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Why Do Adults Still Get Acne? · So That's Why

0:04
Jen Oliver: Welcome to the So That's Why podcast where we unpack the
0:07
science behind everyday questions.
0:09
I'm Jen.
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Chris Smith: I'm Chris.
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Matt Edmundson: And I'm Matt.
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Jen Oliver: So today's question is one that captures a lot of people
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off guard because most of us assumed we'd left this behind in our teens.
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Why do adults still get acne?
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Matt Edmundson: Now we're talking about acne because apparently the
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universe has decided that mortgages back pain and reading glasses are just
0:32
not enough of a package deal for us.
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Chris Smith: And the frustrating thing is that when it does reappear, there's
0:38
often a sense of shame around it.
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Like it shouldn't still be happening.
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Surely, which can get in the way of people actually treating it effectively.
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Jen Oliver: Yeah.
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So today we are gonna answer why adult acne is so common.
0:49
What's happening under the skin when a breakout appears, and what the
0:53
evidence actually says works for treating it when you are no longer 16.
0:59
Matt Edmundson: Yeah.
1:00
And I'm gonna be straight with you.
1:01
I assume this was just a hormone thing.
1:04
And we'd be done in this episode in about four minutes time.
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But a spoiler alert, apparently it's not just a hormone thing and the episode will
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be slightly longer than four minutes.
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Chris Smith: Well, hormones are certainly evolved, but you are right.
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There's a lot more to it than just hormones.
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Jen Oliver: But before we dig into the adult specific picture, it's worth
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us being clear, isn't it, about what acne actually is, because most people
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think of it as just spots without.
1:27
Understanding what's driving them.
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Chris Smith: Yeah, so acne or acne vulgaris to give its full name
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is an inflammatory condition that affects the hair follicles and
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their attached sebaceous clans.
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These are the oil glands in your skin.
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So it's not a surface issue.
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It starts inside that hair follicle.
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Jen Oliver: And it's quite complex, isn't it?
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Would you believe four specific processors all have to align
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for a breakout to develop?
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So the first is excess seran production, so your oil glands over overproduce
1:58
under the influence of androgens, which are hormones like testosterone
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that both men and women have.
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Chris Smith: Yep.
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And the second is what we would consider to be a. Abnormal skin
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cell shedding inside that follicle.
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So our skin does shed naturally, uh, but something's going wrong here.
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And crucially, those cells we're trying to, shed become more sticky
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and rather than clearing out, normally they accumulate and block the pore.
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Matt Edmundson: So the follicle gets blocked from the inside, not
2:26
the outside, which would explain why just washing your face, uh.
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It doesn't really sort of fix it.
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Jen Oliver: Exactly.
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And once that blockage forms, which it's called a comedone, the
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third factor kicks in, and that's a bacterium called cutie bacteria acnes.
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It's probably not cute.
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Matt Edmundson: I was gonna say it's cutie bacteria,
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Jen Oliver: probably the bane of most people's lives.
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But anyway, or C acnes for sure.
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And that grows rapidly in that oxygen pore oily environment of the pore.
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Chris Smith: Um, and as if that wasn't enough, there's a fourth
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piece, which is your immune system responded to that blockage and to
3:01
the bacteria with inflammation.
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And that inflammatory response is what creates the redness, the swelling,
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and the pain of that visible spot.
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Matt Edmundson: So like you say, four separate things going wrong at once.
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Like the stars have aligned.
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I guess it's like a project, isn't it?
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Without a project manager, everyone's doing their own thing and the outcome
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just seems to be mayhem and chaos.
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Jen Oliver: Which it is actually, that's actually a pretty good summary of it.
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And the reason it's so common.
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So studies suggest that up to 50% of women in their twenties experience
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acne with significant numbers climbing into their thirties and forties.
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Chris Smith: Now something for our fact fans.
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Jen Oliver: You mean you're gonna bust a myth?
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Matt Edmundson: Oh, here he comes, captain MythBuster again.
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Chris Smith: Absolutely.
3:45
So I mentioned earlier about sticky dead cells blocking
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the pores, but did you know.
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The concept of pores, opening and closing is one of the
3:53
biggest myths in skin science, or should I say skincare marketing.
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So pores do not open and close what I know, they aren't like little
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trap doors with muscles that make them open and close on demand.
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Matt Edmundson: Are you sure?
