It’s Complicated: The Many Elements that Influence Acne

In a previous post, “Understanding Acne”, we covered the basics of what acne is and how acne lesions (or pimples) form. But what causes acne formation in the first place?

What Causes Acne, the Short Answer: Genetics

If we had to point to one common thread in almost all acne cases, it would be the hormonal stimulation of oil glands and a likelihood of too many dead skin cells shedding into the corresponding hair follicle. Acne-prone individuals tend to have strong inflammatory responses to skin irritants (such as this pile up of oil and dead cells) in comparison to those who don’t have acne issues.1

What Causes Acne, the Long(er) Answer: it’s Complicated

The above explanation is concise, but it certainly doesn’t address the variety of circumstances that can lead to acne for some people but not others, or answer questions about why some people respond well to some acne treatments, but others require different strategies. Acne is influenced by many internal and external elements. Therefore, there is no one single ’cause’ of acne and there is no one single, broad-sweeping solution that works for every person, every time. But by taking a holistic look at all the contributing factors that play a role in acne formation, there is hope of managing the condition and minimizing or controlling the severity of breakouts.

About Those Hormones

Hormones serve as messengers in the body. Produced by glands and released into the bloodstream to be delivered to other areas, they control most major bodily functions, including physiological processes, emotions, and mood. A group of hormones called androgens are the guilty party in acne development. Beginning at puberty, hormones including testosterone and other sexual hormones (generally referred to as androgens) circulate through both male and female systems, triggering important reproductive development, as well as stimulating sebum production. Men tend to have steady androgen production, leading to generally steady acne breakouts for those who are predisposed. Women, however, experience an intricate shifting of hormones, which can lead to surges of sebum production and resulting acne blemishes during high androgen level spikes, contrasting with times of high estrogen, which generally reduces sebum flow and the corresponding breakouts. Menstrual cycles, pregnancy, and birth control pills can all influence acne in women. As with all the other contributing factors, careful consideration of medical needs should be evaluated before making any changes for the sake of clear skin. Only you and your doctor can determine what is right for you.


Without a doubt, stress is the number one aggravating factor[2] that impacts all acne sufferers and can cause fluctuations in severity of symptoms. Breakouts tend to occur around or shortly after periods of stress, such as school finals, family or work problems, or major events such as holidays or weddings. Emotional and mental stress affects the body physically, especially in women where the adrenal glands respond to stress by kicking out extra hormones. This increased level of hormones stimulates the sebaceous gland at the bottom of hair follicles, triggering an increase in the amount of oil that then starts to mix with dead skin cells and begin the formation of a pimple (opens in a new tab). Stress also interrupts the body’s ongoing healing process, which can lead to a weakened immune state where one is more susceptible to colds or viruses. The same effect can be felt in a fragile skin, where the delicate balance of temporary calm can suddenly erupt into an overnight blemish.


Can weather really impact your skin? Yes! Sunlight, as well as seasonal and climate changes, can cause problems for acne-prone individuals. Exposure to the sun stimulates oil production and new skin cell growth, which can prove problematic for those who already have increased number of cells shedding into their hair follicles and creating plugs. Throw in a few inflamed blemishes and you start to impact the dermal layers of the skin where blood supply and collagen reside. UV exposure to tissues in this highly vulnerable state can result in lingering post-inflammatory erythema (the small areas of redness that most people think of as acne scars), long-term damage to the melanocytes, which can lead to hyperpigmentation (uneven browning of the area), and/or deterioration of the collagen cushion, which can play a role in how quickly and completely the skin recovers from acne lesions. Seasonal changes often create unique challenges, with studies2 showing natural circadian rhythms of spiking testosterone production (and therefore sebum production) in the fall months, which can translate into more active blemishes for those acne-prone individuals sensitive to hormonal fluctuations. Climate can also play a role, with heat and humidity causing more oil and sweat production. Acne bacteria thrive in these conditions, feasting on the increased sebum and causing irritation and inflammation in the pores. Poor air quality, such as the smoke-laden air we’ve experienced from forest fires here in British Columbia during the last few summers, also impacts the skin. Nutrients and resources may be diverted away from normal functions or healing processes and called into action to combat the increased oxidative stress created by environmental pollution, leaving the skin vulnerable to acne flare ups.


