It started out innocently enough: the occasional text from a friend complaining about her sudden breakout; a co-worker lamenting the re-occurring pimple on her chin. But then it spread. One by one, as my friends entered their mid-20s, their skin turned on them. 25th birthday parties morphed into emotional debates over spot treatments, while friends who had clear skin in their teens were now messaging me photos of their full-face acne. It felt like a weird epidemic from a bad horror film—one that I had miraculously escaped. And then, one year ago, it came for me, too.
At the start of 2017, for absolutely zero reason, my skin became a raging, incomprehensible, mind-destroying asshole. Up until that point, my biggest face concerns had been the tiny, dainty little zits I’d occasionally get around my period. But seemingly overnight, I was barraged by painful, under-the-skin cystic zits on one side of my chin that took months to heal.
Suddenly, I had acne—something I never even dealt with during puberty. I was now someone who avoided selfies, wore concealer to the gym, hid from direct sunlight, and cried big, helpless, exasperated tears when I took my makeup off at night. I had entered the same mid-20s breakout hell as everyone else in my life, and even though I knew that acne was nothing to be ashamed of, and that good skin wasn’t the end-all be-all, I couldn’t help but feel betrayed and hopeless.
The upside of my zit-filled misery (which I’m finally coming out of) is that I became an unofficial expert on adult acne. For more than a year, I scoured forums, crowdsourced stories, poured over medical journals, and hounded dozens of dermatologists and cosmetic chemists for answers. And now, I’m bringing you a definitive explanation as to why exactly, you, your best friend, that girl on the bus, and Jenna in marketing are all breaking out—and what the hell you can actually do about it. Other than, you know, cry.
CAUSE #1: Your Hormones Are Freaking the Hell Out
Thought your hormonal shifts stopped at middle school graduation? Think again. “Adult female acne appears to be on the rise more than ever,” says dermatologist Melissa Kanchanapoomi Levin, M.D., clinical attending at NYU Langone and Mount Sinai Hospital, giving new meaning to the old cliché misery loves company.
Annoyingly, nobody really knows for sure why. I know, I know—that’s not what you wanted to hear. But until official, widespread studies are conducted by a bunch of fancy universities, dermatologists can only speculate. Luckily, my experts love to speculate, and everyone I spoke with agreed that your hormones are to blame. Mainly because, well, “all deep acne is caused by hormones,” says Dr. Levin.
Yes, even if you ate a tub of ice cream last night and slept in your makeup, your cystic zits will have been caused by a hormonal surge, not the leftover gunk on your face (though that gunk can still aggravate bacteria-caused whiteheads and blackheads). Why? All that sugar you ingested results in an insulin spike, which ramps up the production of androgens—”male” sex hormones, like testosterone—in your body. Those hormones increase your skin’s oil production, which feeds the bacteria in your pores, which causes inflammation and, finally, pimples. Got all that?
The only difference, says Dr. Levin, is when you were a teen, your body often responded to that inflammation with classic, pus-filled whiteheads and oil-slicked blackheads, which were treatable with over-the-counter products. But now, your 20-something body is responding with cystic zits—those deep, painful, underground bumps that never come to a head, can’t (and shouldn’t) be popped, and don’t respond as well to topical medications. The reason for the change is unclear, but experts think it has to do with an increased sensitivity to androgens as we age, along with a more intense stream of acne-causing hormones than when we were teens.
If you’ve already gone to your OBGYN to rule out any possible thyroid issues, ovarian cysts, PCOS, and endometriosis (all of which would have more symptoms than just acne, so don’t freak), talk to your derm about spironolactone, a low-dose prescription pill that blocks some of those androgen hormones, thus decreasing your zits.
It’s the not-so-secret weapon of derms and beauty editors—virtually every editor I know, including yours truly—is currently on spiro and loving it. It starts working within three months and the side effects are pretty innocuous: It’s a diuretic and makes you retain potassium. “That’s it?!” you shout. “I’ll take it.”
CAUSE #2: You’re Messing With Your Birth Control
Here’s the classic, age-old, historically accepted—by most of society, at least—path for women and their reproductive health: You get your period, you go on birth control pills, and you keep taking those pills every single day until you either have babies or go through menopause. But the world is full of information and autonomy, and women are experimenting with their birth control options at higher rates than before—which means they’re also accidentally messing with their hormones.
“Now more than ever, I’m seeing a lot of patients in their 20s who are either coming off the pill, going on the pill, or switching up their birth control more frequently, all of which can cause hormonal acne,” says dermatologist Mona Gohara, M.D. associate clinical professor at Yale. For example, you may have unwittingly switched from a birth control pill that’s FDA-approved for treating acne (like Ortho Tri-Cyclen, Estrostep, or Yaz combination pills) to a pill that can worsen hormonal acne (like progestin-only minipills). Or maybe you just started birth control for the first time in your life—or went off of it for the first time since puberty—and your body is still adjusting to the sudden change in hormones (which can take up to four or five months to regulate).
Or maybe your best friend finally convinced you to the magical, wonderful, life-changing world of IUDs, without realizing that a possible side effect of hormonal IUDs is acne. Since IUDs are progestin-only—and excess progestin is known to trigger an increase in “male” hormones—they’re often the cause of cystic acne outbreaks in acne-prone women. And, even more annoyingly, those breakouts can take up to six months after insertion to appear, so most women don’t even realize their IUD could be at fault.
