Acne: Types, Causes, and Topical vs. Oral Treatments

Acne isn’t just a teenage problem. By 2025, nearly one in three adults in the UK and US are still dealing with breakouts-some mild, others painful and persistent. If you’ve tried every cleanser, scrub, and DIY remedy without results, you’re not alone. The real issue? Most people treat acne like it’s one thing. It’s not. There are different types, different causes, and different treatments that work for each. Knowing the difference between a blackhead and a cyst isn’t just academic-it’s the key to stopping the cycle of frustration and scarring.

What Acne Actually Looks Like

Not all acne is the same. It shows up in several forms, and each needs a different approach. The simplest are comedones-whiteheads and blackheads. Whiteheads are closed pores filled with oil and dead skin. They look like tiny white bumps under the skin. Blackheads are open pores where the trapped material oxidizes and turns dark. These are non-inflammatory, meaning no redness or swelling. They’re often the first sign acne is coming.

Then comes the inflammatory kind: papules and pustules. Papules are small, red, tender bumps. Pustules are similar but have a white or yellow center filled with pus. These hurt. They’re what most people think of when they say they have acne. They form when bacteria, oil, and dead skin trigger an immune response. The skin swells, becomes inflamed, and you get a visible bump.

The most severe forms are nodules and cysts. Nodules are hard, deep lumps under the skin. Cysts are softer, filled with pus or fluid, and often very painful. These aren’t just ugly-they can scar permanently if not treated properly. Cystic acne is the kind that lingers for months, doesn’t respond to face washes, and often needs prescription help.

There are also less common types. Hormonal acne hits women in cycles-deep, painful bumps along the jawline, chin, and neck. It flares before periods, during pregnancy, or after stopping birth control. Fungal acne (or pityrosporum folliculitis) looks like uniform tiny bumps on the chest, back, or forehead. It itches more than it hurts and doesn’t respond to regular acne meds. Mechanical acne comes from friction-helmet straps, tight collars, phone pressure on the cheek. And acne conglobata? Rare, but terrifying: large, connected nodules that form tunnels under the skin.

Why You Get Acne-It’s Not Just Dirty Skin

Acne isn’t caused by not washing your face enough. That’s a myth. The real causes are deeper, biological, and often genetic.

Four things drive acne: excess oil, clogged pores, bacteria, and inflammation. Your skin makes oil (sebum) to stay lubricated. When hormones-especially androgens-spike during puberty, stress, or menstrual cycles, your oil glands go into overdrive. More oil means more chances for pores to get blocked.

Dead skin cells normally shed every 28 days. In acne-prone skin, they stick together and plug the pore. Then comes Cutibacterium acnes, a bacteria that lives on everyone’s skin. When it gets trapped in a clogged pore, it multiplies and triggers inflammation. That’s when redness, swelling, and pus appear.

Hormones are the biggest trigger. Around 85% of teens get acne because their bodies are flooded with androgens. But adults? Hormones are still the culprit. In women, rising testosterone or dropping estrogen can spark breakouts. Insulin spikes from sugary diets or insulin resistance can also ramp up oil production. Studies show people with insulin resistance are 2.5 times more likely to have severe acne.

Genetics matter too. If both your parents had acne, your risk jumps by 50%. Certain medications-steroids, lithium, some antidepressants, testosterone supplements-can also trigger breakouts. Even your pillowcase, phone, or sports gear can contribute if they’re constantly rubbing against your skin.

Topical Treatments: What Actually Works

For mild to moderate acne, topical treatments are the first line of defense. They’re applied directly to the skin and work locally. No pills. No side effects like nausea or dizziness. But they take time. Don’t expect miracles in a week.

Benzoyl peroxide is the most proven. It kills acne bacteria and reduces inflammation. A 2.5% concentration is just as effective as 10%, but far less irritating. Studies show it cuts bacteria by 90% in four weeks. Use it daily. It can bleach towels, so be careful.

Salicylic acid is a beta-hydroxy acid that dissolves oil and exfoliates dead skin. Great for blackheads and whiteheads. Look for 0.5-2% in cleansers or toners. It takes 6-8 weeks to see results, but it’s gentle enough for daily use.

Retinoids like tretinoin, adapalene (Differin), and tazarotene are the gold standard for preventing clogged pores. They speed up skin cell turnover so dead cells don’t stick around to block pores. Adapalene 0.1% is now available over-the-counter and works well for comedonal acne. In user surveys, 78% of people with blackheads saw improvement after 12 weeks. But here’s the catch: retinoids cause purging. Your skin might get worse before it gets better. That’s normal. Stick with it for at least 8 weeks.

