Dr. Alina Sholar Explains When Acne Gets Out of Hand, Look to the Professionals for Help

Doctor or Dermatologist hand exam patient face

Acne is one of the most common skin conditions on the planet. No matter your age, acne can be a regular occurrence in your life. However, that doesn’t make it any less annoying. Few people think that acne deserves professional help, but sometimes it really is the best course of action.

Dr. Alina Sholar is a cosmetic surgeon and skin expert from Austin, Texas. From learning to identify the various root causes and signs of acne to the various treatments available, Dr. Sholar provides her expertise on all things acne.

What is Acne?

First off, Dr. Alina Sholar wants to answer the question, “what is acne?” Although most people have dealt with it, many don’t realize what it is that is actually happening on their skin. Acne Vulgaris (or acne) is a skin disease that can affect people at one time or another during their lives. Typical types of acne include: seborrheic (scaly red skin), comedonal (blackheads and whiteheads), papules (pinheads), pustules (pimples) and nodules (large papules). Acne can be described as a disorder of the skin barrier system and of the pilosebaceous unit (sebaceous follicles). While genetic programming and lifestyle choices certainly play a role in the development of acne, recent research has uncovered a link between the initial formations of an acne lesion, called a comedone, with an essential fatty acid deficiency of linoleic acid within the opening of the hair follicle that make the areas “stickier” and more prone to clogging. On the most basic level, acne is a skin condition that occurs as a result of the hair follicles on your skin becoming plugged by excess oil or dead skin cells. The flow of sebum is controlled by hormones like testosterone and specifically increases when reaching puberty. In case the formation of stratum corneum cells is also increased (hyperkeratosis) the sebum flow around the exits of the sebaceous glands become congested or completely blocked. The sebaceous follicles widen and fill with a mixture of sebum and dead cell residues resulting in the formation of the well-known blackheads, whiteheads, or cysts. Lesions of the sebaceous glands will subsequently lead to irritations of the skin- the perfect environment for anaerobic bacteria to thrive and cause inflammation and infection.

All acne can result in scarring, however in darker skin scarring can be more prevalent. Cystic acne affects the deeper layer of skin tissue more profoundly than common acne and results in more risk of scarring. Aside from scarring, the main effects of cysts or nodulocystic acne tend to be psychological and can result in reduced self-esteem and depression. Acne scars are the result of inflammation within the dermis. They are created by the wound trying to heal itself, resulting in too much collagen in one area. Pigmented scars are usually the result of nodular or cystic acne (the painful ‘bumps’ lying under the skin). They often leave behind an inflamed red mark. Often, pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. Pigmentation scars nearly always fade with time taking between three months to two years to do so, although they can last forever if untreated.

Acne usually appears during adolescence, when teens already tend to be at their most socially insecure. Early and intensive treatment is therefore advocated to lessen the emotional and physical impacts of acne. Topical skin care is only one part of the treatment process. While it is most commonly associated with hormonal teenagers, people of all ages experience acne. Acne generally occurs during adolescence, often continuing into young-adulthood. An increase in testosterone (which accrues in both genders during puberty) is the most common cause. For many people, acne diminishes over time, tending to disappear completely (or at the very least decrease substantially) around our early 20s. However, some will experience acne well into their 30’s and 40’s and can in fact develop acne well into adulthood. It is estimated that 25% of adult men and 50% of adult women will also experience acne at some point in their lives.

Further, acne can pop up all over your body, not just on your face. It is most likely to occur on your face, forehead, upper back, shoulders, and chest.

Acne is classified into four grades according to severity. Specific criteria are used to classify acne symptoms, including:

  • types of non-inflamed comedones present
  • types of inflamed comedones present
  • amount of breakout activity
  • amount of inflammation,
  • areas of the body affected by acne

Assessing the grade of acne by a trained skin treatment therapist or skin physician is an important step in treatment, as all acne grades require different treatment methods. 

