Acne is the most common skin condition worldwide – and by no means just a problem of puberty. Adult acne particularly affects women, often well into their forties or fifties. The causes are varied, the frustration is real, and the flood of information on the internet doesn't make things any easier.

What happens with acne: Sebaceous glands produce too much sebum. Dead skin cells clump together and clog the pores. Bacteria (especially Cutibacterium acnes) multiply in the clogged pores. The immune system reacts with inflammation – pimples, pustules, and nodules develop.

This cascade is influenced by various factors: hormones (especially androgens), genetic predisposition, diet, stress, medications and external factors such as comedogenic cosmetics or mechanical irritation.

The good news: Many of these factors can be influenced. While genetic predisposition and hormonal makeup cannot be changed, there are numerous lifestyle factors that can improve the appearance of the skin – sometimes dramatically.

Important: This guide covers mild to moderate acne. Severe acne with many nodules, cysts, or scarring requires dermatological treatment. Even if you're doing everything "right" and don't see any improvement, a visit to the doctor is advisable.

The approach here is holistic: not a magic cream or a single food will solve the problem, but a combination of nutrition, stress management, care and, if necessary, medical support.

Hormones play a central role in acne – it's no coincidence that the condition typically begins in puberty, when hormone production increases. But even in adults, hormonal factors are often key to understanding and treating acne.

Androgens (male hormones that women also have) are the main drivers of sebum production. Testosterone and its more potent metabolite dihydrotestosterone (DHT) stimulate the sebaceous glands. More sebum means more raw material for clogged pores.

In women, skin often fluctuates with the menstrual cycle. During the first half of the cycle, estrogen, which has an anti-androgenic effect, is dominant – the skin is often at its best. In the second half, and especially before menstruation, estrogen and progesterone levels drop, while the relative androgenic effect increases. This is the origin of the classic premenstrual acne flare-up.

PCOS (Polycystic Ovary Syndrome) is a common cause of hormonal acne in women. It is associated with elevated androgen levels and often manifests as acne, hair loss on the scalp, and increased body hair.

Hormone levels are more stable in men, but some have a genetically determined higher sensitivity of the sebaceous glands to androgens.

Hormonal acne typically appears in the lower face: chin, jawline, neck. It often consists of deep, painful nodules under the skin, rather than superficial blackheads.

Hormonal acne can be treated with medication: In women, antiandrogen contraceptives or spironolactone can help. However, lifestyle factors can also influence hormonal balance – more on this in the following sections.

The link between diet and acne was long disputed, but is now well-established scientifically. Certain dietary patterns can worsen acne, while others can improve it – although individual differences are significant.

High-glycemic carbohydrates are the most thoroughly researched trigger. White bread, sugar, sweets, soft drinks, and other rapidly digestible carbohydrates cause blood sugar levels to rise quickly. The body responds by releasing insulin. Insulin stimulates the production of IGF-1 (insulin-like growth factor 1), which in turn boosts sebum production and promotes the keratinization of pores. Studies show that a low-glycemic-index diet can improve acne.

Dairy products are also under suspicion. The data is less conclusive than with sugar, but several studies show a link, especially with skim milk. Possible mechanisms: Milk contains natural hormones and growth factors that could stimulate the sebaceous glands. The processing of skim milk could concentrate certain proteins that are problematic.

Omega-6 to Omega-3 ratio: A diet high in Omega-6 (typical Western diet with lots of vegetable oil and processed foods) promotes inflammation. More Omega-3 (fatty fish, flaxseeds, walnuts) has an anti-inflammatory effect and can improve acne.

Antioxidants protect against oxidative stress, which plays a role in acne. Colorful fruits and vegetables, green tea, and dark berries are rich in protective polyphenols.

A practical approach: First, reduce sugar and highly processed carbohydrates – this often brings the greatest improvement. Then, if necessary, eliminate dairy products for a few weeks and observe the results. More vegetables, more omega-3 fatty acids, fewer processed foods.