Combination products-like benzoyl peroxide plus clindamycin-are more effective than single ingredients. They attack acne from two angles: killing bacteria and reducing inflammation. Clinical trials show 65-80% clearance with combination therapy versus 40-50% with one alone.

For fungal acne, antifungal creams like ketoconazole or selenium sulfide shampoos used as face washes work better than traditional acne meds. If your bumps are itchy and uniform, this might be your issue.

Oral Treatments: When Topicals Aren’t Enough

If you have more than 10 inflamed bumps, deep cysts, or breakouts that won’t quit after 3 months of topical treatment, you need oral options.

Antibiotics like doxycycline or minocycline are common. They reduce inflammation and kill bacteria. They work well-50-70% improvement in 3 months. But here’s the problem: 25% of people develop antibiotic resistance after long-term use. That means the meds stop working. That’s why they’re usually prescribed for only 3-4 months, always paired with topical benzoyl peroxide to prevent resistance.

Oral contraceptives (birth control pills) help women with hormonal acne. Pills with ethinyl estradiol and a low-androgen progestin (like drospirenone) can reduce breakouts by 50-60% after 3-6 months. They’re not for everyone-especially if you smoke, have migraines, or a history of blood clots. But for many women, they’re life-changing.

Spironolactone is an off-label treatment for hormonal acne. It blocks androgen receptors, so less oil is made. It’s not a birth control pill, but it works similarly for acne. Doses of 25-200mg daily show 40-60% improvement in 3 months. Side effects? Dizziness, dry mouth, irregular periods. About a third of users stop because of these. But for many, the trade-off is worth it.

Isotretinoin (Accutane) is the nuclear option. It shrinks oil glands, reduces bacteria, and prevents clogging. For cystic acne, it clears 80-90% of cases. Sixty percent of users never get acne again. But it’s serious. It can cause dry skin, mood changes, and birth defects. Women must use two forms of birth control during and for a month after treatment. Blood tests are required monthly. It’s not for everyone-but for severe, scarring acne, it’s the most effective treatment ever developed.

What Doesn’t Work (And Why)

There’s a lot of noise out there. Tea tree oil? It’s natural, but studies show it’s only 40% as effective as benzoyl peroxide. Zinc supplements? They might help a little when added to conventional treatment, but alone? Not enough. Apple cider vinegar, toothpaste, lemon juice-these are myths. They irritate skin, damage the barrier, and make acne worse.

Over-the-counter products often promise quick fixes. La Roche-Posay Effaclar Duo gets great reviews for blackheads-68% of positive reviews mention it clears pores. But 72% of negative reviews say it does nothing for cysts. That’s because it’s designed for mild acne. Don’t waste money on products that don’t match your type.

And don’t expect overnight results. Topical treatments take 6-8 weeks. Oral meds take 3-4 months. If you stop too soon, you’ll never know if it would’ve worked. Most people quit before the real results kick in.

How to Choose the Right Treatment

Start by identifying your acne type:

• Whiteheads/blackheads only? Try adapalene or salicylic acid.
• Red, inflamed bumps? Benzoyl peroxide + topical antibiotic.
• Deep, painful cysts? See a dermatologist. You likely need oral meds.
• Breakouts around jawline, monthly? Hormonal acne. Ask about birth control or spironolactone.
• Itchy, uniform bumps on chest? Fungal acne. Try antifungal washes.

Don’t self-prescribe antibiotics or isotretinoin. These require a doctor’s supervision. Even over-the-counter retinoids can cause irritation if used wrong. Start slow: use them every other night, then build up. Always use sunscreen-retinoids make skin sun-sensitive.

Consistency beats intensity. Twice-daily application, gentle cleansers, and patience will get you further than scrubbing your face raw every morning.

What to Expect-and How to Stick With It

Most people give up too soon. The American Academy of Dermatology says 70% quit topical treatments before 8 weeks because of dryness, redness, or no visible change. That’s normal. Your skin is adjusting. Purging happens with retinoids-40% of users see a temporary flare-up in the first month. It’s not failing. It’s working.

For oral treatments, give it 3 months. Antibiotics show results around week 6. Birth control and spironolactone take 3-6 months. Isotretinoin requires 5-6 months of treatment.

Cost is a barrier. Winlevi (clascoterone), a newer topical that blocks androgens, works well-but costs $650 a month without insurance. Generic options like tretinoin or adapalene are far cheaper. Ask your dermatologist about samples or patient assistance programs.

Access is another issue. In the UK and US, waiting for a dermatologist can take 3-6 weeks. If your acne is severe, ask your GP for a referral. Don’t wait until it scars.

Early treatment prevents scars. If you wait, the chance of scarring jumps from 15% to 40%. That’s why seeing a professional early matters-not just for clearing skin, but for protecting your face long-term.