Acne (Pimples): Causes, Treatment Options, Why It Keeps Coming Back and What to Expect
By Dr Lim Tzyy Huei | Consultant Dermatologist, Pantai Hospital Batu Pahat, Johor, Malaysia
Acne, commonly known as pimples, is one of the most common skin conditions affecting teenagers and adults.
For some people, pimples appear occasionally and settle on their own. Others may experience persistent breakouts, inflamed pimples, dark marks or scarring.
Having acne does not mean someone has poor hygiene or has done something wrong with their skincare. It is a common skin condition influenced by hormones, oil production, genetics and inflammation.
While not everyone with acne requires medical treatment, understanding why it develops, what treatments are available and when professional assessment may be helpful allows individuals to make informed decisions about their skin.
The aim of acne care is not necessarily to achieve perfectly clear skin, but to manage inflammation, prevent complications when appropriate and support healthy skin over time.
What Causes Acne?
Acne develops when hair follicles become blocked by excess oil (sebum) and dead skin cells.
Four main processes contribute to acne formation:
Excess oil production: Hormonal changes stimulate the sebaceous glands to produce more oil.
Clogged pores: Dead skin cells accumulate inside hair follicles, forming blackheads and whiteheads.
Bacterial activity: Cutibacterium acnes, a bacterium naturally present on the skin, can contribute to inflammation within blocked follicles.
Inflammation: This causes red pimples, pus-filled lesions and sometimes deeper, painful nodules.
Acne commonly affects the face, chest, shoulders and back.
Importantly, acne is not simply caused by dirty skin. Excessive washing and harsh skincare products may actually irritate the skin and worsen inflammation.
Why Does Acne Keep Coming Back?
Acne often follows a recurring pattern, particularly during adolescence and early adulthood.
Even after successful treatment, new pimples may appear because the underlying factors contributing to acne are still present.
Common contributing factors include:
Hormonal changes: Puberty, menstrual cycles and hormonal fluctuations in adulthood can stimulate oil production.
Genetics: Individuals with a family history of acne may have a greater tendency to develop persistent breakouts.
Skincare products: Certain oily or pore-clogging cosmetics may contribute to acne in susceptible individuals.
Stress and lifestyle: Emotional stress and inadequate sleep may aggravate acne in some people.
Diet: High-glycaemic foods and certain dairy products may worsen acne in susceptible individuals, although the relationship varies.
Stopping treatment too early: Discontinuing medication before adequate control is achieved may allow new pimples to develop.
Acne recurrence does not necessarily mean that previous treatment has failed.
Some patients benefit from maintenance treatment, while others may need only occasional treatment when breakouts occur.
What Are the Different Types of Acne?
Acne can present in several forms:
Comedonal Acne
Blackheads and whiteheads caused by clogged pores, usually with minimal inflammation.
Inflammatory Acne
Red bumps and pus-filled pimples, commonly affecting the face, chest and back.
Nodular or Cystic Acne
Deeper, painful inflammatory lesions that may persist longer and carry a greater risk of permanent scarring.
Some individuals have a combination of these types.
A few occasional pimples may be manageable with simple skincare, while persistent inflammatory acne or painful nodules may benefit from medical treatment.
Could It Be Something Other Than Acne?
Not every pimple-like eruption is necessarily acne.
Other skin conditions, such as rosacea, folliculitis and perioral dermatitis, can sometimes cause similar-looking bumps but may require different treatments.
For example, rosacea often causes facial redness, flushing and sensitive skin, while folliculitis may produce small, similar-looking bumps that are sometimes itchy.
Unlike typical acne, these conditions usually do not produce blackheads or whiteheads.
If acne-like bumps persist despite treatment, particularly when accompanied by itching, burning or facial flushing, a dermatological assessment may help clarify the diagnosis.
For more information, read my related article: Not All Pimples Are Acne: 5 Skin Conditions Commonly Mistaken for Acne.
What Are the Treatment Options for Acne?
Treatment depends on the type and severity of acne, skin tolerance, previous treatment response and risk of scarring.
