Why am I getting pimples?

Hint: four things work together to cause those breakouts.

Asian woman on yellow background

Is it the air quality, your diet, stress levels, or fluctuating hormones? Nope - pimple formation is more fundamental than that. We break it down here for you.

The four culprits are pores, sebum, dead skin cells and bacteria.

1. Pores

These miniscule holes are present in every skin surface and are your body's natural openings to release sweat to regulate your body temperature (called sweat pores), and oils to prevent your skin from getting dry (called oil pores). They are connected to your hair follicles. It may be more visible on your cheeks and your nose and may enlarge due to age and oily skin.

Pores are not the enemy when it comes to acne, however, in its regular work at sweeping the sweat and oil away, it can get blocked by dead skin cells, oil, and/or sweat. A blocked oil pore almost always cause acne, while a blocked sweat pore produces a heat rash.

2. Sebum

Sebum is the natural oil that is produced by your sebaceous glands, which are attached to your hair follicle. Sebum production keeps your skin from drying out. However, excess production of sebum and/or the clogging of a pore causes acne.

The production of sebum is controlled by androgens, sex hormones. These hormones include testosterone, 5-testosterones and 5-androstene-317diol. Changes in androgens can be attributed to puberty (hence correlating to teen acne), and in women, it's the menstrual cycle, sensitivity to androgen, and in some cases, Polycystic Ovary Syndrome (PCOS).

Cross section of sebaceous glands, Wikimedia
Sebaceous glands, Wikimedia

3. Dead skin cells

Shedding 40,000 dead skin cells per hour may sound like something from a horror film, but it is only a natural process that our skin cells (kerinatocytes, which are made of… you guessed it. Keratin.) go through. Skin cells travel from the inner layer of our skin to the outermost layer (the stratum corneum). When it gets to that surface later, the skin cells meets its end and sheds. Unfortunately, it could get caught in the pore when the lining is sticky -- owing to our frenemy, the androgen and sebum. When it gets stuck, it becomes a comedone, or a spot with a white or blackhead.

4. Bacteria

Here's something scarier than a horror film -- BACTERIA! While not all bacteria are the bad guys, the cutibacterium acnes (formerly known as Princ.., I mean, Propionibacterium acnes) is certainly identified as our enemy. An opportunistic infection, or what we know to cause our comedones to become inflamed and even painful and develop into pustules, papules, cysts and nodules, is caused by the (i) presence of such bacteria, (ii) having a host (in this case, our face), and (iii) having some physiological disturbances (in this case, our clogged pore) (Source: Microorganisms. 2019 May; 7(5): 128).

While general practitioners (GPs) and dermatologists may prescribe an oral tetracycline antibiotic such as doxycycline and lymecycline, prolonged use of oral antibiotics can cause the population to develop antibiotic resistance, which is not great news for you or the public health. Switching to an antibiotic cream combined with Benzoyl Peroxide or Adapelene is a safer option. If you are on oral antibiotics, remember to finish your course and consider taking a probiotic supplement to restore your gut microbiome.