Two Thousand Years of Getting Acne Wrong
Acne has been described in medical writing since antiquity, and for almost all of that time it was treated as a problem of dirt, diet or morals. The treatments followed the theory, which is why they included sulphur, arsenic, radiation and, within living memory, a great deal of unnecessary scrubbing. The modern understanding, that acne is an inflammatory condition of the hair follicle with four interacting causes, is barely a lifetime old, and it changed the treatment completely.
Doctors have been writing about acne since ancient times, and for almost all of those two thousand years they treated it as a problem of dirt, food or bad character. The treatments matched the theory, which is how we ended up with sulphur, arsenic, radiation, and, within living memory, an enormous amount of pointless scrubbing. What we know now, that acne is an inflamed hair follicle with four things going wrong inside it at once, is barely a lifetime old. It changed the treatment completely.
Two Thousand Years of Getting Acne Wrong: the essentials
The short version
Described by Greek and Roman physicians; the word acne enters medical Latin from a Greek term
Greek and Roman doctors described it, and the word acne comes to us through them.
Dirt, diet and character, which produced treatments based on scrubbing and restriction
Dirt, food and character. Which led to scrubbing, and to being told what not to eat.
Excess oil, blocked follicles, Cutibacterium acnes and inflammation, interacting
Too much oil, a blocked pore, one particular germ, and inflammation, all feeding each other.
Isotretinoin, approved in the United States in 1982, transformed severe acne
A medicine called isotretinoin, approved in the United States in 1982, changed what was possible for severe acne.
Antibiotic resistance, which is why antibiotics are paired and time-limited
Germs learning to survive antibiotics. That is why antibiotics are given with something else, and only for a set time.
Scarring is easier to prevent than to treat, which is the argument for treating early
Preventing a scar is far easier than fixing one. That is the whole argument for treating acne early.
The long wrong answer
Two thousand years of the wrong answer
Ancient and medieval treatments for acne were, with remarkable consistency, forms of cleaning. Sulphur preparations appear across cultures and centuries; so do abrasives, astringents and dietary restriction. The logic was that visible impurity implied actual impurity, and that removing it from the surface would remove the condition.
Old treatments for acne were, almost without exception, a form of cleaning. Sulphur turns up across cultures and centuries. So do scrubs, harsh toners, and being told to give up certain foods. The reasoning was simple: if it looks unclean, it must be unclean, and scrubbing the surface should get rid of it.
Sulphur, as it happens, does have genuine antimicrobial and keratolytic activity, so the tradition was not entirely fruitless. But the theory it rested on was wrong in a way that mattered, because it located the problem on the surface. Acne begins several millimetres down, inside the follicle, and no amount of surface treatment reaches it.
As it happens, sulphur does kill germs and does help loosen dead skin, so the tradition was not a complete waste. But the theory behind it was wrong in a way that mattered, because it put the problem on the surface. Acne starts several millimetres down, inside the pore, and nothing you do to the surface reaches it.
The twentieth century added more forceful versions of the same error. Radiation therapy was used for acne into the middle of the century. Arsenic compounds were prescribed. Vigorous scrubbing was routine advice well into living memory, and it makes inflammatory acne worse by damaging an already inflamed follicle.
The twentieth century simply came up with stronger versions of the same mistake. Radiation was used on acne into the 1950s. Arsenic was prescribed. Scrubbing hard was standard advice within living memory, and it actually makes inflamed acne worse, because you are grinding away at a pore that is already angry.
The four things that are actually happening
The four things that are really going on
Modern understanding describes four processes acting together inside the follicle: an increase in oil production driven largely by hormones, an abnormal build-up of cells lining the follicle that blocks it, colonisation by Cutibacterium acnes, and an inflammatory response that produces the redness, swelling and pain.
We now know four things happen together inside the pore. The skin makes more oil, mostly because of hormones. The lining of the pore sheds cells too fast and they pile up and block it. A germ that lives on everyone’s skin multiplies in the blocked pore. And the body reacts to all of that with inflammation, which is what makes a spot red, swollen and sore.
This is why single-agent treatment so often disappoints. A product that reduces oil does nothing about the blockage. An antibiotic addresses the bacteria and some of the inflammation but not the reason the follicle blocked in the first place. Effective regimens usually address more than one process at once, which is why a dermatologist prescribes a combination rather than a product.
That is why one product on its own so often disappoints. Something that cuts oil does nothing about the blockage. An antibiotic deals with the germ and some of the inflammation, but not with why the pore blocked in the first place. Treatments that work usually tackle more than one of the four at once, which is why a skin doctor prescribes a combination rather than handing you a single tube.
It also explains the timeline. Because the visible spot is the end of a process that began weeks earlier inside the follicle, a treatment that works on the process shows its effect on the surface some weeks later. Judging an acne treatment after ten days is judging it before it has had the chance to be judged.
It also explains the waiting. The spot you can see today is the end of something that started inside the pore weeks ago. So a treatment that fixes the process only shows up on your face some weeks later. Judging an acne treatment after ten days is judging it before it has had any chance to show you anything.