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So all the times like I've seen skincare products or treatments claim
4:11
to open pores or said to myself that even exercise may be opens, pores.
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It's just not true.
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So how come then if that is true, Mr. Chris?
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And I'm not denying that that is true.
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Uh, how come pores are sometimes more visible than other times?
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Um, I thought that's because they were sometimes more open.
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Jen Oliver: So now it's because instead of opening and closing, they dilate contract.
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So the dilated pores.
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Are more visible.
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Chris Smith: Exactly that.
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And dilated pores can be caused by them being clogged.
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Uh, being inflamed or by a loss of skin elasticity or just through age.
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Matt Edmundson: And so cleaner and clearer pores look tighter then.
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Right.
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It doesn't just mean that they're somehow slammed shut.
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Chris Smith: Exactly.
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That.
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So we want pores to contract and be tight and clean.
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Um, 'cause Yeah.
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Looks far better.
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Matt Edmundson: Mm-hmm.
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Chris Smith: I do apologize.
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I kind of took us off on a bit of a, a tangent there
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Matt Edmundson: that's unlike you Chris.
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Chris Smith: I, I know I'm, yeah, apologies.
5:11
Um, so we were talking about, I think we were talking about the four
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processes that contribute to acne.
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So there was excess sebum production, uh, the skin not shedding
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properly and clogging those pores.
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Um, the commo formation, as Jen mentioned, and then the skin's inflammatory response.
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The important thing to point out here is that.
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Those processes are identical in teenagers or adults.
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So the difference is what triggers them in adult life, because the driving
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forces shift considerably beyond puberty.
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Jen Oliver: So the biggest adult specific trigger is changes in hormones.
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And even though changes in hormones are often behind teenage acne in adults,
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it's the irregular shifts that cause the problems, particularly the drops
5:54
and the spikes, rather than like the steady high that's seen in puberty.
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Chris Smith: Yeah.
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And for women, um, the most common pattern is cyclical.
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Acne.
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So it's tied to the menstrual cycle.
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So specifically the days before menstruation when progesterone
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falls, but androgen activity, those sex hormones such as testosterone,
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they remain relatively elevated,
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Jen Oliver: and that shift alone can boost the sebum and production and cause
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the skin cells in the follicle to shed faster, which is why so many women see
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breakouts popping up in the same place at roughly the same point in their cycle.
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Matt Edmundson: And by same place you mean specifically the jawline and lower face?
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Chris Smith: Yeah.
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Almost always because, um, that pattern is so, in fact, that pattern is so
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consistently recognized that persistent lower face acne in adult women is
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now treated as a hormonal flag in dermatology, not just a skin issue.
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Jen Oliver: And it's just delightful being a woman.
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Perimenopause is another window where.
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It becomes significant 'cause estrogen levels drop, but the androgen
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activity that still remains high.
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And so that shifts the hormonal balance in a way that reactivates
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those sebaceous gland activity.
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Um, and that might have been, your skin might have been clear for years.
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Matt Edmundson: So you spend your twenties then dealing with hormonal acne, your
7:15
thirties finally getting on top of it.
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And then perimenopause seemed to say, why not so fast?
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Jen Oliver: Yeah,
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Chris Smith: I know.
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It's just not fair, is it?
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Let's be honest.
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Yeah, no, I agree.
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It genuinely is quite common.
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Um, and then the stress on top of everything else, which operates through
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a completely separate pathway, but is a massive contributor to adult acne.
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Jen Oliver: Yeah, cortisol, which is your primary stress hormone, and
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that's getting a lot of press lately, that directly stimulates the sebaceous
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glands to increase sebum production.
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But research has shown that by itself, it drives inflammation in the skin.
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So the effect is actually two pronged.
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Chris Smith: Yeah, and I suppose you can think of it of less of a case of,
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um, stress creating acne from nothing.
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A more like stress lowering the threshold at which everything that was already
8:00
kind of quietly ticking over tips over the edge into a full on breakout.
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Jen Oliver: It's just great.
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But research, it's also shown that psychological stress ramps up the
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pro-inflammatory cytokine activity in the skin, even without changes in sebum.
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So it's not just about oiliness, it's how your immune system reacts,
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Matt Edmundson: Which probably explains the timing then, doesn't it?
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The spot that appears the morning before something important
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has been in the pipeline, uh, longer than we seem to think.
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Jen Oliver: Mm-hmm.
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Chris Smith: Absolutely.
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And then we've got diet.
