Clear skin right this way.
by Jessica Toscano Jan 20, 2022
If you’ve ever battled zits that are inflamed, tender to the touch, and nearly impossible to pop, then you know a little something about stubborn acne. Especially if a series of OTC treatments, trips to the dermatologist, and DIY remedies have cleared your wallet, but not your skin. Sound familiar? Then, you might be suffering from nodular acne, cystic acne, or a combination of the two.
Although both are characterized by deep, painful bumps under the skin that can lead to hyperpigmentation (dark spots) and atrophic scarring (indents in the skin), nodular acne or nodules are harder to the touch, whereas cystic acne or cysts contain fluid, so they tend to be on the gushier side, according to Cleveland Clinic. Either can appear on the face, shoulders, chest, or back and heighten from hormone fluctuations, eating habits, and lifestyle, which makes pinpointing the exact cause seem impossible.
Luckily, ditching these acne woes doesn't have to be. Here, dermatologists uncover everything you need to know about stubborn acne, including the steps you can take to (finally) clear it.
What causes stubborn acne?
“One of the first things that lead to acne formation is the trapping of dry skin cells in micro-cysts called comedones,” Syril Keena Que, MD, MPH, an assistant professor of clinical dermatology and the director of dermatologic surgery and cutaneous oncology at Indiana University School of Medicine in Carmel, tells Intrigue. “As more oil, bacteria, and dry skin accumulate, and as inflammation increases, this can lead to the formation of larger cysts.” Ultimately, build-up is dependent on genetics — whether your skin is naturally dry, oily, or combination — but can happen for a number of reasons.
One main culprit during this time of year is climate. Between frigid temps and indoor heat, skin tends to be drier in the winter, which prompts your sebaceous glands to produce more oil than usual to compensate, per the American Academy of Dermatology Association (AAD). Likewise, holiday stressors can trigger your adrenal glands to secrete cortisol and ultimately, increase sebum. Combine that with some of the 30,000 to 40,000 skin cells humans shed daily and bacteria, namely P. acnes, normally present on the skin’s surface, and you’ve got yourself inflamed — and probably painful — nodular or cystic acne.
You may also notice an increase in flare-ups when you eat certain foods, says Joshua Zeichner, MD, a board-certified dermatologist and associate professor of dermatology at Mount Sinai Medical Center in New York City. “Dairy (particularly cow’s milk), foods with a high glycemic index, whey protein, and vitamin B12 supplements have all been associated with worsening acne.” That means all the cookies, doughnuts, and pastries binged during the holidays can up your odds of breaking out by 20%, per a 2011 study of 2,300 participants published in Journal of the European Academy of Dermatology and Venereology. Especially if your dieting habits followed you into the new year. While the connection between diet and acne remains unclear, one popular theory maintains that these foods promote inflammation inside the body, which clogs pores and causes breakouts, per AAD.
What about acne scarring?
As if impossible-to-clear acne lesions aren’t painful enough (literally), 20% of acne sufferers between ages 11 and 30 are left with scarring after their skin clears, per Cleveland Clinic. Thankfully, much of this darkening or scarring resolves itself over time, assures Dr. Que, but it’s dependent on the severity of the outbreak and injury. “Larger cysts are usually associated with more inflammation, which is likely why cystic acne leads to so much hyperpigmentation and scarring,” she says. And because inflammation increases the production of skin coloring agent melanin, darker-toned skin is more prone to discoloration due to its naturally high melanin presence, per the AAD.
To both lighten dark spots and prevent new acne lesions from forming, topical retinoids [like Tretinoin] can be prescribed by your derm, says Dr. Que. Although not as effective, she also recommends OTC retinol-based products (you can start by rummaging through your acne and anti-aging collections for a retinol percentage, but be sure to first check the expiration date or batch number to make sure it’s not expired, which could lower its effectiveness). Hydroquinone is another topical cream prescribed by derms to treat hyperpigmentation, but because it needs to be monitored for adverse effects (such as rare but serious ochronosis, a blue-black skin discoloration) and temporarily halted after a few months’ use, it’s often only administered in more severe cases. For a hydroquinone-free alternative, we like Skinuva® Brite, a brightening cream that’s clinically proven to outperform hydroquinone 4% by nearly 30%, with zero reports of adverse reactions. It also features tranexamic acid, an ingredient that’s taken recent spotlight as highly effective and safe in treating discoloration.
