Acne Causes: Beyond Hygiene—Hormones, Genetics, and Inflammation

Acne vulgaris is a multifactorial disease of the pilosebaceous unit. Poor hygiene is not a primary cause. Over-cleansing can worsen it by disrupting the skin barrier.

Core Pathogenic Factors

1. Androgen-driven sebum overproduction: Testosterone/DHT stimulate sebaceous glands. Peaks in puberty; persists in adult female acne (PCOS, hormonal fluctuation).
2. Follicular hyperkeratinization: Abnormal desquamation of keratinocytes forms a microcomedone (plug).
3. Cutibacterium acnes proliferation: Anaerobe thrives in lipid-rich, hypoxic plugged follicle. Biofilms enhance virulence.
4. Inflammation: C. acnes activates TLR2 → IL-1, TNF-α, IL-17 → neutrophilic infiltrate → papules, pustules, nodules.

Contributing Factors

• Genetics: Heritability ~80%. Influences sebum composition, follicular keratinization, immune response.
• Diet: High glycemic load, dairy (especially skim milk) associated with severity in some studies.
• Stress: ↑ cortisol/adrenal androgens → sebum; neuropeptides (substance P) → inflammation.
• Medications: Corticosteroids, lithium, anticonvulsants, EGFR inhibitors, anabolic steroids.
• Cosmetics: Comedogenic products (occlusive oils, certain silicones).
• Mechanical: Friction (helmets, masks), picking (acne excoriée).

Effective Management

• Gentle cleanser + non-comedogenic moisturizer.
• Topical retinoids (adapalene, tretinoin) – normalize keratinization (first-line).
• Benzoyl peroxide – bactericidal, anti-inflammatory.
• Topical/oral antibiotics (with BP to prevent resistance).
• Hormonal therapy (COCs, spironolactone) for adult females.
• Isotretinoin for severe, scarring, refractory cases.

See a dermatologist for personalized regimen. Consistency > intensity.