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So diet is the third major adult driver and the mechanism
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here runs through blood sugar.
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So high glycemic foods being white bread, sugary drinks.
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Refined carbohydrates.
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You know, the things we all kinda like.
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They cause this rapid insulin spike, which in turn elevates a hormone called IGF one.
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Matt Edmundson: IGF one.
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Sounds like mission impossible
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Jen Oliver: for us.
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It does.
8:52
It does.
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It's definitely a weapon of the MythBuster.
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Matt Edmundson: Done, should pun done.
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Done.
9:00
10.
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Jen Oliver: So I'll help you out here, Chris.
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IGF one is insulin growth factor one, and that directly stimulates the sebaceous
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glands and speeds up the abnormal shedding of the cells in the skin follicle.
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Um.
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There was a review in 2023 and they found a consistent link between
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high glycemic diets and acne severity, especially in adult women.
9:24
Chris Smith: Yeah.
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And um, dairy is worth mention here too, so the association is less consistent
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across studies, but some research points to the insulin and growth
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factor content of milk as a potential contributor for certain individuals.
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Matt Edmundson: So a, a meal deal then with your white bread, your sugary drink.
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A yogurt is not just, it seems a nutritional compromise, but also
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potentially having a conversation with your sebaceous glands that
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you didn't really ask it to have.
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Jen Oliver: Yep.
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And that's, we're not even counting what you put on your skin.
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So that's just what you put in you, in your body.
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Um, acne cosmetica is actually a real thing.
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So breakouts that are triggered or worsened by skincare and makeup,
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and that's things like heavy creams, sun, sun, cream formulas, and certain
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foundations can actually block the follicles and lead to comedones.
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Chris Smith: Yeah.
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And of course that could be particularly frustrating because people often
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reach for more skincare in response to acne without checking whether
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the products they're actually using are already part of the problem.
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Jen Oliver: Mm-hmm.
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Matt Edmundson: Yeah.
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So who does this actually affect then?
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Um, and does it look the same across different people?
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Jen Oliver: So it's definitely not uniform.
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There was a large epidemiological study across multiple countries,
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and they found that adult acne affects women at a significantly
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higher rate than men overall.
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Um, and adult onset acne, meaning like new breakouts that
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started after the age of 25.
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With no teenage history is considerably more common in women than in men.
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Great news for us women
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Chris Smith: I know, and in by contrast, when it comes to men, men are more likely
11:01
to have persistent acne that's continue from adolescents without fully clearing.
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So it's driven by constantly higher androgen levels, and it tends to persist
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as more severe when it does persist.
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Matt Edmundson: So men, fewer acne episodes, but going for maximum
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impact when they do occur seems to be the, seems to be the consensus.
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Jen Oliver: Yeah.
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Essentially, yes.
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And for women, it's just another joy for women, there's a specific condition that
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amplifies that pattern significantly, and that's polycystic ovary syndrome,
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which is actually quite common, POS.
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And that involves chronically elevated androgen levels that
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drive acne, that's persistent.
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It's often more cystic, and it frequently doesn't really respond
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to like your standard topical treatments without addressing.
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The hormonal picture underneath.
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Chris Smith: Yeah.
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And that's so important because you know, if you are experiencing a series
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of breakouts that don't shift even after several months of consistent treatment,
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it's well worth the conversation with your doctor to investigate whether
12:02
something systemic is going on.
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Matt Edmundson: So what about the idea then that acne means your skin is dirty?
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'cause I, this one.
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It still makes a rounds for me.
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Jen Oliver: I feel like, I feel like Captain MythBuster should join
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in now, but I'll be a sidekick.
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We need a name for that, but it's,
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Matt Edmundson: he could be Madam
12:22
Jen Oliver: MythBuster.
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Be Madam MythBuster
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doesn't sound quite as heroic,
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Chris Smith: does it?
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Pen like an alternate Penfold,
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the younger viewers?
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No idea.
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No
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Matt Edmundson: idea what we're talking about.
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Jen Oliver: Well actually your skin being that dirty, that's
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completely without biological basis.
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So the four processes we described are all happening inside the follicle,
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the excess oil, the sticky cells, the bacteria, the immune response, none
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of which are driven by surface dirt.
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Chris Smith: Absolutely right.
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And in fact, over washing and harsh scrubbing of the
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skin strips away its barrier.
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It also increases inflammation, um, and it can worsen the very condition
13:01
that people are trying to treat.
