Acne & Pimples

Acne develops when hair follicles become plugged with oil (sebum) and dead skin cells. Four factors drive it: excess sebum production (stimulated by androgens — which is why acne peaks at puberty and in hormonal conditions), abnormal skin cell turnover inside the follicle (cells stick together instead of shedding, blocking the pore), colonisation with Cutibacterium acnes bacteria (which thrive in the blocked follicle and trigger inflammation), and the inflammatory immune response. Acne recurs because the underlying tendency — oily skin, hormonal influences, susceptible follicles — doesn't switch off with one course of treatment. In women, hormonal fluctuation around the menstrual cycle, PCOS, and starting or stopping hormonal contraception all affect acne. Stress increases sebum production and worsens existing acne. Dairy and high glycaemic index foods have modest evidence for exacerbating acne in susceptible individuals.

Treatment is graded by severity. Mild acne (blackheads, whiteheads, few papules): topical retinoids (adapalene 0.1% gel — available OTC in India) are first-line; they normalise follicle cell shedding and are effective for both inflammatory and non-inflammatory acne. Add benzoyl peroxide (kills C. acnes, reduces resistance) for inflammatory lesions. Moderate acne (more papules and pustules): combine a topical retinoid with a topical antibiotic (clindamycin) and benzoyl peroxide. Avoid topical antibiotics alone (resistance risk). Severe or cystic acne: oral antibiotics (doxycycline 100mg daily for 3 months, never more) combined with topicals, or oral isotretinoin — the most effective acne treatment available, clearing acne long-term in most patients. For hormonal acne in women: combined oral contraceptive pills or spironolactone. All acne treatment takes 8-12 weeks to show significant effect — patience is essential.

Isotretinoin (Accutane, Roaccutane — available generically in India) is an oral vitamin A derivative that reduces sebum production, normalises follicle cell shedding, reduces C. acnes, and has anti-inflammatory effects — addressing all four acne mechanisms simultaneously. A standard 4-6 month course achieves long-term remission or significant improvement in over 80% of patients with severe acne. Side effects are real but manageable: very dry lips and skin (moisturiser and lip balm essential), temporary worsening of acne in weeks 1-4, elevated liver enzymes and triglycerides (monitored with blood tests), sun sensitivity, and rarely, joint aches. The most serious risk: severe teratogenicity — isotretinoin causes major birth defects and must never be taken during pregnancy. Women of childbearing age require two forms of contraception throughout treatment and for one month after. Depression is listed as a side effect — evidence is debated, but monitor mood and discuss with your dermatologist.

Scarring happens when deep inflammatory acne — nodules and cysts — damages the dermis. The most important prevention: treat acne effectively and early, before it reaches the stage of deep inflammation. Two specific behaviours to stop: picking and squeezing acne lesions (this pushes inflammation deeper and dramatically increases scarring risk) and using irritating home remedies (lemon juice, toothpaste, baking soda) that damage the skin barrier and worsen inflammation. For post-inflammatory hyperpigmentation (the dark marks left after pimples heal — common in Indian skin tones): sunscreen daily (UV exposure darkens these marks significantly), niacinamide, and topical retinoids help fade them over 3-6 months. For true atrophic scars (pitting): procedures including chemical peels, microneedling, subscision, and fractional laser improve scar appearance — best done once acne is controlled.

The relationship is real but modest — diet is not the primary cause of acne but can be a contributing factor in susceptible people. The strongest evidence: high glycaemic index foods (white bread, sugary drinks, maida-based items) cause insulin and IGF-1 spikes that stimulate sebum production and follicular hyperkeratosis. Studies in populations transitioning to Western diets show rising acne rates. Dairy milk — particularly skimmed milk — has moderate evidence for exacerbating acne, possibly through its hormonal content (milk contains IGF-1 and androgens). Whey protein supplements used by gym-goers are associated with acne flares. Chocolate and fatty food have weaker evidence than commonly believed. The practical approach: if you suspect a food link, eliminate the candidate (high-GI foods or dairy) for 6-8 weeks and assess. Don't abandon effective medical treatment in favour of dietary restriction alone.