Of course, if you just had an “Oh, my god” moment and suspect your IUD or birth control pills are to blame for your skin issues, don’t freak—your doctor can prescribe you spironolactone in addition to your IUD to mitigate acne, or switch your minipill to a combination birth control pill to regulate your hormones, or give you a topical retinol to help prevent future breakouts. Basically, there’s no reason why acne should stop you from using your preferred birth control method.
CAUSE #3: You’re Getting Healthier
When you turn 25, your metabolism starts to slow down for the first time, which is why you’ve probably noticed an uptick in healthy eating and exercise habits among your 20-something friends. But major health shifts, even positive ones, can also lead to major skin upheaval. “Any rapid weight fluctuations can mess with your hormones and lead to breakouts,” says Dr. Gohara.
Even if your weight has stayed the same, your skin hygiene itself may have changed—never washing your face might have been fine in college when you didn’t exercise, but never washing your face now, when you’re, say, wearing makeup to work then getting sweaty at the gym, is a recipe for breakouts. And no, quickly scrubbing your face with a makeup wipe won’t cut it, either.
“But I’ve always been active!” you cry, clutching your pimples. Great—let’s look at your diet. While it’s awesome that you’ve replaced your morning doughnut with a green smoothie, dietary shifts can also wreak havoc on your skin at first, especially if you’re suddenly ingesting a bunch of known zit-triggers.
The biggest culprits? “Sugar, dairy, and whey,” says Dr. Gohara, noting that all three of these are converted to glucose—i.e. simple sugars—in your body as soon as you eat them. That glucose then causes an insulin spike that triggers skin inflammation and hormonal fluctuations, which directly lead to acne. Annoyingly, you’ll find high levels of these culprits in a ton of seemingly healthy food, like yogurt, smoothies, protein powders, nutrition bars, and dried fruit, so make sure to remember the “everything in moderation” rule.
Of course, if your diet has only gotten worse since college—are your primary food groups are wine and pasta?—you’ve probably found your answer. “Foods with a high glycemic index, like bagels, potatoes, rice, and even certain fruits trigger insulin spikes that lead to breakouts,” says Dr. Gohara. And I think you already know the solution to that.
CAUSE #4: You’re Starting to Take Care of Your Skin
When your parents were in their 20s, they weren’t spending their evenings applying triple sheet masks and a six-step skincare routine. But for today’s generation, that’s an average Monday night. Though recent skin awareness is, overall, a good thing, it’s also been a major cause of dermatologist appointments in the last few years.
“A lot of people in their 20s are now jumping on the trendy skincare bandwagon and caring for their skin for the first time, even though they have no idea what they should be using or why,” says Dr. Gohara. “So they’ll apply a bunch of new, popular, often irritating products all at once, and then break out in weird rashes that look like acne.” And, because the world is unfair, most at-home acne treatments will only worsen these rashes, so by the time patients finally see a derm, “their skin barrier is basically destroyed,” she says.
“This shogun beauty approach of trying everything and applying everything will only irritate and inflame your skin until it erupts in rosacea, perioral dermatitis, seborrheic dermatitis, and contact dermatitis,” says Dr. Gohara. “Everyone thinks they’re breaking out, but it’s often a dermatitis that you can’t self-treat.” To make the whole thing even more fun, dermatitis presents a little differently in every patient, making it nearly impossible to diagnose yourself. (Trust me; I’ve tried.)
That’s not to say you should avoid the drugstore skincare aisle for the rest of your life, but you do need to be smart about it. Ask a dermatologist—not Google—about the ingredients you should actually be using for your skin issues, so you don’t drop a bunch of money on formulas you don’t need. Then stick to testing only one new product (yes, even sheet masks) a week, and try to give your skin a week off between new products to see if you have a delayed adverse reaction.
And, never, ever, ever use a product that “kinda stings” or “tingles” or “burns”—it’s a warning sign that the formula is damaging your skin, which will inevitably lead to both dermatitis and hardcore acne. And if you do suspect your new routine is disrupting your skin, please, for the love of beauty, go to a doctor.
CAUSE #5: Your Skin Is Just Being an Asshole
Sometimes, despite your best efforts, your skin is just an asshole (like mine!). Breakouts don’t always have a one-and-done answer—they’re often a culmination of a bunch of things, like a new medication that’s accidentally messing with your skin, or a stressful life change (like graduating, moving, or a new job) that’s raising the acne-causing cortisol hormone for months at a time.
For me, my skin hell had multiple factors: using a harsh product that caused a rash, making that rash worse with acne-fighting products, breaking out from the inflammation, and then stressing and worrying so intensely about my skin that I screwed my hormones up, leading to cystic acne.
At least, that’s what I’ve pieced together. Because frankly, unless you can Ms. Frizzle your way into your body, you might never know the exact cause of your shitty mid-20s skin—and that’s okay. Medicine and technology have come so far in the last decade that dermatologists have an endless list of solutions to help with your skin issues.
So even if you feel like you’ve tried everything under the sun, and that all hope is lost, and that you’ll be the only 82-year-old woman with a chin full of zits, trust me—these breakouts won’t last. There are treatments, there is hope, and there are endless amounts of dog memes to comfort you when you feel like crying under a blanket. But in the meantime, remember that your skin is not your worth. You’re a million more wonderful things than some stupid zits, and that’s really, truly all that matters in the end.