It is clear that acne cannot be avoided by a little “preven­tive maintenance.” For this reason both doctors and pa­tients often focus their attention on several larger issues in which there is some potential to influence the course of the skin problem. These factors include skin hygiene, climate, diet, and stress.


Skin Hygiene
It can be said unequivocally that acne has nothing to do with “dirty” skin. As we have already learned, blackheads are not dirt but are impactions or collections of dead skin cells and oil found inside the follicle opening. Certainly acne-prone skin is apt to be oilier than healthy skin, but the bacteria living on the skin surface are much the same in people with acne as in those without acne. Moreover, the bacteria that are involved in the acne process live deep inside the follicle and sebaceous gland. Washing the skin frequently or vigorously does little to reduce the number of these acne bacteria or diminish their activity in acne inflammation.
Cleaning the skin as a form of treatment remains popular, but vigorous cleansing can actually make the acne worse by damaging the already weakened follicles.


Climate
Acne has no respect for climate or weather. The disease is found in all regions of the world, hot or cold, wet or dry. Sunny climes produce as many acne sufferers as the more temperate areas.
The long-held impression that natural sunlight is good treatment for acne is open to question for two reasons. First, only 50 percent of acne patients improve with sun exposure and tanning. The remaining 50 percent experience no change or a worsening of the condition. Sun-induced flare-ups of acne may occur because the sun causes a thickening of the skin, which can contribute to the blockage of follicles. In fact, “sun acne” on the back and shoulders is common among lifeguards and other people who spend a lot of time at the beach. Second, with the dramatic increase in all forms of skin cancer, which is thought to be related to excessive sun exposure, dermatologists are reluctant to treat acne with artificial ultraviolet light or encourage sunbathing, even for those who do notice im­provement of their acne during the summer months. High humidity is another climatic factor that can promote acne. Presumably it is caused by overhydration of the skin, as in the case of an ordinary heat rash, when the skin gets saturated with water and the sweat pores and follicles are blocked. In fact, high humidity rather than the sun may be the cause of some acne flare-ups in the summer.


Diet
It is difficult to eliminate the widespread belief that certain foods can cause acne. It is only in the past twenty years that doctors themselves have come to realize that diet has little to do with the development of the disease. However, many people still cling to the dietary factors as a probable cause of their acne because of the erratic behavior of the disease and the lack of a better explanation for sudden outbreaks.
The belief that chocolate causes acne was discarded years ago. A careful study of chocolate eaters versus those who do not eat chocolate revealed no difference in the severity of acne. Although very low calorie, starvation diets can markedly decrease the amount of sebum produced by the oil glands, in the normal dietary range there is no apparent relationship between calories consumed and the se­verity of acne. Furthermore the kinds of foods eaten whether carbohydrates, fat, or protein play no role in the development of acne.
Another common misconception suggests that an oily skin, a possible promoter of acne, is directly related to the amount of oil consumed in the diet. Thus, oily foods such as pizza and french fried potatoes should be taboo for in­dividuals who are acne-prone. The reality is that the oil glands produce sebum in quantities that are quite independent of the amount of oil in the diet. For a while there was speculation about the role of the halogen chemicals - iodine, bromine, and fluorine in acne formation. These chemicals are found in some food­stuffs and in medications. It is true that in rare cases, iodine or bromine has caused acnelike skin reactions, but it is un­likely that the iodine present in a normal diet, or the fluoride found in many toothpastes, can initiate or aggravate acne. Nevertheless, lingering doubts and long-held dietary prejudices encourage many dermatologists to play it safe and tell their acne patients to avoid the particular foods that they believe aggravate their acne.


Stress and Emotional Factors
There is no doubt whatsoever that acne can create emotional problems for the person who has it. Studies have shown that people with mild acne have much the same psychological profile as people without acne, but people with severe acne have a wide range of mild to severe emotional reactions, including anxiety, depression, anger, and lowered self-esteem. To be sure, part of this emotional reaction is related to our cultural values, which tend to overemphasize the importance of the physical appearance, particularly the skin.
Evidence for the opposite situation, that our emotions can cause acne, is much less obvious. There is some suggestion that occasional stress in some individuals can cause acne to flare, as in the case of college students at exam time, but the role of stress in the ups and downs of acne is generally overestimated.
One aspect of the role of the emotions in causing acne is not at all controversial. A condition called acne excoriee (excoriee means “scratched or abraded”) takes in those acne sufferers who are chronic self-mutilators, compulsively picking and squeezing pimples and damaging their skin far beyond the injury caused by the acne condition itself. The severity of this emotional problem varies. Mild pickers can break the habit themselves when the destructive nature of their behavior is pointed out to them. Severe pickers, on the other hand, who find tiny insignificant blemishes and turn them into large craters and permanent scars, are more difficult to restrain and may require professional counseling.

Despite the fact that currently accepted theories about the origins of acne leave little room for prevention, and long accepted influences (particularly stress and diet) are more mythical than real, there is no reason for despair. Acne can be treated effectively and controlled, even cured.