1. Topical Treatments (Creams and Gels)
Topical medications are commonly used for mild to moderate acne and may also be prescribed alongside oral treatment.
Common options include:
Benzoyl peroxide: Reduces acne-associated bacteria and inflammation.
Adapalene or tretinoin: Topical retinoids that help prevent clogged pores and new acne formation.
Azelaic acid: Helps improve inflammatory acne and post-inflammatory pigmentation.
Topical antibiotics, such as clindamycin: Generally combined with benzoyl peroxide to reduce antibiotic resistance.
Topical anti-androgen treatment, such as clascoterone 1% cream (Winlevi), offers another treatment approach by targeting androgen receptors in the skin.
I also discussed this treatment and the importance of maintaining the skin barrier during acne treatment at a recent GP educational session in Batu Pahat. Read more: Beyond the Surface: Balancing Sebum and Reinforcing the Skin Barrier.
These treatments require several weeks of consistent use before meaningful improvement becomes noticeable.
Temporary dryness, peeling or irritation may occur initially. Using a suitable moisturiser and adjusting application frequency under medical guidance can improve tolerance.
Topical retinoids should be avoided during pregnancy and when planning pregnancy.
2. Oral Antibiotics
For moderate to severe inflammatory acne, oral antibiotics such as doxycycline may be prescribed.
They help reduce inflammation and acne-associated bacterial activity.
Oral antibiotics are generally used for a limited duration and combined with appropriate topical treatment, usually including benzoyl peroxide.
Prolonged or unnecessary antibiotic use should be avoided because it increases the risk of antibiotic resistance.
3. Hormonal Treatment
For selected female patients, particularly those experiencing persistent adult acne or menstrual-related breakouts, hormonal treatment may be considered.
Options include certain combined oral contraceptive pills or spironolactone.
These treatments are not suitable for everyone and require individual medical assessment, particularly regarding pregnancy and other contraindications.
4. Oral Isotretinoin
Oral isotretinoin is one of the most effective treatments for severe, scarring or treatment-resistant acne.
It works by significantly reducing oil production, improving follicular blockage and reducing inflammation.
Isotretinoin may be considered for :
Severe nodular or cystic acne
Acne causing permanent scarring
Persistent acne that has not responded adequately to conventional treatment
Acne causing substantial personal distress
A typical treatment course often lasts approximately 4–6 months, although some patients require longer treatment depending on the prescribed regimen and response.
Common side effects include dry lips, dry skin and dry eyes. Blood tests and medical monitoring may be required.
Isotretinoin must not be used during pregnancy because it can cause severe birth defects. Strict pregnancy-prevention precautions are essential for patients who can become pregnant.
Many patients experience prolonged improvement after completing treatment, although acne may occasionally recur.
Not everyone with acne needs isotretinoin. Treatment should be based on clinical indications, expected benefits, possible risks and individual circumstances.
5. Additional Dermatological Procedures
Depending on the type and severity of acne, additional treatments may include:
Intralesional corticosteroid injections for selected large, painful inflammatory nodules.
Comedone extraction for appropriate blackheads and whiteheads.
Chemical peels as an adjunctive treatment in selected patients.
These procedures complement, rather than replace, appropriate medical acne treatment.
How Long Does Acne Treatment Take to Work?
Acne treatment requires patience, as improvement usually occurs gradually.
Treatment period | What patients may expect |
First 2–4 weeks | Early improvement may begin; some treatments can initially cause dryness or irritation |
6–8 weeks | New pimples and inflammation may become less frequent |
8–12 weeks | More noticeable improvement, allowing treatment response to be assessed |
3–6 months | Further improvement with continued appropriate treatment |
These timelines are approximate and depend on acne severity, treatment type and individual response.
Changing skincare products too frequently or stopping prescribed medication prematurely may interfere with progress.
What About Acne Marks and Scars ?
After active acne settles, some people notice residual red marks, dark pigmentation or permanent scarring.
These are different conditions and do not always require treatment.
