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 worse than they were at 16. Whether you’re seeing whiteheads on your forehead or deep, painful cysts along your jawline, understanding what’s really going on under your skin is the first step to fixing it. Not all acne is the same. And not all treatments work for every kind. This isn’t about scrubbing harder or buying the most expensive serum. It’s about matching the right treatment to the right type of acne-and knowing when to go beyond the bathroom cabinet.

What Actually Causes Acne?

Acne starts deep inside your pores. Your skin naturally sheds dead cells, and your sebaceous glands make oil (sebum) to keep things lubricated. In acne-prone skin, those dead cells stick together and mix with excess oil, clogging the follicle. Then comes the bacteria-Cutibacterium acnes-that thrives in that blocked, oxygen-poor environment. The body reacts with inflammation, and boom: a pimple forms.

But why does this happen to some and not others? Hormones are the main driver. During puberty, androgens spike, telling your oil glands to go into overdrive. That’s why 85% of teens get acne. But it doesn’t stop there. In adult women, hormonal shifts during periods, pregnancy, or menopause can trigger deep, tender cysts around the chin and jaw. Insulin spikes from sugary diets or insulin resistance can also ramp up oil production. Genetics play a role too-if both your parents had bad acne, your risk jumps by 50%.

Other triggers? Tight clothing, helmets, phone screens, greasy hair products, and certain meds like lithium or steroids. Even stress can make it worse by increasing cortisol, which nudges your oil glands into overdrive.

The Six Main Types of Acne (And How to Spot Them)

Not all breakouts are created equal. Treating a blackhead the same way you treat a cystic acne flare-up is like using a bandage for a broken bone. Here’s what you’re really dealing with:

• Comedonal acne: Whiteheads (closed pores) and blackheads (open pores). These aren’t red or painful-they’re just clogged. Blackheads look dark because the oil and dead skin oxidize when exposed to air. Whiteheads stay under the skin, forming small, flesh-colored bumps.
• Inflammatory acne: Papules (tiny red bumps) and pustules (red bumps with white pus). These are tender, inflamed, and often appear in clusters. They’re the result of the clogged pore bursting and triggering your immune system.
• Nodular acne: Hard, painful lumps deep under the skin. These don’t come to a head. They’re larger than papules and can last for weeks.
• Cystic acne: The most severe form. Large, soft, fluid-filled cysts that are extremely painful and prone to scarring. Often hormonal.
• Hormonal acne: Not a separate type, but a pattern. Deep cysts or papules that appear monthly around the chin, jaw, and neck. Common in women 25-45. Often flares before periods.
• Fungal acne (pityrosporum folliculitis): Looks like acne but is caused by yeast overgrowth. Small, itchy, uniform bumps on the chest, back, and sometimes face. Doesn’t respond to regular acne treatments.

Most people have a mix, but one type usually dominates. If your breakouts are mostly on your forehead and nose, you’re likely dealing with comedonal or mild inflammatory acne. If you’re getting deep, painful lumps under your skin, especially around your jaw, hormonal or cystic acne is probably the culprit.

Topical Treatments: What Actually Works

For mild to moderate acne, topical treatments are the first line of defense. They work right where the problem starts-on your skin. But not all creams and gels are equal.

Benzoyl peroxide (2.5-10%) kills acne bacteria and reduces inflammation. Studies show it cuts C. acnes by 90% in four weeks. Start with 2.5%-higher strengths don’t work better, but they irritate more. Brands like Clean & Clear and Neutrogena On-the-Spot use this as their main ingredient.

Salicylic acid (0.5-2%) is a beta-hydroxy acid that dissolves oil and exfoliates inside pores. Great for blackheads and whiteheads. It’s in many drugstore cleansers and toners. Results take 6-8 weeks, but it’s gentle enough for daily use.

Retinoids like tretinoin (prescription) and adapalene (Differin, over-the-counter) are game-changers. They don’t kill bacteria-they fix the root problem: clogged pores. Retinoids speed up skin cell turnover so dead cells don’t stick together. In clinical trials, they reduce inflammatory lesions by 70% in 12 weeks. But they cause purging-your skin might get worse before it gets better. Stick with it. Most people see real improvement after 8-12 weeks.

Combination treatments like benzoyl peroxide + clindamycin (an antibiotic) are more effective than either alone. They clear up inflammatory acne faster and reduce the chance of antibiotic resistance. Products like BenzaClin and Epiduo (adapalene + benzoyl peroxide) are commonly prescribed.

