Persistent Acne: Why Does It Keep Coming Back?

Q: Persistent Acne: Why Does It Keep Coming Back?

Dear Jeri： From the description in your letter, the acne on your face has driven you to frustration. <br>It is rare for someone to research their condition so thoroughly, which can lead to mental stress. <br>Based on your description, you may be suffering from cystic acne and pos

Acne

Hello, Doctor: I consider myself to be someone with moderate acne.
During my puberty from ages 14 to 20, it was quite severe.
Eating oily foods or peanuts tends to trigger breakouts.
In recent years, I've been paying attention to my diet and facial hygiene, and as I moved further away from puberty, the number of breakouts has decreased.
However, I've noticed a particular issue: over the past decade, I've had acne in various locations on my face, but there is one specific area that consistently develops severe pustular acne, resulting in noticeable scarring on both sides of my face.
This is the only area that has this problem.
I believe my skin is not too bad overall, with about 80% of it looking decent, but those two symmetrical spots have significant uneven texture and severe pigmentation issues.

The troublesome area is not in the T-zone, but about 1.5 cm outward from the sides of my nostrils and about 1.5 cm downward.
(Its horizontal line is approximately at the philtrum, and the vertical line is about 2 cm outside the corners of my mouth.) Even if I eat a vegetarian, low-oil, and light diet for an entire month, that specific area still frequently develops acne.
When it does, it is never just a regular comedo or small pimple; it is always a deep-rooted, extensive pustular acne that has been brewing for a long time.
Initially, it presents as a large, swollen, round red papule with no head, and it is very painful to touch.
Once the papule matures, if I accidentally touch it while washing my face, it easily bursts, releasing a large amount of yellowish pus mixed with blood, which has a foul odor.
The time from the emergence of the pustule to its maturation and bursting takes at least a week or more.
After the pus is expelled, the opening is noticeably wide (about slightly larger than a needle's head), and the depression feels very deep, as if it extends over a centimeter.
During the worst of my puberty, even after the mature pustule had completely burst, a new large pustule would already be forming beneath it, meaning there could be two overlapping pustules.
Over the years, this specific location has been the most problematic, never deviating more than 0.1 cm to the right, up, or down.
When it appears, it is always a pustule...
The right side is worse than the left, but both are severe...
There were even instances where for three consecutive months, that area kept developing pustules, with one not fully matured while another was forming deeper underneath, leaving no days for recovery.
As a result, my facial skin has been severely damaged, and the most noticeable scars are in those two areas.
Although I now have fewer breakouts, those two spots still occasionally develop acne, which is also pustular.

I would like to ask you two questions: (1) Why has that specific area consistently developed pustular acne for so many years? (2) I have had small, quickly healing comedones in various areas of my face that do not leave scars, but that specific area only ever develops pustules and has never had comedones.
Why is that? Thank you!

jeri, 20~29 year old female. Ask Date: 2009/12/15

Dr. Du Zhiqiang reply Dermatology

Dear Jeri: From the description in your letter, the acne on your face has driven you to frustration.
It is rare for someone to research their condition so thoroughly, which can lead to mental stress.
Based on your description, you may be suffering from cystic acne and possibly an abscess infection.
It is advisable to visit the hospital for a consultation.
There is no need to overthink; communicate openly with your doctor for appropriate treatment.
Wishing you peace and health.
Sincerely, Dr.
Du Zhi-Liang, Attending Physician, Department of Dermatology, Taoyuan Hospital, Ministry of Health and Welfare.

Reply Date: 2009/12/15

More Info

Persistent acne, particularly in specific areas of the face, can be a frustrating and distressing condition. Your experience with recurrent pustular acne in a localized area, despite improvements in your overall skin condition and dietary habits, raises several important points that can help us understand the underlying mechanisms at play.

Why Does Acne Persist in Specific Areas?
1. Hormonal Influence: Acne is often influenced by hormonal fluctuations, particularly androgens, which can increase oil production in the skin. The area you described, near the sides of the nose and mouth, is often associated with hormonal activity. Even if you are past your teenage years, hormonal changes related to menstrual cycles, stress, or other factors can still trigger acne in these areas.

2. Sebaceous Glands: The skin in certain areas of the face, such as around the nose and mouth, has a higher concentration of sebaceous (oil) glands. Overactivity of these glands can lead to increased oil production, which, when combined with dead skin cells, can clog pores and lead to the formation of acne. The persistent nature of your acne in this specific location may be due to the unique characteristics of the skin and glands in that area.

3. Bacterial Colonization: The presence of *Propionibacterium acnes*, a bacteria that thrives in oily environments, can contribute to the development of pustular acne. If this bacteria is particularly prevalent in the area where you experience acne, it may lead to recurrent breakouts.
4. Skin Texture and Scarring: The history of severe acne in that area may have altered the skin's texture, making it more susceptible to future breakouts. Scarring can lead to changes in how the skin behaves, potentially causing blockages that lead to deeper, more painful cysts or pustules.

5. Inflammation and Immune Response: Chronic inflammation in the skin can perpetuate the cycle of acne. If your skin has been inflamed for an extended period, it may continue to react to stimuli (like oil production or bacteria) in a way that leads to the formation of pustules.

Why Only Pustular Acne in That Area?
1. Deep Follicular Involvement: The formation of pustules indicates that the acne is not just superficial but involves deeper structures of the hair follicle. This could be due to the unique anatomy of the hair follicles in that area, which may predispose them to deeper infections.

2. Blockage and Cyst Formation: The area may be prone to blockages that lead to the formation of cysts. When these cysts become inflamed, they can develop into pustules. The fact that you have not experienced smaller comedonal acne (like blackheads or whiteheads) in that area suggests that the follicles may be more prone to deep-seated inflammation rather than superficial blockage.

3. Skin Care Products and Irritation: Sometimes, the products used on the skin can exacerbate acne in specific areas. If you are using heavy or comedogenic products, they may contribute to the problem. It’s essential to evaluate your skincare routine to ensure that it is suitable for your skin type.

Recommendations for Management
1. Consult a Dermatologist: Given the chronic nature of your acne and the scarring, it would be beneficial to consult a dermatologist. They can provide targeted treatments, which may include topical retinoids, antibiotics, or hormonal treatments if indicated.

2. Topical Treatments: Consider using products with salicylic acid or benzoyl peroxide, which can help reduce inflammation and prevent clogged pores.
3. Avoid Picking: It’s crucial to avoid picking at the acne, as this can lead to further scarring and inflammation.

4. Regular Skincare Routine: Maintain a consistent skincare routine that includes gentle cleansing, exfoliation, and moisturizing. Look for non-comedogenic products that won’t exacerbate oiliness.

5. Diet and Lifestyle: Continue to monitor your diet and lifestyle, as these can impact skin health. Staying hydrated, managing stress, and maintaining a balanced diet can contribute positively to your skin condition.

In conclusion, persistent acne in specific areas can be attributed to a combination of hormonal influences, skin characteristics, and bacterial activity. Understanding these factors can help in managing and potentially reducing the frequency and severity of breakouts.

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