Prescription, over-the-counter, and recreational drugs alike can cause or aggravate acne. Marijuana is one of the most common culprits because it first raises, then lowers testosterone levels. This hormonal fluctuation can aggravate acne in those already at risk. Topical and systemic steroids are obvious offenders. Frequently, the anabolic steroids that athletes use for perfomance enhancement are synthetic modifications of testosterone. Extra testosterone translates into increased sebum production and food for P. acnes bacteria. Many body-builders suffer from acne flare ups and should be made aware that steroid abuse can be at fault.


Most acne experts agree that diet plays a subtle role in acne, but perhaps not the one that most people assume. Chocolate, pizza, and other junk food do not directly translate into blemishes. It is only when individuals are already acne-prone that certain food sensitivities can aggravate the condition.3 One of the main culprits that shows some correlation to increased acne breakouts is excess iodine/iodides in foods. While an important trace element for thyroid health, iodine/iodides have the ability to enhance inflammatory reactions, which can influence the severity of acne breakouts and lead to acne-like eruptions. Sources of iodine include the obvious iodized table salt, as well as sea-based foods like kelp snacks, nori-wrapped sushi, and seafood. (It is likely the iodized salt in pizza, chips, and fast food that triggers post-binge breakouts for some.) Even certain vegetables contain naturally occurring iodides, like asparagus, broccoli, and onions. Dairy products such as milk, cheese, and butter contain levels of iodine that should also be taken into consideration for acne-prone individuals. One can also check labels of vitamins and health supplements for hidden sources of iodine.


It of course has to be said that skin care formulas and cosmetics can contribute to acne. From ingredients that directly clog pores (‘comedogenic’), to others that irritate already vulnerable follicles, topical preparations are one of the first things most estheticians take into consideration when addressing acne. Even some medications prescribed for treating acne can contain comedogenic ingredients. Additionally, just because a product claims to be non-comedogenic does not mean that it won’t cause problems for certain individuals. Awareness and diligence in reading entire product labels is one of the first steps in controlling acne.


We’re all guilty of it. We feel an impaction develop and we can’t keep our fingers away from it. The more we fuss with it, the worse it usually gets. So whWith at’s the story there? Remember the stages of blemish formation? When improper extraction techniques put the wrong pressure around a blemish, instead of forcing the intended extraction out of the skin, the pressure causes the already vulnerable hair follicle to rupture downwards. This triggers the body’s inflammation response, guaranteeing development of an inflamed, aggravated papule or pustule. Picking and scratching at your skin can lead to larger wounds and scabs, which require time and resources to heal properly. Chronic picking can lead to significant scarring and often exacerbate self-esteem issues.

Controlling Your Acne

With so many internal and external factors playing a role in acne formation, it’s no wonder that acne is so difficult to get under control. However, with awareness and attention, these factors can be mitigated or avoided. This is why we stress customized, personalized skin routines and care for acne-prone skin. In next week’s blog post, we take a look at a variety of strategies to compensate for and improve many of the elements that can contribute to acne breakouts. Stay tuned!


  1. Danby, F. William, (2007). “Acne and iodine: Reply.” Journal of the American Academy of Dermatology Volume 56, Issue 1 , 164 – 165.
  2. Stanton, S. J., Mullette-Gillman, O. A., & Huettel, S. A. (2011). Seasonal variation of salivary testosterone in men, normally cycling women, and women using hormonal contraceptives. Physiology & Behavior104(5), 804–808.
  3. Goulden, Mcgeown, and Cunliffe, (1999), The familial risk of adult acne: a comparison between first‐degree relatives of affected and unaffected individuals. British Journal of Dermatology, 141: 297-300.
  4. Pappas, Apostolos, (2009). “The Relationship of Diet and Acne: A Review.” Dermato-endocrinology 1.5: 262–267.
Disclaimer: The information we provide on this site is for general use as an information resource only and is not to be used or relied on for any diagnostic or medical treatment purposes. Be sure to talk to a healthcare professional before making medical decisions.
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