There’s a volcanic eruption forming on your face, and you’ve just dressed for a charity ball: Wasn’t this acne thing supposed to end at 20? Or at least by 30?

According to the American Academy of Dermatology, 50 percent of women get acne at some point in adulthood—disproportionate to the rate of men. 

Don’t blame chocolate, fatty foods, or heavy moisturizers; it’s more complicated than that. While increasing scientific evidence suggests foods with a high glycemic index and dairy products can make acne worse, says Dr. John Knox, adult acne also stems largely from things even harder to avoid: stress and hormonal changes. 

Knox, a Swedish-affiliated dermatologist who practices at Minor & James Medical in Seattle, says there are three common types of acne he tends to see. The first is the teenage-era kind that can also flare up throughout adulthood, especially during stressful times and hormone changes.

The second type, acne rosacea, is associated with broken blood vessels and skin that flushes easily. Like rosacea in general, it is exacerbated by red wine, certain foods, and sun exposure. “My rosacea patients tend to be better at wearing sunscreen than my skin cancer patients” because their skin’s reaction is more immediate and visible, Knox says.

Then there’s perioral dermatitis, which causes a fine rash as well as pimples primarily around the mouth, including on the nose and chin. This type is even more stress related, comes on suddenly, and almost exclusively affects middle-aged women. 

The skin creams that work on teenage acne are too strong for most adult acne. They can cause excessive irritation and don’t address its underlying causes. “Adult skin is very different from teenage skin. You have to be much more aware of what can irritate the skin,” Knox says.

Fight the temptation to scrub acne-prone skin. The American Academy of Dermatology recommends washing with lukewarm water and using mild cleanser in the morning, evening, and after sweating. 

After all, says Dr. Nicola Nylander, a dermatologist with the Polyclinic, adult acne isn’t just about how clean you keep your skin. “It’s about hormones. Babies get it—both male and female—and it comes from the mother during birth, then disappears quickly. Teens get it, naturally. Then, adult women are prone to acne, too, much more so than men. That’s because our hormones are changing regularly—on a monthly basis—in a way that men’s don’t,” Nylander says. “Oral medication—not just topical solutions—may be needed to treat adult onset acne.”

Most important, Knox recommends dealing with the underlying causes of adult acne, including stress. That means trying known stress reducers such as yoga and, he adds, “avoiding mean people.”

The bottom line: Treating acne means being gentle on your skin—and on yourself. 

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