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Acne forms over the course of several weeks and through a series of complex events in the skin. The pimple that you see on your chin as if it appeared overnight, has in fact been hard at “work” below the surface of your skin for weeks before you see it. Below I’ll describe the entire process of how acne forms.
Acne begins its life in the hair follicle or pilosebaceous unit. This unit consists of the hair follicle itself and an attached sebaceous gland which produces sebum or oil. There are three types of hair follicles: vellus, terminal, and sebaceous. In the first two types of follicles the hairs (though at different stages of development and appearance) fit closely into the follicles which is to say that the diameter of the growth channels are the same as the hairs themselves. Because of this tight fit there isn’t room for debris or sebum to remain in the follicle and subsequently form a pimple. But what then happens in the sebaceous follicles? The hairs in those follicles are small and frail leaving more than enough room for debris and sebum to accumulate and get stuck there. These sebaceous follicles are concentrated on the face, neck, shoulders, upper chest, and back subsequently explaining why these are the areas where people experience breakouts. Furthermore, these follicles are largest and most numerous on the face.
People who are prone to acne tend to produce abnormal amounts of sebum; this production of sebum is triggered by hormones known as androgens. There are different types of androgens but the significant one in terms of acne breakouts is testosterone which circulates in the body via the bloodstream and reaches the hair follicles that way. In the hair follicle an enzyme changes the testosterone into a chemical called dihydrotestosterone, or DHT for short, which then signals the sebaceous glands to start producing sebum. Just because you suffer from oily skin or acne does not necessarily mean you suffer from a hormonal imbalance or an overabundance of DHT. Typically it just means that your sebaceous glands are very sensitive to the above mentioned hormones and then your oil production becomes excessive.
Yet even if you have oily skin you might never breakout and even people with dry skin can breakout. So how does that happen? The main cause of acne are comedones or blocked pores. The pores or openings that lead down into the sebaceous glands are the issue here. Comedones are formed when something goes wrong with the skin cells lining the follicular channel. If the skin processes are working normally then the sebaceous glands are continually expelling dead skin cells or keratinocytes onto the surface of the skin along with the normal flow of sebum. But this process can malfunction and two things can happen – the follicle can actually step up its production of keratinocytes thus creating a huge amount of debris or dead skin cells and then secondly, that excess amount of cells stick together much like if they were cement. So instead of leaving the follicle as they should these dead cells remain where they are and mix together with the sebum already in the follicle. This produces a microcomedo. Doctors call these microcomedones “precursor lesions” to acne, and if you suffer from acne your skin is full of them. The microcomedones take about six to eight weeks to form and by the end of that time period enough dead cells and oil have accumulated in the follicle in order to produce a closed comedone which feels like small bumps on your skin (you can see them as well). This closed comedone can mature into what is known as an open comedone or a blackhead. As it grows the comedone presses the pore open at the surface, and then the accumulated oil and dead cells oxidize turning black. Some sources say that the skin pigment melanin is what accumulates at the top of the pore and turns black. Blackheads can grow to anywhere between 2 to 5 millimeters and remain in place for months and even years. Inside the follicle of a blackhead cell production slows down considerably and the sebaceous glands all but stop secreting oil. Another form of a comedone is a whitehead which like a blackhead in that the pore is filled with oil and dead cells. But unlike a blackhead the accumulation takes place beneath the surface of the skin and the mixture of materials does not oxidize. People who have what is called non-inflammatory acne suffer