Causes of Acne

Now that you know what acne is, let’s consider what causes acne to occur on your skin. Dr. Alina Sholar claims that the main factors that cause acne are as follows: excess sebum production (sebum is the natural oil your skin produces), bacteria, inflammation, or hair follicles being plugged by oil and/or dead skin cells. The reason why acne is so common on your face, upper back, chest, and shoulders is because these areas have the most oil glands out of anywhere on the body. This makes them especially prone to blockage.

All of these factors can happen on their own; however, there are certain triggers that can make acne worse. For example, certain medications, like those containing corticosteroids, testosterone, or lithium can lead to acne. Stress is another important factor. While it can’t cause acne outright, it can make already existing acne worse. Hormonal changes, such as those that both boys and girls go through during puberty, as well as those that women experience during pregnancy or menopause, can lead to breakouts. Typically, hormonal changes can cause the sebaceous glands to become enlarged, which results in greater sebum production. Finally, Dr. Alina Sholar claims that diet can be another trigger for acne. Although she believes that further proof is needed to verify these claims, some studies have indicated that eating foods that are rich in carbohydrates, such as bread, can make acne worse. However, she wishes to debunk the myth that chocolate or greasy food causes acne. Although this has become a popular belief, there is no scientific evidence to support it.

There are also a few risk factors that can make you more prone to acne, including your age (with teenagers being the most likely to suffer from acne), your genes (if your parents had acne, it’s likely you will too), and the substances or pressure that are put on your skin. Regularly applying oily lotions or creams on your skin can cause acne, as can frequent friction or pressure on your skin, such as that caused by wearing a helmet, a tight collar, or a backpack.

Aggravating Factors of Acne

Blocked or compromised follicles

Acne develops as a result of blockages in hair follicles. Hyper-keratinization and the formation of a plug of keratin and an increase in sebum production is the earliest symptom.

Enlargement of sebaceous glands and an increase in sebum production also occur with increased androgen (DHEA-S) production at puberty. The initially small comedones may enlarge to form an open comedone (blackhead) or closed comedone (milia). Comedones are the direct result of sebaceous glands becoming clogged with sebum, a naturally occurring oil, and the accumulation of dead skin cells. In these conditions, naturally occurring Propionibacterium acnes (P. acnes) can cause inflammation, leading to lesions (papules, infected pustules, or nodules) in the dermis around the comedone, which results in redness and can result in scarring or hyperpigmentation.

Comedogenic substances

P. acnes are found naturally within our skin and produce a series of fatty acids with potentially comedogenic and inflammation-inducing effects. Additional substances that can contribute to acne are mineral oils (oil acne), tar (tar acne), chlorinated hydrocarbons (chloracne), drugs (acne medicamenta) and a multitude of cosmetic substances such as lanolin, cetyl alcohol (in a ton of cosmetics and skincare products!), saturated fatty acids and their esters.

Those with sensitive skin should avoid ingredients such as ethoxilated alcohols and polyethylene glycols (PEG’s) as both are used as emulsifiers and solubilisers. With the influence of ultraviolet rays and atmospheric oxygen they develop peroxides which in turn generate aggressive radicals which can cause Majorca Acne.

Given these substances are widely used in many cosmetic products, the skin treatment therapist and educated consumer is advised to carefully study the ingredient list on products before prescribing products to treat acne. Even sun protection products can contain these harmful substances. Ethoxilated alcohols can be recognized on the ingredients listing either by their middle or final syllable (-eth), eg. Ceteareth-10. 


Hormonal activity, such as alterations in menstrual cycle and puberty, may contribute to the formation of acne. During puberty, an increase in male sex hormones called androgens (occurs in both males and females) causes the follicular glands to grow larger and produce more sebum. Use of anabolic steroids may have a similar effect. Acne associated with menopause occurs as production of the natural anti-acne ovarian hormone Estradiol ceases to be produced at the onset of menopause. The lack of Estradiol can also cause thinning hair, hot flashes, thin skin, wrinkles, vaginal dryness, and can trigger acne (known as Acne Climacterica in this situation).

Development of acne vulgaris in later years is uncommon, although this is the age group where Rosacea can occur. Indications of Rosacea are often confused with acne as they can present with similar symptoms. 