In instances of atrophic scarring (caused by traumatic injury to the skin, namely picking and popping zits), which tends to be deeper and longer-lasting, skin might take longer to heal, or scars may become permanent. “For deeper acne scars, the best treatments include chemical peels, laser treatments, fillers, and surgical techniques that release the scar tissue from underneath,” says Dr. Que. While most procedures require a trip to your derm, at-home versions of particular treatments, like microneedling, are becoming more readily available.
“Microneedling is a procedure where tiny needles are punched into the skin, creating a controlled wound,” says Dr. Zeichner. “This takes advantage of the skin’s wound healing properties, creating new collagen to fill in scars in the skin.” Although DIY options have proven less successful at producing desired results, they’re often more affordable than in-office treatments (which can cost on average anywhere between $100 to $700 per session) and can still yield results in as little as three treatments. For DIY, we like the Banish Kit 2.0, which includes the Banisher 2.0, an easy-to-clean microneedling pen with antimicrobial 24k gold plated titanium bristles and a twist-off cap that doubles as a protective case during travels and storage and as a cleaning component, as well as Banish Oil, a hydrating and potent vitamin C serum that when applied immediately post-treatment, improves skin tone and texture.
Still, “the best way to prevent hyperpigmentation and scarring is to prevent acne in the first place,” says Dr. Que.
How to ditch stubborn acne ASAP
“Benzoyl peroxide is perhaps the most effective ingredient to [combat] acne,” says Dr. Zeichner. An OTC cream can help exfoliate the skin, decrease the number of clogged pores, and lower the amount of P. acnes bacteria that causes acne lesions, adds Dr. Que. To focus on problem areas and avoid all-over skin irritation, Dr. Zeichner recommends a spot treatment like La Roche-Posay Effaclar Duo. Likewise, salicylic acid can remove excess oil and dead cells and dry out already-existing pimples, according to both experts. Try Bliss Clear Genius Acne Spot Treatment, suggests Dr. Zeichner.
Still haven’t noticed a difference? Consider adding a retinoid to your regimen. “Adapalene is a prescription-strength topical retinoid, available over the counter,” says Dr. Zeichner. “It prevents cells from sticking together and blocking the pores, so you can think of it like a pipe cleaner.” He recommends an Adapalene Gel, like Differin. For more sensitive skin, we like Flora + Bast Clarifying Facial Treatment for its soothing full-spectrum hemp that moisturizes without clogging pores.
For those with extremely sensitive skin, consider cleansing with a sulfur wash like Kate Somerville EradiKate Daily Foaming Cleanser, says Dr. Zeichner. “Sulfur has both anti-microbial and anti-inflammatory properties [and] is a great option for people who have sensitive skin and cannot tolerate other ingredients.” Oil-based cleansers can also be used across all skin types, he adds. “The idea is that oil dissolves oil, so it can effectively remove soiling from the skin.” We like Botanical Republic Double Cleansing Duo: Its Nourish Hydrating Cleansing Oil uses a blend of apricot, avocado, and pomegranate oil to moisturize while it cleanses, while its Revive Gentle Emollient Cleanser relies on German chamomile to soothe and calendula to calm inflammation and keep sebum at bay.
If all else fails, a trip to your derm can help decide if prescription meds are right for you, says Dr. Que. “For those prone to develop cystic acne, [isotretinoin — in the past, it was prescribed under brand name Accutane]...can dramatically decrease the number of new acne lesions and lead to less scarring.” However, this oral retinoid is one of the most controversial acne meds on the market, according to a 2017 meta-analysis published in Journal of American Academy of Dermatology. Although proven effective, isotretinoin is warned by the Food and Drug Administration (FDA) to cause depression and suicidal tendencies and should be avoided by those who are pregnant or plan to become pregnant, as it can result in severe birth defects. That said, this all might sound like a lot for a clear complexion, but for severe acne sufferers who’ve tried everything else, it might just be a risk worth taking.