The medicine that changed the argument
The medicine that changed the argument
Isotretinoin, approved in the United States in 1982, was the first treatment that acted on all four processes at once. For severe, scarring, treatment-resistant acne it changed what was possible, and it remains the most effective option for that group.
Isotretinoin, approved in the United States in 1982, was the first treatment that worked on all four problems at once. For severe acne that scars and does not respond to anything else, it changed what was possible, and it is still the most effective option for that group.
It also brought a serious safety burden with it, including well-known risks in pregnancy that require a strict prevention programme, and monitoring during treatment. That combination, an unusually effective medicine with unusually strict requirements, is a fair summary of why acne care belongs with a clinician who can assess, prescribe and follow up rather than with a shelf.
It also came with serious safety strings attached, including well known risks in pregnancy that require a strict prevention programme, and checks while you are taking it. An unusually effective medicine with unusually strict rules is a fair summary of why acne belongs with a clinician who can examine you, prescribe, and follow you up, rather than with a shelf in a shop.
What is still being got wrong
What we are still getting wrong
Two things, mainly. The first is antibiotics: they work, and using them alone and for long periods breeds resistance, which is why current practice pairs them with benzoyl peroxide and limits the course. The second is the persistent moral framing, the idea that acne reflects hygiene or diet or discipline, which delays treatment and does real harm.
Two things, mainly. First, antibiotics. They work, but using them on their own for months on end teaches germs to survive them. That is why they are now given alongside benzoyl peroxide and stopped after a set time. Second, the old moral idea that acne says something about your hygiene, your diet or your self discipline. That one is still around, it delays people getting treated, and it does real harm.
The clinical consequence of that framing is scarring. Acne that is left to run because it is thought of as a phase, or as the patient’s own fault, has more time to damage the deeper skin, and that damage is permanent in a way the spots are not. Treating acne early is not vanity; it is the only reliable way to prevent scars, because treating a scar afterwards is considerably harder than preventing one.
The harm shows up as scarring. Acne that is left alone because it is thought of as a phase, or as somehow your own fault, has more time to damage the deeper skin. That damage is permanent in a way the spots are not. Treating acne early is not vanity. It is the only dependable way to avoid scars, because fixing a scar later is far harder than preventing it now.
Questions patients ask
Does chocolate or greasy food cause acne?
Does chocolate or greasy food cause acne?
Diet is not the primary cause. Some evidence associates high-glycaemic diets and, less consistently, skimmed milk with acne severity in some people, but the effect is modest and individual. Acne is driven by hormones, follicular blockage, bacteria and inflammation, not by a single food.
Food is not the main cause. There is some evidence linking diets high in sugar and refined carbohydrates, and less consistently skimmed milk, with worse acne in some people. The effect is small and varies from person to person. Acne is driven by hormones, blocked pores, germs and inflammation, not by one thing on your plate.
Will washing my face more often help?
Will washing my face more often help?
No, and over-washing usually makes inflammatory acne worse by damaging the skin barrier and irritating already inflamed follicles. Gentle cleansing twice daily is sufficient; the treatment does the work, not the washing.
No, and washing too much usually makes inflamed acne worse. It strips the skin’s protective layer and irritates pores that are already inflamed. Washing gently twice a day is enough. The treatment does the work, not the washing.
How long before I know if a treatment is working?
How long before I know if a treatment is working?
Most acne treatments need eight to twelve weeks for a fair assessment, because they act on a process that takes weeks to reach the surface. Some cause an initial worsening before improvement, which is expected rather than a sign of failure.
Most acne treatments need eight to twelve weeks before you can judge them fairly, because they act on something that takes weeks to reach the surface. Some make things look worse before they get better, which is expected and is not a sign of failure.
Should I pop a spot?
Should I squeeze a spot?
Squeezing forces the contents deeper as often as it releases them, extending the inflammation and increasing the risk of a mark or a scar. Professional extraction of suitable lesions is a different procedure performed under controlled conditions on lesions selected for it.
Squeezing pushes the contents deeper about as often as it gets them out. That drags the inflammation on for longer and raises the chance of a mark or a scar. Having spots professionally extracted is a different thing: it is done in controlled conditions, and only on the spots that are suitable for it.
Is acne only a teenage problem?
Is acne only a teenage problem?
No. Adult acne is common, particularly in women, and often has a different pattern and different drivers, including hormonal ones. It responds to treatment, and the treatment chosen is frequently not the same as that used in adolescence.
No. Adult acne is common, especially in women. It often shows up in a different pattern and has different causes behind it, including hormones. It responds well to treatment, and the treatment is often not the one that would be used on a teenager.
Where to go next
Talk it through with a physician first.
Every plan starts with an assessment of your skin, your anatomy and what you actually want to change.
This page is general health information, not medical advice. It cannot tell you whether a treatment is right for you. Approved uses, risks and results differ from person to person, and product labelling changes. Ask us at Dermatology and Laser Centre about your own situation, or make an appointment, and seek urgent care for any serious symptom.
