What Is the Real Root Cause of Chronic Acne
Acne is far more complex than most people realize. While many think it’s simply about dirty skin or poor hygiene, the truth involves multiple interconnected factors working together. Understanding what actually causes chronic acne requires looking beyond surface-level explanations to the biological and lifestyle factors that drive persistent breakouts.
The Microbiome and Bacterial Imbalance
At the heart of acne lies an imbalance in the skin’s bacterial community. The bacterium Cutibacterium acnes, formerly known as Propionibacterium acnes, plays a central role. However, here’s the surprising part: this bacteria exists on most adults’ skin without causing problems. The difference between clear skin and acne comes down to specific strains of the bacteria and how they behave. Different strains have different genetic profiles, and only certain ones trigger inflammation and breakouts. This means acne isn’t simply about having the wrong bacteria, but rather having bacteria that behave in ways that promote inflammation and skin damage.
The Four-Part Process Behind Acne Formation
Acne develops through a specific sequence of events in the hair follicle. First, the skin cells lining the follicle start multiplying abnormally in a process called hyperkeratinization. This creates tiny blockages called microcomedones that trap material inside the follicle. Second, the sebaceous glands produce excess oil, or sebum, which accumulates in these blocked follicles. Third, bacteria multiply in this oxygen-poor, oil-rich environment. Fourth, the immune system reacts to this situation, causing inflammation that appears as redness, swelling, and the various types of acne lesions people experience.
Hormones: The Master Controller
For many people, especially women, hormones are the primary driver of chronic acne. Androgens, which are male hormones present in both men and women, directly stimulate sebaceous glands to produce more oil. When androgen levels rise relative to estrogen, or when the skin becomes overly sensitive to normal androgen levels, sebum production increases dramatically. This excess oil creates the perfect environment for acne to develop and persist.
Hormonal acne often appears in specific locations, particularly along the jawline, chin, and lower cheeks, which is different from the acne patterns seen during puberty. Women experience adult acne more frequently than men, and hormonal fluctuations throughout the menstrual cycle, pregnancy, menopause, and conditions like polycystic ovary syndrome (PCOS) all contribute to breakouts. Even hormonal birth control methods can trigger or worsen acne in some women.
The Lifestyle and Environmental Factors
Beyond biology, everyday choices significantly impact acne severity. Diet plays a measurable role, particularly foods high in dairy and sugar. Whey protein, high-glycemic foods like pastries and sodas, and chocolate can spike insulin and androgen activity, worsening sebum production. Stress triggers the release of cortisol and other hormones that indirectly increase oil production and inflammation. Poor sleep habits compound these effects by disrupting hormone regulation.
The products people use on their skin matter too. Washing the face too frequently can damage the skin barrier, causing the skin to produce even more oil to compensate. Using pore-clogging ingredients or the wrong skincare products for your skin type can trap bacteria and dead skin cells. Environmental factors like chlorine exposure or friction from tight clothing can also irritate skin and worsen acne.
Genetics and Individual Susceptibility
Why does the same treatment work for some people but not others? Genetics play a significant role. Some people are simply more prone to acne due to inherited traits affecting how their skin responds to bacteria, hormones, and inflammation. This genetic component explains why acne runs in families and why identical triggers produce different results in different people.
Underlying Health Conditions
Sometimes chronic acne signals an underlying health problem that needs attention. Conditions like hypothyroidism and adrenal disorders can elevate androgen levels, exacerbating acne. Gut dysbiosis, an imbalance in the bacteria living in the digestive system, may also contribute to skin problems. Certain medications can trigger or worsen acne as a side effect. This is why persistent acne sometimes requires medical evaluation to identify and address root causes beyond the skin itself.
The Multifactorial Reality
The real root cause of chronic acne isn’t one thing, but rather a combination of factors unique to each person. For one person, hormones might be the dominant factor. For another, diet and stress might play larger roles. A third person might struggle primarily with bacterial dysbiosis or an underlying health condition. This is why dermatologists emphasize that acne management must be personalized and why the same treatment doesn’t work for everyone.
Effective long-term acne management requires identifying which factors matter most for your specific situation. This might involve tracking breakout patterns, keeping a food diary, managing stress, adjusting skincare routines, and sometimes seeking medical evaluation to rule out hormonal imbalances or other health conditions. Understanding that acne is a chronic, multifactorial condition rather than a simple skin problem is the first step toward finding lasting solutions.
Sources
https://pmc.ncbi.nlm.nih.gov/articles/PMC12735603/
https://www.medicaldaily.com/hormonal-acne-adults-acne-causes-skin-hormones-explained-474128
https://www.fivensondermatology.com/acne