The tendency to develop acne can run in families. A family history of acne is associated with an earlier occurrence of acne and an increased number of retentional acne lesions.


While the connection between acne and stress continues to be debated, scientific research indicates that “increased acne severity” is “significantly associated with increased stress levels”. The National Institute of Health lists stress as a factor that “can cause an acne flare.” A study of adolescents in Singapore “observed a statistically significant positive correlation between stress levels and severity of acne.” Adrenal stress stimulates the body to produce cortisol and adrenalin. These hormones trigger changes in the skin, such as increased oil & sebum production.


Bacteria in the pores, Propionibacterium acnes (P. acnes) is the anaerobic bacterium that causes acne. Resistance of P. acnes to commonly used antibiotics has been increasing.


A high glycemic diet and regular ingestion of cow’s milk have been associated with worsening acne.

Look out for these things that can lead to acne.

  • UV exposure
  • Incorrect skincare
  • Poor quality and composition of makeup and cosmetics
  • Over-use of fruit acids or chemical peels
  • Overuse of lipid substances or occlusive substances in topical skincare
  • Alcohol substances of more than 10% concentration in cosmetic skincare
  • Tight fitting clothes or hats
  • Emulsifiers in creams can lead to dissolving of natural lipids
  • Some medications
  • Hormonal fluctuations such as menopause
  • Digestive disorders
  • Constipation
  • Vitamin A & vitamin C deficiency

Signs of Acne

The signs of acne are often obvious, so you likely won’t have trouble identifying it on your skin. However, understanding the specific way that the acne is presenting itself, whether it’s a blackhead or a cystic lesion, is critical. Dr. Alina Sholar breaks down the different types of acne as follows: A whitehead is a pore that is closed and plugged and has a white end. This is in contrast to a blackhead, where the pore is also plugged but is open and this oxidation has led to a black end forming. Then there are papules, which are small, red bumps that are often tender. These are different from pimples, which are also small, red bumps but which have white pus at their tips. Nodules are another type of acne and they present themselves as large, solid, painful lumps that are under the skin. Lastly, cystic lesions are the most serious form of acne and they are painful lumps underneath the skin, like nodules, except they are also pus-filled.

Dr. Alina Sholar on Acne Treatments

Many people believe that acne must be solved using at-home remedies, like various cleansers and toners you might find at the drugstore. While these will work for some people, more serious or persistent cases of acne may require professional help. In many cases, these drugstore products can make things much worse. Dr. Alina Sholar urges anyone who experiences acne that is particularly painful or recurrent to consider seeking out a doctor or dermatologist who can prescribe something of better quality than what you’ll find at a drugstore. Many ‘over-the-counter’ products contain the ingredient Benzoyl Peroxide. Please carefully consider using these products as research indicates increased sensitivity to sunlight and allergies reactions to it. Whilst these ingredients can lead to short term fixes in the skin, often longer term problems can be created.

What your doctor recommends or prescribes will depend on a variety of factors, including your age and the severity of the acne, but the most common treatments involve either a topical or an oral medication. Topical medications most commonly prescribed for acne include clinical skincare products with azelaic acid, salicylic acid, and anti-inflammatory barrier-building creams, or pharmaceutical antibiotics or dapsone. Meanwhile, oral medications could include anything from antibiotics to oral contraceptives. In more extreme cases, different therapies, like steroid injections, chemical peels, Celluma LED or light therapy, or drainage and extraction, might be the answer.

Effective treatments for acne are very different depending on whether the acne is a dry acne (acne tarda), or a wet/oily acne. All too often people think all acne is produced from oily skin, however, many cases of acne are actually caused by the skin being ‘dried out’. Sadly, this is generally caused by the inappropriate use of cosmetics and products for the true skin type. When the natural lipidic balance of the skin is out of shape, the skin produces an over-abundance of sebum. Simple mistakes such as this can send the sebaceous glands into overdrive, which can result in acne.

Suggested treatments based on your individual root cause of acne will be necessary to resolve your acne and prevent it from resurfacing again. Acne can be difficult to properly diagnose at its root cause. Hence a thorough skin consultation with a specialist is recommended.