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Blemish: The truth about blackheads

The views expressed are those of the author and are not necessarily those of Scientific American.

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Cartoon from Statistically Funny BlogspotSome old wives’ and doctors’ tales are pretty harmless. Behind the myths about blackheads and acne, though, it gets very ugly. And what the truth shows us about how superficial we can be isn’t pretty either.

The sisters in this cartoon are very unusual. They’re blasé about their blemishes and the rather untoward experience they’re having in a type of clinical trial favored by some dermatologists. But blackheads, pimples and the adverse effects of acne treatments often cause a lot of misery. And lingering misunderstandings that are taking too long to die out contribute to that.

Most adolescents don’t have “clear” skin – less than 20% in fact. It’s pretty much the luck of the draw. Genes may be involved. More often than not, for as much as a decade or longer from the age of 15, people are going to have at least some blackheads and pimples to deal with, if not full-blown acne. Acne might be getting more common and may be starting youngera sign of puberty starting earlier, perhaps.

Around one in five adolescents will have moderate to severe acne, and about the same number will have scarring. For those with dark skin, post-inflammatory hyper-pigmentation can follow acne lesions – and even common treatments might make the pigmentation worse. Although to add insult to injury, that’s not an issue that’s gotten all that much study.

Egyptian hieroglyph

The Egyptian hieroglyph thought to have been used for acne

Acne is so common, and it’s only “skin deep” after all. It just shouldn’t be a big deal, right? It is, though. It’s such a big deal, that the effects on young people – sometimes out of proportion to the objective severity of their skin’s condition – go all the way to a higher risk of self-harm and getting suicidal. As Darwin’s contemporary, Herbert Spencer, said: “The saying that beauty is but skin deep is but a skin-deep saying.”

Newspaper clipping

Advertisement in The Portsmouth Daily Times, September 1900

Blackheads and pimples are only skin conditions, caused by oil and a specific bacterium that doesn’t make people sick. But we didn’t always know that – and some time-honored myths remain deeply entrenched.

The technical word for blackhead is comedo (plural – comedones, adjective – comedonal). It comes from the Latin for gluttony, which was used to describe parasitic worms … and for the wormy look of a squeezed blackhead. Revolting, eh? And revolting imagery and explanations for skin problems is a large contributor to the misery they cause. We’ve historically had a lot of disgust for our own body products.

In 1930, seeing blackheads, pimples and oily skin on others’ faces had all made it to an academically derived list of people’s greatest annoyances (along with “to see a woman drinking liquor” and “to just miss a streetcar”). In the 1960s, blackheads even managed to rank as the most repulsive of all bodily excretions – yes, all – in some surveys of disgust.

Newspaper clipping

Extracts from an advertisement in The Pittsburgh Press, November 1919

We assign a disproportionate amount of disgust, in fact, to skin conditions – including something so inherently trivial as blackheads. A blackhead is simply a pore clogged with a bit of oil that’s open to the air – oxidation turns it black. (If skin covers the oil and any pus from infection with Proprionibacterium acnes, that’s a whitehead, pimple or zit.)

Newspaper clipping

Advertisement in The Milwaukee Journal, February 1930

Blackheads do not mean that skin is clogged with dirt, and acne isn’t a sign of lesser hygiene. Although reducing oil gets at the problem, very abrasive scrubbing can damage the skin and actually increase the inflammation that causes pimples.

Yet people are still marketing their products with this “dirt” myth. It’s a hard notion to dispel. Here are snippets from the packaging of products currently on sale in my local drugstore:

  • Washes away problem-causing dirt…
  • Clear breakouts and blackhead-causing impurities.
  • Deep cleans even dirt and oil you can’t see.

Which brings us inevitably to an industry that has a lot at stake in making us unhappy enough about our skin that we’ll be hooked onto skin products our whole lives. More than $300 million will be spent on over-the-counter acne products alone in the US each year. Skin-care and cosmetics are chewing up an increasing proportion of teenagers’ budgets (around 20% for those with an average or high amount of cash).

Women in particular are manipulated emotionally with claims of “flawless” skin, and products that do all sorts of often biologically impossible things for the skin, especially “revitalize”. It’s the language of a previous medical tradition – of humors – lingering still.