Research on the gut-skin axis has revealed astonishing connections in recent years. The gut microbiome – the trillions of bacteria in our digestive tract – influences systemic inflammation, immune function, and thus also the skin.

People with acne often have an altered gut microbiome compared to people with clear skin. Whether this is a cause or a consequence is still being researched, but the connections are clear.

An imbalance in the gut can weaken the intestinal barrier. When this becomes more permeable, bacterial components and other substances can enter the bloodstream and trigger systemic inflammatory reactions – which can also manifest in the skin.

Short-chain fatty acids, produced by gut bacteria from dietary fiber, have anti-inflammatory effects. A low-fiber diet reduces their production.

Practical measures for a healthy gut: Aim for a variety of fiber from different sources – vegetables, fruits, whole grains, and legumes. Aim for at least 25-30 grams of fiber daily, ideally more. Fermented foods like yogurt, kefir, sauerkraut, and kimchi provide probiotic bacteria. Prebiotics (onions, garlic, leeks, asparagus, and chicory) nourish the beneficial gut bacteria.

Reducing factors that disrupt the microbiome: excessive sugar, artificial sweeteners, alcohol, unnecessary antibiotics. Stress also negatively affects the gut microbiome.

Probiotic supplements can help some people, but the quality varies greatly and not every strain works the same. Certain strains (such as Lactobacillus rhamnosus) have been specifically studied in relation to skin health.

The relationship between stress and acne is bidirectional and can become a vicious cycle: stress worsens the skin, bad skin causes stress, and so on.

When stressed, the body releases cortisol. Cortisol stimulates the sebaceous glands, promotes inflammation, and weakens the skin barrier. Furthermore, stress increases the release of CRH (corticotropin-releasing hormone) directly in the skin, which intensifies the inflammatory response in acne.

Stress-related behavioral changes exacerbate the problem: poorer sleep, unhealthier diet (sugar as a comfort food), more alcohol, less exercise, neglect of skin care – or obsessive picking at pimples.

The psychological burden of acne is often underestimated. Studies show increased rates of anxiety and depression in people with acne, regardless of severity. Perception is subjective: some people suffer greatly from objectively mild acne, while others cope better with more severe cases.

Stress management as an acne treatment: Regular relaxation practices such as meditation, yoga, or breathing exercises have been proven to have positive effects on the complexion. Sufficient sleep (seven to eight hours) is essential – both for stress regulation and skin regeneration. Physical activity is a powerful stress buffer. Social support and enjoyable activities are also important.

Don't ignore the psychological aspect: If acne is causing you significant distress, causing you to withdraw socially or negatively impacting your self-esteem, professional support is advisable – both dermatological and, if necessary, psychological.

For persistent acne, especially when it shows hormonal patterns, laboratory diagnostics can be helpful. They help identify underlying imbalances and make treatment more targeted.

Hormone levels in women: If hormonal acne is suspected, testosterone (total and free), DHEA-S, SHBG (sex hormone-binding globulin), and androstenedione can be informative. Ideally, these tests should be performed in the first half of the menstrual cycle. If PCOS is suspected, LH and FSH should also be measured.

Thyroid function: Both hyperthyroidism and hypothyroidism can affect the skin's appearance. TSH, free T3, and free T4 provide an overview.

Insulin resistance: Fasting glucose and fasting insulin levels are used to calculate HOMA-IR. Insulin resistance is closely linked to the blood sugar-acne connection and is common in PCOS.

Inflammatory marker: CRP (C-reactive protein) indicates systemic inflammation, which may play a role in acne.

Micronutrients: Zinc is important for skin health and has anti-inflammatory properties. Zinc deficiency is relatively common. Vitamin D influences immune function and skin processes. Ferritin (iron stores) can be relevant for women with heavy menstrual bleeding.

Important: Not everyone with acne needs laboratory testing. It's unnecessary for mild acne that responds to lifestyle changes and topical treatment. However, it's advisable for persistent, hormonally related acne or when other symptoms are present (irregular menstrual cycle, hair loss, weight problems).