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So the evidence consistently points to gentle kind of twice
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daily cleansing as the best route.
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Matt Edmundson: Okay, so the person in scrubbing their face three or
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four times a day, which is what I did when I was a teenager.
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Um.
13:15
They're making their skin worse, and if they are, they're not imagining it, right?
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Jen Oliver: No, they're generally make, genuinely making it harder
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for their skin to regulate itself.
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So once the skin barrier is compromised by like the excessive
13:28
washing, the inflammatory response can become more pronounced, not less.
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Chris Smith: That's right.
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So if we look at beyond standard skincare, what does treatment actually look like?
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Um, for mild to moderate adult acne, there are three over the counter
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actives with genuinely solid, uh, evidence behind them aren't there?
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Jen Oliver: Yeah.
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So there's benzoyl peroxide and that targets that.
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C Acnes, we talked about targets that The cutie one.
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The cutie one, yeah.
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Yeah.
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Not so cute.
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In this state, in this case, the cutie one, it targets that directly
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and has an anti-inflammatory action.
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And then salicylic acid, you often see that in skincare products that dissolves
14:06
the bonds between the abnormal sticky skin cells in the follicle, helping to
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break down the blockage and clear it.
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And then there's also, um, a retinoid now available without
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prescription in many countries.
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And that normalizes follicle cell turnover at the source
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Matt Edmundson: and, okay.
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That's all very helpful.
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But is there any particular order or priority there, or is
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it just pick one and see Chris?
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Chris Smith: Well, I'd say as a general rule, starting with one at a time is
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really important because introducing multiple active simultaneously makes
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it impossible to know which is working.
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And the combination can cause significant irritation to already very
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inflamed skin, especially if you've got a kind of sensitive skin type.
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Jen Oliver: And I think the single most important thing to understand about
14:51
topical treatments is the timeline.
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So most of them require a minimum of about six to eight weeks for any noticeable
14:58
improvement, and three months really to properly evaluate its effectiveness.
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Matt Edmundson: Six to eight weeks, which is.
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Roughly four times longer than I. Most people, including me, give
15:10
anything before declaring this thing doesn't work in ordering three new
15:13
products at midnight on Amazon, right?
15:15
Jen Oliver: Yeah.
15:15
We've all been there.
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Chris Smith: Uh, totally.
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And of course that, I mean, that is the single biggest reason, isn't it, that,
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uh, treatments get abandoned because before they've had a chance to work,
15:23
people are kind of moving on already.
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And the thing to remember here is there are multiple things at play,
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including calming your own skin, your skin's own inflammatory responses.
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So.
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Treatments are never gonna be a quick fix.
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Um, it's really important to keep in mind though, that for those who have
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stuck with it and tried products for long periods of time, you know the
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the time they're recommended for.
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If you're not seeing successful changes, then prescription options are available
15:47
and it may be time to talk to your doctor.
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Jen Oliver: Yeah, in some prescriptions they include like stronger topical
15:53
retinoids or antibiotic combinations to reduce bacterial resistance and systemic
16:00
treatments like certain birth control pills that try to address the issue added
16:04
source rather than just on the surface.
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Matt Edmundson: Okay, so when, so when should uh, someone stop
16:12
managing this themselves and actually search out, say a dermatologist?
16:16
Chris Smith: So I think if that acne is leaving, um, scarring or dark
16:20
marks, which is technically post, um, inflammatory hyperpigmentation, that's
16:26
a reason to escalate rather than weight.
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And the same applies if consistent, like over the counter product use
16:31
for two to three months hasn't made a dent in the problem at all.
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Jen Oliver: And actually as well don't underestimate the psychological impact.
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So research has shown that acne in adults significantly affects people's
16:43
quality of life, their self-esteem.
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And you know, that alone is a legitimate reason to seek proper support and not just
16:50
to push so through something on your own.
16:52
Matt Edmundson: Yeah, absolutely.
16:53
And something here that strikes me having worked through all of this is acne.
16:58
I guess it doesn't feel like a, a skin condition as such.
17:01
Once you understand it, it's more like a skin symptom.
17:04
Of things happening elsewhere.
17:06
Jen Oliver: Mm.
17:06
Chris Smith: That's actually a really useful framing.
17:08
Matt Edmundson: Thanks, Chris.
17:09
Chris Smith: Um, I shouldn't sound surprised by the way.