Picture of book cover

The Beauty Myth, by Naomi Wolf (image via Wikimedia Commons)

In The Beauty Myth, Naomi Wolf points out that the language of skin care – “calm,” “soothe,” and “nourish” – are claims on women’s emotional needs, not their skin. They prey on women’s feeling of vulnerability, and weaken self-esteem while offering a way to restore it. Wolf gathered some amazing claims. My personal favorite? “When your skin is acting confused.”

Even though acne affects far more young men than women, women have been bombarded with messages about the importance of “clear” skin for a long time. Consider this advertisement from 1909: “Every woman strives to acquire and preserve a clear, faultless, rose-and-lily complexion. This is apparently the height of the feminine ambition.” Racism, sexism and commercial exploitation rolled into one: now that’s gross.

There’s more behind all this, however, than money, specific notions of beauty and squeamishness about body excreta. Faces are critically important to us. We judge others by them, and know we are judged in turn. Moral judgments also accrue to the way we see those we find beautiful – or those we judge to be contagious.

Facial disfigurement has been seen as a mark placed by the devil in the past. An analysis of cinema showed we still have an association between skin conditions, scars and evil. As dermatologist Hywel Williams points out, even children know if you’re drawing a witch, she’s gotta have warts.

Robert Kurzban and Mark Leary argue that our tendency to stigmatize others has evolutionary origins. We need to choose mates, avoid many people and protect ourselves from contagious disease. Social exclusion, then, would be an adaptive response to living closely with people in large groups. That could explain, they write, why “an inherently social species with a strong need for social acceptance should be inclined to reject members of its own kind.”

In 1613, the man who probably first committed the concept of beauty being “only skin deep” to print, was apparently murdered by the woman he was describing – thus rather decisively proving his point. We’ve made a lot of progress on skin diseases in those four hundred years. But how can we move faster towards the time when we narrow down our social choices by things that aren’t so literally superficial as blemished skin? Doing more to scrub away the remnants of old ways of thinking about skin conditions as a sign of poor hygiene might help, at least a little.


For more information about acne, check out this evidence-based information for people with acne and this dermatology overview. There’s more specific information about blackheads in a Wikipedia article (to which I contribute).

The cartoon is original, from my post about within-person trials at Statistically Funny (Creative Commons, non-commercial, share-alike license). My sketch of the ancient Egyptian hieroglyph, Aku-t, is based on the representation from Budge’s “An Egyptian hieroglyphic dictionary” in Grant’s article on the history of acne.

The advertisement clippings come from: The Portsmouth Daily Times (1900), The Pittsburgh Press (1919) and The Milwaukee Journal (1930).

The thoughts Hilda Bastian expresses here are personal, and do not necessarily reflect the views of the National Institutes of Health or the U.S. Department of Health and Human Services.

Hilda Bastian About the Author: Hilda Bastian likes thinking about bias, uncertainty and how we come to know all sorts of thing. Her day job is making clinical effectiveness research accessible. And she explores the limitless comedic potential of clinical epidemiology at her cartoon blog, Statistically Funny. Follow on Twitter @hildabast.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. ironjustice 2:37 pm 09/16/2013

    One might wonder whether vegetarians would have a lower risk of acne due to their body fatty acid content being somewhat different from a meat eater, higher linolenic in the vegetarian.

    “A greater salivary concentration of alpha-linolenic acid (18:3 n-3) (2.82) was found”

    “Components possessing antimicrobial activity against acne causing bacteria, namely alpha-linolenic acid”

    Link to this
  2. 2. Hilda Bastian in reply to Hilda Bastian 3:07 pm 09/16/2013

    Yes, lots of theoretical possibilities. Jury’s still out on diets that have been shown to reduce acne – see Bhate and Williams, although low glycemic diet regarded as a candidate.

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  3. 3. Robert_Britt 3:24 pm 09/16/2013

    I like this article, warts and all. But seriously as a father of four, two who went through serious acne issues, I am glad to see light shed on the truth and rumors put to rest.

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  4. 4. ironjustice 3:38 pm 09/16/2013

    “Iron dermis levels might be implicated in atopic dermatitis patients”

    It may be a variety of factors which are different because of diet between meat eaters and vegetarians. The combination of increased iron levels caused by eating meat, accompanied by decreased plant fatty acids and decreased antioxidants destroyed by the high oxidative state induced by the iron.
    “High iron and low ascorbic acid concentrations in the dermis of atopic dermatitis patients”

    “Dietary, but not topical, alpha-linolenic acid suppresses UVB-induced skin injury in hairless mice when compared with linoleic acid.”