The DoctorBox metabolism check offers a comprehensive analysis of important blood values ​​that are also relevant for skin health.

External skincare doesn't replace internal treatments, but it's an important component. Many people with acne make mistakes in their skincare routine that worsen the problem.

Cleansing: Twice daily, morning and evening. A gentle cleanser with a pH value around 5.5 (the skin's natural pH) is ideal. Harsh cleansing with soap or alcohol-based products damages the skin barrier and can paradoxically lead to increased sebum production. Avoid scrubbing with rough washcloths – this irritates and spreads bacteria.

Active ingredients: Salicylic acid (BHA) dissolves sebum in the pores and has an anti-inflammatory effect – ideal for clogged pores. Benzoyl peroxide kills acne bacteria, but can be drying and bleach fabrics. Retinoids (vitamin A derivatives) normalize cell renewal and prevent clogged pores – very effective, but requires some getting used to. Niacinamide regulates sebum production and has an anti-inflammatory effect.

Moisture: Even oily, acne-prone skin needs moisture. A light, non-comedogenic moisturizer is important. When skin dries out, it often produces more sebum to compensate.

Sunscreen: Daily, even on cloudy days. Many acne treatments make the skin more sensitive to light. Choose a light, non-comedogenic sunscreen or a daily moisturizer with SPF.

What to avoid: Using too many products at once (irritation, confusion). Aggressive scrubs or brushes. Comedogenic ingredients – look for 'non-comedogenic' on the packaging. Constantly touching your face. Picking and squeezing – leads to inflammation and scarring.

Patience is key: skincare products need time to work. Use them consistently for at least six to eight weeks before deciding if something is working.

Besides diet, stress and skincare, there are other factors that influence the risk of acne – some obvious, some surprising.

Sleep affects the skin on many levels. Lack of sleep increases cortisol, weakens the skin barrier, and reduces nighttime regeneration. Seven to eight hours is optimal. The pillowcase should be changed regularly – it collects sebum, bacteria, and product residue.

Exercise improves blood circulation, promotes detoxification through sweating, and reduces stress. However, sweat should be washed off promptly. Tight-fitting sportswear can cause friction and heat, which promotes acne on the body ('acne mechanica').

Mobile phone hygiene: Holding your smartphone against your face transfers bacteria and dirt to your cheek skin. Clean it regularly and ideally use a hands-free device or headphones.

Facial touching: Most people unconsciously touch their face dozens of times a day. Become aware of it and reduce it.

Hair care: Products that get on your face (oils, waxes, sprays) can clog pores. The forehead is particularly prone to this. If you have bangs or hair that falls across your face, use light, non-comedogenic products.

Makeup: Choose non-comedogenic, oil-free formulas. Clean brushes and sponges regularly. Remove makeup thoroughly in the evening – never sleep with it on.

Smoking worsens blood circulation in the skin, promotes free radicals and has been linked to a specific form of adult acne ('smoker's acne' with many blackheads).

Alcohol dehydrates, disrupts sleep, increases inflammation, and often leads to poorer choices in nutrition and care.

Lifestyle changes and good skincare can make a big difference, but they have their limits. Some forms of acne require medical treatment.

You should see a dermatologist if you have: severe acne with many inflamed nodules and cysts; acne that leaves scars; acne that doesn't respond to lifestyle and over-the-counter products after three to four months; psychological distress caused by the skin condition; the sudden onset of severe acne in adulthood; or acne along with other symptoms (irregular menstrual cycles, hair loss, weight gain).

Medication options: Topical retinoids (prescription only) are very effective in normalizing skin renewal. Topical antibiotics (in combination with benzoyl peroxide) for inflammatory acne. Oral antibiotics for moderate to severe acne, for a limited time. Hormonal treatment for women (certain contraceptives, spironolactone). Isotretinoin (Roaccutane) for severe, treatment-resistant acne – very effective, but with significant side effects and close monitoring.

