There are bacteria that live on the skin. Under normal circumstances, they are perfectly harmless. But if they have access to food, they grow. In this case, Propionibacterium acnes feeds on sebum. As this bacterium grows, it excretes chemicals that trigger your body’s immune system and this produces the redness and soreness as your body fights the infection. At first, the problems will be mild. If you feel that something more than simply washing your face with a neutral soap is required, the best forms of treatment are available over the counter. Look for products containing benzoyl peroxide. This has an antibacterial effect by drying out the skin. As the skin dries, your body sheds the surface layer of dead skin. This helps to reduce the amount of dead skin cells available to block up the pores and therefore reduces the chances of an infection. Note that benzoyl peroxide can cause your skin to peel when you begin to use it. Over time, this reaction reduces.

But if the inflammation persists, you may have to use an antibiotic like Doxycycline. Some topical creams combine benzoyl peroxide with an antibiotic. These can produce slightly faster results because they are rubbed directly into the skin affected. Taken orally, several months will be required to produce an effect, assuming the bacteria are susceptible to the antibiotic. If this approach fails, you will have to consider taking medications that treat the underlying cause of acne, namely excess hormones.

Antibiotics are only useful when you have a bacterial infection. If your sickness comes from any other cause, antibiotics will be completely useless. Worse, antibiotics are reasonably specific. Bacteria come in many different strains and the effectiveness of antibiotics is limited either to one of those strains or, like Doxycycline, to a limited number. There are thousands of different bacteria in the world and only some of them are susceptible to treatment with the antibiotics currently on the market.

So what is acne? Acne is where the sebaceous glands in your skin grow overactive as the level of hormones increases. This releases more sebum, a natural oil, into the skin. Under normal circumstances, dead skin cells fall from the surface of the skin or are expelled from the skin and drop off. But with more oil in the skin, dead skin cells remain in the hair follicles and block the follicles. This environment is perfect for the growth of a bacterium called Propionibacterium acnes. This bacterium lives harmlessly on your skin but once a warm, moist environment is created, it feeds on the sebum. As a result of this additional food, the bacteria expel chemicals that trigger your body’s immune system. In turn, this causes an inflammation of the skin. You know this because your skin turns red and can grow a little painful.

The moment anyone sees the two words in the same sentence, “bacteria” and “inflammation” everyone assumes that antibiotics are the answer. Indeed, it’s not inappropriate to prescribe an antibiotic like Doxycycline. So what is the standard treatment? Many physicians prescribe Doxycycline as a daily dose for anywhere between three and six months. Unfortunately, the use of an antibiotic does nothing to prevent the formation of the pimples and zips. Antibiotics do not prevent the blockage of the follicles. The only possible benefit is to reduce the inflammation that may accompany the pimples. Even then, not all the strains of Propionibacterium acnes are susceptible to antibiotics. And the final problem? You may be making a powerful antibiotics less effective in your body for the treatment of a cosmetic condition. It’s always better to save an effective medication for the times when a bacterium has made you seriously ill.

So the first question is a simple one. When you get pimples and zits, is this always acne? The answer, unfortunately, is “no”. Even though you may get “pustules” or “papules”, the technical terms for those “spots” that come on your face, neck and upper body, you may have Pityrosporum folliculitis. This is a common inflammatory skin disorder that looks almost exactly the same as acne. Indeed, it’s perfectly possible to have both conditions at the same time. There’s just one problem. To cure Pityrosporum folliculitis, you need an antifungal medication, whether in tablet form or as a topical cream. No antibiotic of the market will have any effect on Pityrosporum folliculitis. Worse news! Many of the treatments for acne will make Pityrosporum folliculitis flare up and become even more visible and painful!

So, before you resort to ever more powerful treatments for your skin problem including the use of antibiotics like Doxycycline, make sure you are treating the right problem. This means seeking a proper diagnosis either from a physician with the relevant knowledge or a specialist dermatologist. How do you tell the two apart? The lesions in acne are usually larger, i.e. they may be more than 4cm in diameter and are distributed evenly over the face, neck and upper body. Pityrosporum folliculitis most often affects the body and the lesions are smaller. The only definitive way of distinguishing the two conditions is to have a punch biopsy. This takes a small sample from the skin and tests for the presence of yeasts. If yeasts are found, this proves the source of the inflammation as Pityrosporum folliculitis. Because this is not a bacterial infection, antibiotics are ineffective.

Sitting in the back booth in a diner, we were both enjoying a coffee and Danish. “I guess puberty hit me quite young,” she said between bites. “I was around 12 years old. When it happened I began to get a little acne. Nothing serious. Just an annoyance really. I figured I wasn’t washing enough so I would faithfully clean my skin and the acne would fade away. Then I would get casual and the pimples would slowly creep back. This was the pattern until I turned 17.” The waitress mooched over with some more coffee. It was interesting to watch how she tried to act cool and not make a big thing of looking at Maureen’s face as she refilled our cups. When she had gone, Maureen nodded and confirmed this was a standard reaction. People rarely stared openly. Just looked elsewhere when they were around her. I wondered whether she ever used any of the heavy duty foundation powders.

She laughed. “Most of them make me look like one of the living dead. People actually stare more.” She munched some more on her Danish. “I used to wear makeup when I was younger. Except the acne grew steadily worse which was frustrating. My friends had their acne when they were younger and it didn’t matter so much. Mine was getting worse over time.” She paused. “I stopped dating. Boys can be so unkind.” Which she said as a throwaway line suggesting she would like to throw most young men in the dumpster. She was understandably bitter.

“This last year has seen my life get messed up. My face, neck and shoulders have a rash all the time. I’ve tried all the usual skin products but most of them just irritated my skin and made the pimples blister. I’ve given up any makeup on my face and just live with it.”

She waved the waitress over for another refill of coffee. “I’m in college and keep a low profile. I’m hoping it will all clear up before I start looking for a job.” But I could tell she was not optimistic. There were dermatologists in her life and they were not giving her good news but, as is always appropriate in these cases, she was putting a brave face on it.