For fungal acne, regular acne products won’t help. You need antifungal treatments-ketoconazole shampoo used as a face wash, or oral antifungals like fluconazole.

Oral Treatments: When Topicals Aren’t Enough

If your acne is moderate to severe-deep nodules, cysts, or widespread breakouts-you’ll likely need oral medication. These work from the inside out.

Antibiotics like doxycycline and minocycline reduce inflammation and kill bacteria. They’re often used for 3-6 months. Studies show 50-70% improvement. But here’s the catch: 25% of people develop antibiotic resistance after long-term use. That’s why they’re not meant to be lifelong solutions. They’re a bridge-to get you to a point where you can switch to something else.

Oral contraceptives (birth control pills) are a top choice for women with hormonal acne. Pills containing ethinyl estradiol and a progestin like drospirenone (Yaz, Beyaz) lower androgen levels. Clinical data shows 50-60% reduction in breakouts after 3-6 months. Side effects? Nausea, mood changes, and a small increased risk of blood clots. Not for everyone.

Spironolactone is a diuretic that blocks androgens. It’s not FDA-approved for acne, but dermatologists prescribe it off-label for women with stubborn hormonal breakouts. Studies show 40-60% improvement after 3 months. Side effects include dizziness, increased urination, and menstrual changes. About 1 in 3 women stop taking it because of these.

Isotretinoin (Accutane) is the nuclear option. It shrinks oil glands, reduces bacteria, and prevents clogging. For severe cystic acne, it clears 80-90% of cases. Sixty percent of people never have acne again after one course. But it’s not simple. It causes extreme dryness, mood changes, and birth defects. Women must use two forms of birth control and sign a strict consent form. Blood tests are required monthly. It’s not a first-line treatment-but for those with scarring, it’s life-changing.

What Doesn’t Work (And Why)

There’s a lot of noise out there. Tea tree oil? It’s got some antibacterial properties, but clinical trials show it’s only 40% as effective as benzoyl peroxide. Zinc supplements? A few studies show a 25% boost when added to conventional treatment, but alone? Not enough. Aloe vera? Soothing, yes. Healing? No. Charcoal masks? They pull out surface dirt, but they don’t touch what’s happening deep in your pores.

And don’t fall for the “natural acne cure” hype. Acne isn’t caused by toxins you need to detox. It’s a biological process driven by hormones, bacteria, and genetics. No juice cleanse or essential oil will fix that.

How Long Until You See Results?

Patience isn’t optional-it’s essential. Topical treatments take 6-8 weeks to show real change. Oral meds? 2-3 months. Retinoids? You might get worse before you get better. That’s called purging. It’s your skin clearing out old clogs. It’s not a reaction to the product-it’s the product working.

Here’s the hard truth: 70% of people quit too early. They see no change at week 3 and give up. But if you stick with it, your odds of clearing up double. Consistency matters more than intensity. Twice-daily application, gentle cleansing, and sunscreen (yes, even if you’re acne-prone) are non-negotiable.

Cost, Access, and What’s Coming Next

The global acne market hit $5.4 billion in 2023. Most of that is spent on topical products. But prescription treatments are growing fast. New drugs like Winlevi (clascoterone), a topical androgen blocker, are showing 60% adherence rates-higher than older creams. Why? Fewer side effects and better results.

But access is a problem. In the US, the average wait for a dermatologist is 3-6 weeks. In the UK, NHS wait times can be even longer. And newer treatments like Winlevi cost $650 a month without insurance. That’s out of reach for many.

The future? Personalized acne care. AI tools that analyze your skin via smartphone photos are already in development. In the next five years, you might get a treatment plan generated by an algorithm trained on millions of acne cases. Microbiome therapies-targeting the skin’s good and bad bacteria without wiping everything out-are in clinical trials. This isn’t sci-fi. It’s coming.

What to Do Now

Start by identifying your acne type. Take a photo of your breakouts. Note where they are and how they feel. Are they deep and painful? Around your jaw? That’s likely hormonal. Are they blackheads on your nose? That’s comedonal.

For mild cases: Try adapalene gel (Differin) at night and a 5% benzoyl peroxide wash in the morning. Be consistent for 12 weeks.

For moderate to severe cases: See a dermatologist. Don’t wait. Delaying treatment increases your risk of scarring by 40%. If you’re a woman with hormonal acne, ask about spironolactone or birth control. If your acne is cystic and hasn’t responded to anything else, isotretinoin is worth discussing.

And skip the Instagram hacks. Your skin doesn’t need a 10-step routine. It needs the right treatment, applied consistently, and enough time to work.