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Jen Oliver: Well done Matt.
17:13
Chris Smith: Absolutely.
17:14
Pat on the back.
17:14
Yeah.
17:15
And that point for a Tuesday.
17:17
Um, but yeah, the skin is a visible output.
17:21
The visible output, but the inputs, the hormones, the
17:24
cortisol that Jen mentioned, the.
17:26
Blood sugar, the inflammation, they are whole body processes.
17:29
And the skin is of course the body's largest organ, but
17:32
it's also the one we can see.
17:34
So it can reflect things going on elsewhere in the body.
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It's basically the visible thing.
17:38
Mm-hmm.
17:40
Jen Oliver: And those are the threads that run through a lot of what we've
17:42
discussed in other episodes, isn't it?
17:44
Cortisol dysregulation, blood sugar spikes, systemic inflammation.
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They've all, they've all downstream effects across
17:52
multiple systems and the skin is.
17:55
One of the more visible places that registers them.
17:58
Chris Smith: Absolutely.
17:59
And ski, uh, sleep is a really good example.
18:02
I know we always talk about sleep
18:04
Jen Oliver: with
18:05
sleep champions.
18:05
Chris Smith: Absolutely.
18:06
Um, but poor sleep elevates cortisol directly and that cortisol then
18:10
feeds into both sebum production and cellular inflammation.
18:15
Um, it's another area where sleep quality has a knock on effects that
18:18
people don't necessarily expect.
18:20
Mm,
18:20
Matt Edmundson: yeah.
18:21
We do like to talk about sleep on this podcast.
18:23
Um, and it's interesting, isn't it, because poor sleep then is
18:25
quietly implicated it seems in, in everything, and at some point.
18:30
We're gonna have to accept maybe that get more sleep as a lifestyle
18:33
tip and a more fundamental, uh, biological requirements that we're
18:37
all maybe collectively ignoring.
18:38
I don't know.
18:39
Mm-hmm.
18:39
Jen Oliver: Yeah.
18:40
No, I like sleep.
18:42
Matt Edmundson: Sleep is good.
18:43
We should change the name of the podcast.
18:45
Sleep is Good podcast.
18:47
Jen Oliver: Yeah, I know.
18:47
'cause it, it fits into everything we chat about, but we talked about diet before.
18:53
And the diet piece connects back to that too.
18:55
You know, blood sugar and insulin response pathway that affects acne
18:59
is the same pathway talked about on the food cravings episode.
19:03
And these mechanisms, they don't operate in isolation.
19:06
They're part of the same metabolic picture.
19:08
Chris Smith: Yeah, which is actually good news, right?
19:11
Because the lifestyle factors that support skin health are largely the same ones that
19:15
support a lot of other health outcomes.
19:17
So there's nothing niche or complicated being required here.
19:20
Jen Oliver: Okay.
19:21
So why do adults still get acne?
19:24
Chris Smith: So adults still get acne because the four biological
19:27
processes behind acne being excess, sebum production, um,
19:31
abnormal skin cell, shedding in the follicle, bacterial overgrowth,
19:35
and immune driven inflammation.
19:38
Don't stop being possible just because puberty ends, they get
19:41
reactivate throughout adult life by things like, um, hormonal shifts,
19:46
uh, cortisol levels, blood sugar fluctuations and environmental triggers.
19:51
Matt Edmundson: And the gap between you should have grown out of this.
19:54
And this is a real well understood physiological process with effective
19:58
treatments is exactly the kind of gap this show, uh, exists to close.
20:05
Jen Oliver: So that's why adult acne is so common, why it has nothing to do
20:10
with hygiene or effort and why matching your treatment to what's actually
20:14
driving it makes such a difference.
20:17
Chris Smith: Yeah.
20:18
And that knowing the mechanism puts you in a much better position
20:20
to do something useful about it.
20:21
Yeah,
20:22
Matt Edmundson: yeah.
20:22
No longer at the mercy of your sebaceous glands and their terrible sense of timing.
20:28
Jen Oliver: So that's it for this week.
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Make sure you hit that subscribe button.
20:32
We're unpacking the science behind everyday questions every week.
20:36
Tell us in the comments what you'd like us to explore next.
20:40
Thanks for geeking out with us, but for now, that's it from me.
20:43
Matt Edmundson: That's it from me,
20:45
Chris Smith: and that's it from me.
20:46
Jen Oliver: Bye for now.