Professional treatments: Chemical peels, laser therapy, light therapy and extractions by trained personnel can be useful as a supplement.

A good dermatologist will not only prescribe medication but also ask about triggers and offer lifestyle recommendations. The combination of medical treatment and lifestyle optimization is often the most effective approach.

Patience remains important: Even prescription treatments take time. With retinoids, the skin may initially worsen ('purging') before improving. Three to six months is a realistic timeframe for significant improvements.

Does chocolate really cause pimples?

The connection is more complicated than you might think. Pure cocoa is probably not the problem – it's more likely the sugar and milk in many chocolates. However, a small study showed that even sugar-free chocolate worsened acne in some people. Dark chocolate with a high cocoa content (>70%) and little sugar is the better choice. Observe how your skin reacts.

Should I completely avoid dairy products?

The data isn't conclusive enough for a general recommendation. However, a four- to six-week elimination diet can be informative. If your skin improves, milk was likely a trigger for you. Some people tolerate fermented dairy products (yogurt, cheese) better than milk itself. Important: When eliminating dairy products, be sure to use alternative sources of calcium.

Does drinking lots of water help with acne?

Adequate hydration is important for overall skin health, but excessive water consumption won't cure acne. Two to three liters a day is a good starting point. The myth that you can 'flush out toxins' is exaggerated – detoxification is done by the liver and kidneys, not liters of water.

Does stress really make my acne worse?

Yes, the connection is scientifically proven. Stress increases cortisol and CRH, which stimulate sebum production and promote inflammation. Furthermore, stress often leads to poorer sleep and an unhealthier diet. Stress management is therefore a legitimate part of acne treatment – ​​meditation, exercise, and sufficient sleep can bring measurable improvements.

Is adult acne different from teenage acne?

Adult acne is more common in women and often shows hormonal patterns: appearance in the lower face (chin, jawline), worsening before menstruation, deep inflammatory nodules rather than superficial comedones. The skin is often both dry and oily. Adult acne often responds better to hormonal treatments than to traditional teenage acne therapies.

Can exercise improve my acne?

Exercise can indirectly help: it reduces stress, improves insulin sensitivity, promotes blood circulation, and supports good sleep. However, sweat can clog pores, especially under tight clothing. Showering after exercise and removing sweat from your face is important. Sweatbands, helmets, and tight straps can trigger acne mechanica.

How long does it take for a change in diet to have an effect?

Skin needs time to regenerate – about four weeks for a complete cycle. Initial improvements from dietary changes often appear after two to four weeks, with the full effect visible after three months. Patience is key: fluctuations are normal, and not every dietary change works the same for everyone.

Should I squeeze my pimples?

Generally, no. Squeezing can push bacteria deeper into the tissue, worsen the inflammation, and lead to scarring. If a pimple has a distinct white "head" and appears ripe, you can try to open it with clean hands and gentle pressure. But: Never squeeze deep, painful pimples – that will only make things worse.

Can makeup worsen acne?

Comedogenic (pore-clogging) products can contribute to acne. Choose products labeled 'non-comedogenic' or 'oil-free'. More important than the makeup itself is thorough removal in the evening. Clean brushes and sponges regularly. Mineral makeup is often well-tolerated, but individual reactions vary.

Do probiotics help with acne?

Research on the gut-skin axis is promising, but not yet conclusive. Individual studies show positive effects of certain probiotic strains (such as Lactobacillus rhamnosus) on acne. Trying them may be worthwhile, especially if digestive problems are also present. However, not all probiotics are the same, and their effects vary from person to person.

When should I go to the doctor?

You should consult a doctor if you have severe acne (many inflamed nodules, cysts), if scarring occurs, if over-the-counter treatments and lifestyle changes are ineffective after three months, or if the acne is causing you significant psychological distress. A medical evaluation is also advisable if acne suddenly appears in adulthood or occurs alongside other symptoms (menstrual irregularities, hair loss).