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  5. 5. Hilda Bastian in reply to Hilda Bastian 3:44 pm 09/16/2013

    There are so many things that might travel side-by-side with being a vegetarian, that it can’t be entangled in theory. Trials are really needed to be sure and/or very large, rigorous epidemiological studies. I wrote about some relevant methodological pitfalls with ascribing outcomes to diets in this post.

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  6. 6. Hilda Bastian in reply to Hilda Bastian 3:46 pm 09/16/2013

    Thanks – yes, it’s a subject that’s under-appreciated, that’s for sure. Sounds like it’s past tense for your family – glad it’s behind you all.

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  7. 7. ironjustice 8:40 pm 09/16/2013

    “that it can’t be entangled in theory”

    The studies can be done in your head, up to a point, and with a computer, one need but know the questions to ask. The genius Linus, with his insane vitamin C regimen as an example of work completed? His belief oxidation being a problem in humans, explained by the recently coined, age-related iron accumulation. Reverse engineering a theory, once you have come up with the theory, is allowed by data mining because most of the studies have been completed, again, an example being the different fatty acid content of spit.

    Link to this
  8. 8. Hilda Bastian in reply to Hilda Bastian 12:53 am 09/17/2013

    We’ll need to agree to disagree on this, ironjustice. Actually, the science of assessing the effectiveness of an intervention can’t be done that way and also lead us reliably close to “the truth.” While you can, with effort, often find some data somewhere that appear to show almost anything you want, with additional effort you can also generally find some data that would appear to show the opposite. If there hadn’t been rigorous trials of supplements of antioxidants, we wouldn’t know that they can sometimes do more harm than good (see a summary here).

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  9. 9. tetchystar 9:10 am 09/17/2013

    I’ll be one to chime in to say that I’m not really convinced diet is a big factor in acne. I think, as the article suggests, that it might just be luck of the draw in genetics and possibly hormones.

    As a teenager I always had little to no acne to speak of, I was one of those kids with supremely clear skin, but I had a terrible diet (plenty of meat and junk food and very very little vegetables) and was quite overweight. One thing I did have was very dry skin (so less oil production in general?), which I’ve had to use thick lotions on all my life. Even now as an adult, though I eat much better and have lost all that weight, and what little acne I had is almost non-existent, I get one or two pimples around my time of the month like clockwork. In fact, if I see I have pimples, I know my cycle is right around the corner.

    What does any of this mean? Who knows, my sister was a vegetarian for years because she thought it would help with her own bad acne, though it never did. She used topical prescription acne medication instead, which worked to a degree. Now that she’s an adult she doesn’t have as much anymore except, like me, around her cycle, thought she gets more and bigger pimples than I do.

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  10. 10. karl 9:57 pm 09/20/2013

    somehow we humans seem to be always in the mindset more is better, “clean” skin is ok because it means youth and health, get the cleanest skin you can (I am thinking of replacing it with silicon based rubber) being thin is good for health, ok starve to death, and this isn`t just human related, beauty contests for dogs are pushing forward unhealthy configurations for certain species such as basset hounds with skin folds too big for their own good.
    I’d love to see mankind die because of this.

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  11. 11. blukbluk 9:53 pm 09/24/2013

    Thanks for this article. Two things I’d like to add as a sufferer of cystic acne for many years.

    One – the most useless thing that was said to me ad nauseum by family and friends was ‘If you just stopped touching/picking them they would go away’. I felt such relief when my dermatologist said ‘well, of course you touch them too much, they’re so painful you can’t help it’. I felt so understood!

    Two – I’ve been a vegetarian for more than 15 years and it didn’t make a jot of difference to my acne. The only thing that worked for me was accutane.

    Link to this
  12. 12. Hilda Bastian in reply to Hilda Bastian 7:04 am 09/25/2013

    So glad that accutane helped, katemcg – and very glad you found a dermatologist who gets how tough this condition is.

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  13. 13. bucketofsquid 5:26 pm 09/26/2013

    @Karl – You are a sick puppy.

    @IronJustice – Give it a rest already. I have anodized steel water pipes in my old crumbling house and I don’t have any of the insane multitude of illnesses you have blamed on iron over the last few years. I’ve been in this house for 2 decades so far and still none of the problems you ascribe to iron.

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