Post-inflammatory hyperpigmentation (PIH): Brown or dark marks remaining after acne inflammation. They may gradually fade over several months.
Post-inflammatory erythema (PIE): Red or pink marks caused by residual vascular changes following inflammation.
Atrophic acne scars: Permanent depressions in the skin, including ice-pick, boxcar and rolling scars.
Treatments for established acne scars may include microneedling, subcision, chemical reconstruction techniques or laser-based procedures, depending on the scar type.
However, not everyone with acne marks or scars needs procedural treatment.
For individuals with active inflammatory acne, early treatment may help reduce the risk of further scarring.
How Should You Care for Acne-Prone Skin?
A simple and consistent skincare routine is often more helpful than using multiple products.
Morning Routine
Wash your face with a gentle cleanser.
Apply prescribed acne medication if instructed.
Use a lightweight, non-comedogenic moisturiser.
Apply broad-spectrum sunscreen with SPF 30 or above.
Evening Routine
Cleanse gently to remove sunscreen, makeup and excess oil.
Apply prescribed acne treatment according to instructions.
Use a suitable moisturiser to reduce dryness and irritation.
Avoid squeezing pimples, harsh facial scrubs, excessive exfoliation and frequently changing treatment products.
Some acne medications, particularly topical retinoids and benzoyl peroxide, may initially cause dryness or irritation.
For more information on protecting sensitive skin and improving treatment tolerance, read my related article: Sensitive Skin: Why Your Face Stings, Burns or Turns Red.
Can Acne Be Permanently Cured?
Acne often improves with age, although some individuals continue to experience breakouts into adulthood.
Many patients achieve good control with appropriate treatment. However, recurrence remains possible because hormonal, genetic and inflammatory factors may continue to influence acne development.
Some individuals benefit from maintenance treatment, such as topical retinoids or benzoyl peroxide, while others may not need ongoing medication once their acne has settled.
Patients who complete oral isotretinoin may experience prolonged remission, although relapse can occasionally occur.
The goal is to manage acne according to individual needs, rather than expecting everyone to achieve permanently flawless skin.
When Should You See a Dermatologist?
Not everyone with acne needs specialist treatment.
However, dermatological assessment may be helpful if:
Acne persists despite appropriate over-the-counter treatment.
Pimples are deep, painful or frequently inflamed.
Acne is causing persistent marks or permanent scarring.
Breakouts repeatedly return despite treatment.
You are considering oral medication such as isotretinoin.
You would like to understand the available treatment options.
Early assessment is particularly useful for patients developing painful nodules, cysts or signs of permanent scarring.
Understanding Acne Without Unnecessary Pressure
Acne is particularly common during adolescence, and understanding the condition can help young people make informed decisions about their skin.
During an acne education session at Chinese High School, Batu Pahat, I shared information about acne, common misconceptions and available treatment options, together with insights from our previously published acne research.
The purpose of acne education is not to encourage everyone to pursue perfectly clear skin, but to help people understand their condition and recognise when treatment may be beneficial.
Understanding Acne and Making Informed Treatment Choices
Acne is a common skin condition, and having pimples does not mean that someone has unhealthy skin or poor hygiene.
For some individuals, occasional breakouts may require little more than gentle skincare. Others may benefit from treatment, particularly when acne becomes persistent, painful or begins to cause scarring.
Understanding the available treatments, their benefits and limitations allows individuals to make decisions that suit their own needs.
Healthy skin does not have to mean perfectly clear skin. The aim of acne care is to understand your skin, manage problems when necessary and make informed choices without unnecessary pressure to achieve perfection.
About the Author
Dr Lim Tzyy Huei (林子辉医生) is a Consultant Dermatologist at Pantai Hospital Batu Pahat, Johor, Malaysia.
His clinical interests include acne, rosacea, eczema, psoriasis, hair disorders and other medical dermatological conditions.
Disclaimer: This article is intended for general patient education and does not replace individual medical consultation. Treatment suitability depends on individual circumstances.