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Acne is caused by an abnormal response in the skin to normal levels of the hormone testosterone. Both men and women have testosterone circulating in the blood, but in the acne sufferer, this hormone has profound effects on the skin. This abnormal response is usually self-limiting and in 70% of cases resolves without treatment, but there is no way of predicting how long this will take - it may be years or even decades.

There are two main problems - over-production of oil from the sebaceous glands causes a build-up of sebum in the pores while over-growth of skin cells at the mouth of the pore create a bottle-neck preventing the release of the oil. This results in solidification of the oil, which fills the pore, forming a comedone, or blackhead. The "black" of the blackhead is not due to dirt, but to oxidation of pigment in the sebum. If the blockage becomes complete, the oil becomes infected with bacteria, normally present on the skin but only a problem in oxygen poor, oily environments such as a blocked pore. The bacteria breaks down the oil creating an acidic environment that causes inflammation, redness, pus formation and pain . If the inflammation is deep and severe, or if the spot is squeezed, the pus can burst deep into the skin rather than on to the surface. This deep-routed inflammation and infection can result in scarring and cyst formation.

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