne may be evoked.

Androstenedione

Androstenedione (andro) is a hormone produced by the adrenal glands, ovaries, and testes. It’s a precursor hormone that’s normally converted in the body to testosterone and estrogen in both men and women. Andro made the news after the former baseball player Mark McGwire admitted taking it around the time of his record-breaking home run season.

Although ads claim that androcontaining supplements promote increased muscle mass, studies have shown that andro poses the same kinds of health hazards as anabolic steroids. The U.S Food and Drug Administration (FDA) cautions about the risks for young people who take andro: acne, an early start of puberty, and stunted growth.

DHEA (dehydroepiandrosterone)

This hormone, sometimes billed as the “fountain of youth” hormone, is also a steroid hormone, a chemical cousin of testosterone and estrogen. Because DHEA is converted into testosterone, it has been noted to produce excessive facial and body hair, besides causing acne.

Other oral medications

Other drugs that have been observed to have acnegenic properties include:

• Lithium
• Iodine
• Isoniazid
• Diphenylhydantoin
• Certain androgenic contraceptive pills

Initiating or irritating factors?

In this section, I list some of the activities, exposures, or things done to the skin that have historically been reported to bring on or exacerbate acne.

Acne cosmetica

This condition is described as a persistent, low-grade type of acne usually involving the chin and cheeks of women who use cosmetics. The lesions arise primarily as closed comedones as well as papules and pustules. It is often thought to be caused by comedogenic (blackhead- and whitehead-producing) substances in the cosmetics.

In all likelihood, however, these folks probably have adult-onset acne, and they just happen to use the cosmetics to hide the acne lesions — and of course, the cosmetics get the blame for causing the acne!

Because most major cosmetics are noncomedogenic — meaning they don’t cause acne — this type of acne is unlikely to be seen much, if at all, nowadays.

Pomade acne

A variant of cosmetic acne, known as pomade acne, can occur if greases, like oils, Vaseline, cocoa butter, and hair oils are used to style hair or are applied to the skin. If pomade or hair oil spreads onto the forehead, it can block pores, causing comedones.

Pomade acne is almost exclusively seen in African-Americans and usually appears on the forehead and temples. Treatment consists of avoiding pomades. If you must continue using a pomade, try applying it to the ends of the hair only to avoid contact with the scalp and hairline.

Sunlight and acne (Mallorca acne)

Also called acne estivalis (“estivalis” means summer); this is a rare form of acne that occurs in the summer or following a vacation in the sun. This condition is so rare that I don’t think I’ve seen a case of it. But I have seen the damaging results that excessive exposure to the sun can have on both healthy skin and skin with teenage and adult-onset acne.

Acne mechanica

This variation of acne is due to mechanical factors, including friction, sweating, and pressure. It is provoked by such factors as chin straps, bra straps, articles of clothing, orthopedic casts, backpacks, chairs, and car or bus seats.

The acne is seen at the sites where these items rub and persistently press against the skin, such as under a chin strap or cast. This type of acne is often simply an aggravation of the existing lesions of acne or an inflammation of hair follicles known as folliculitis.

Acne detergens

This refers to the aggravation of the existing lesions of acne by too frequent washing with comedogenic soaps and rough cloths and abrasive pads. It certainly can be irritating, but overwashing doesn’t cause acne.

Dioxins and Agent Orange (chloracne)

Agent Orange, an herbicide, was used during the war in Vietnam. Some veterans reported a variety of health problems and concerns attributed to exposure to this agent, including chloracne. Agent Orange contains dioxins (halogenated aromatic hydrocarbons), a group of chemicals known to increase the likelihood of cancer.

The first disease associated with dioxins was the extreme skin disease chloracne. It causes acnelike pustules on the body that can and do last for several years and result in significant scarring. It develops a few months after swallowing, inhaling, or touching the responsible agent.

Most cases are due to occupational exposure, but it can also arise after accidental environmental poisoning. Deliberate dioxin poisoning is blamed for Ukrainian President Victor Yushchenko’s dramatically changed appearance during the “Orange Revolution” in 2004.

Making Up and Breaking Out?

Makeup doesn’t cause acne. Acne cosmetica is the traditional name for the type of acne that cosmetics supposedly cause. I realize that some reactions to cosmetics can sometimes look like inflammatory acne, but it’s really just your skin reacting negatively to one or more of the ingredients found in your makeup that makes already-existing acne get redder and look worse.

And between you and me — I don’t believe that cosmetics have much to do in the development or worsening of acne!! There, I’ve said it. I generally tell my patients, “If you’re happy with your cosmetics, stay with them; if you feel that your cosmetics are causing or worsening your acne, just stop using them for a few weeks and see if the bumps go away!”

However, there are plenty of folks who disagree with me, some of whom are fellow dermatologists. In the next sections, I tell you what others have to say. I present the information to be inclusive and present the traditional belief that makeup and cosmetics are very important issues when it comes to acne.

Reading the ingredients

Nowadays, most cosmetic products boast of being non-poreclogging and “oil free.” And most of them have a label that states that the product has been tested and verified as being noncomedogenic. It’s on virtually every label on every cosmetic product.

However, some skin-care products are considered to be comedogenic, which means they cause whiteheads and blackheads. The damaging effect of cosmetics on acne has been attributed to the presence of excess oil in such cosmetics.

What ingredients in the leading cosmetic products are believed by some dermatologists to cause acne? The following three are considered to be the leading candidates:

• Lanolin: This is oil from the skin of sheep. It’s similar to the fatty acids found in human skin.

• Isopropyl myristate: This substance adds “slip,” which makes a product go on the skin smoother and causes a slick sheer feel. There are a number of chemicals similar to isopropyl myristate, including isopropyl isostearate, butyl stearate, octyl stearate, and laureth-4.

• D & C red dyes: These dyes derived from coal tars are also believed to be comedogenic.

Although some experts believe these ingredients are acne-causing, I don’t personally believe they cause acne. However, if your acne seems to get worse when wearing cosmetics, look for these ingredients on the label of your current products. Try new products that don’t contain them to see whether your skin condition improves.

Living in an oil-free world

Is your cosmetic really, absolutely oil free? On the assumption that sebum is a beneficial component of the skin, chemists have tried to imitate this substance, but the “oil free” claim isn’t exactly valid and can be misleading because the oil substitutes that are used in these products are synthetic and are considered to be more harmful than the excess sebum found in the skin that can block pores.

The alleged bad guys

Generally speaking, the most acne-causing cosmetics are:

• Foundation makeup
• Pressed powders
• Thick creams
• Blushers

Moisturizers can also be a source of acne-producing substances. In order to make these moisturizing products smooth onto the skin easily, they’re often manufactured with ingredients such as acetylated lanolin, searic acid, and cetyl alcohol. All of these ingredients are considered to be comedogenic.

The alleged good guys

The recommended moisturizers are those that have a base of petrolatum or mineral oil. Powder blushers are usually preferred over creams, and cream/powder foundations are usually preferred over the liquid type because loose powders help to “mop up” the oil. If a liquid foundation is chosen, it should be silicone-based (containing cyclomethicone or dimethicone).