clinical guide to acne

The Clinical Guide to Acne: What Acne is, Why We Get It, and

What To Do About It

Illustrations By: Shirley Rozgonyi

Prepared in Collaboration with:

What is Acne? 3

Acne Overview 4

Acne Prevention Tips 6

Acne Treatment 7

Topical Medications 9

Oral Medications 10

Therapies 12

Child Acne 14

Teen Acne Tips 15

Healthy Skin Diet 16

Acne Myths 22

Who Gets Acne? 25

Who Gets Acne? 25

What Causes Acne? 25

Skincare 26

Dry Skin Care 26

Sun Protection 28

Facial Skin Care For Mature Skin 30

Facial Skin Care For Acne-Prone Skin 30

References 33

Table of Contents

Hi there, We are so glad you’ve joined us on the first step to improving and clearing your acne-prone skin.

In this book, you’ll find information on medications and tips you can follow to improve your skin, and ultimately your confidence.

These tips and guidelines are just the start, make sure to consult with a doctor or physician before starting any treatments or taking any medications.

We hope you’ll find this information useful. If you have any questions please reach out to us at [email protected].

We would love to hear from you and hope to be part of your journey to clearer skin!

Sincerely, The Proclear Team

What is Acne? Chapter 1

/aknē/noun

the occurrence of inflamed or infected sebaceous glands in the skin; in particular, a condition characterized by red pimples on the face, prevalent chiefly among teenagers.

Acne Overview Chapter 2

Acne is the most common skin condition that people experience. Most people develop acne to some

degree, but it primarily affects teenagers undergoing hormonal changes. Acne might be mild (few,

occasional pimples), moderate (inflammatory papules), or severe (nodules and cysts). Scarring can

occur. Treatment depends on the severity of the condition.

[1].[2]

Acne is primarily a hormonal condition driven by male hormones, which typically become active

during the teenage years. Sensitivity to such hormones — combined with surface (skin) bacteria and

lipids (fatty acids) within sebaceous (oil) glands — yields acne. Common sites for acne are the face,

chest, shoulders, and back—the sites of oil glands.

Acne lesions include comedones (whiteheads, blackheads), papules and pustules (small bumps, often

with scarring), nodules, and cysts, often followed by scarring.

Although acne is essentially a normal physiologic occurrence, certain conditions might aggravate the

disease:

• Fluctuating hormone levels around the time of menses (women)

• Manipulating (picking/prodding) acne lesions

• Occlusive clothing and headgear, such as hats and sports helmets

• Air pollution and certain weather conditions, especially high humidity

What causes acne?

5 Acne Overview

Acne Prevention Tips Chapter 3

1) Wash acne-prone areas only twice a day.Washing removes excess oil and dead skin cells. But too much washing can irritate the skin. Wash

affected areas with a gentle cleanser and use oil-free, water-based skin care products.

2) Use an over-the-counter acne cream or gel to help dry excess oil.Look for products containing sulfur or salicylic acid as the active ingredient.

3) Use nonoily makeup.Choose oil-free cosmetics that won’t clog pores (noncomedogenics).

4) Remove makeup before going to bed.Going to sleep with cosmetics on your skin can clog your pores. Also, it’s a good idea to throw out

old makeup and regularly clean your cosmetic brushes and applicators with soapy water.

[3]

5) Wear loosefitting clothing.Tightfitting clothing traps heat and moisture and can irritate your skin. When possible, avoid

tightfitting straps, backpacks, helmets, hats and sports equipment to prevent friction against your

skin.

6) Shower after strenuous activities.Oil and sweat on your skin can lead to breakouts.

7) Avoid touching or picking at the problem areas.Doing so can trigger more acne.

7 Acne Prevention Tips

Acne Treatment Chapter 4

Excessive scrubbing or washing can irritate your skin and actually make acne worse. So can using

astringents and facial scrubs. Instead, wash problem areas with a gentle cleanser. To dry excess oil,

try using an over-the-counter acne lotion that contains salicylic acid. [4]

If over-the-counter (nonprescription) products haven’t cleared up your acne, your doctor can

prescribe stronger medications or other therapies. A dermatologist can help you:

• Control your acne

• Avoid scarring or other damage to your skin

• Make scars less noticeable

Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial

infection or reducing inflammation — which helps prevent scarring. With most prescription acne

drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets

better. It can take many months or years for your acne to clear up completely.

The drug your doctor recommends depends on the type and severity of your acne. It might

be something you apply to your skin (topical medication) or take by mouth (oral medication).

Often, drugs are used in combination. Pregnant women will not be able to use oral prescription

medications for acne.

Talk with your doctor about the risks and benefits of medications and other treatments you are

considering.

Acne Treatment 8

The drug your doctor recommends depends on the type and severity of your acne. It might

be something you apply to your skin (topical medication) or take by mouth (oral medication).

Often, drugs are used in combination. Pregnant women will not be able to use oral prescription

medications for acne.

Topical MedicationsThese products work best when applied to clean, dry skin about 15 minutes after washing. You may

not see the benefit of this treatment for a few weeks. And you may notice skin irritation at first, such

as redness, dryness and peeling.

Your doctor may recommend steps to minimize these side effects, including using a gradually

increased dose, washing off the medication after a short application or switching to another

medication.

The most common topical prescription medications for acne are:

Retinoids. These come as creams, gels and lotions. Retinoid drugs are derived from vitamin A and

include tretinoin (Avita, Retin-A, others), adapalene (Differin) and tazarotene (Tazorac, Avage). You

9 Acne Treatment

apply this medication in the evening, beginning with three times a week, then daily as your skin

becomes used to it. It works by preventing plugging of the hair follicles.

Acne Treatment 10

Antibiotics. These work by killing excess skin bacteria and reducing redness. For the first few months

of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the

morning and the retinoid in the evening. The antibiotics are often combined with benzoyl peroxide

to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with

benzoyl peroxide (Benzaclin, Duac, Acanya) and erythromycin with benzoyl peroxide (Benzamycin).

Dapsone (Aczone). This gel is most effective when combined with a topical retinoid. Skin side effects

include redness and dryness.

Oral MedicationsAntibiotics. For moderate to severe acne, you may need oral antibiotics to reduce bacteria and fight

inflammation. Choices for treating acne include tetracyclines, such as minocycline and doxycycline.

Your doctor likely will recommend tapering off these medications as soon as your symptoms

begin to improve or as soon as it becomes clear the drugs aren’t helping — usually, within three to

four months. Tapering helps prevent antibiotic resistance by minimizing undue exposure to these

medications over a long time.

You will likely use topical medications and oral antibiotics together. Studies have found that using

topical benzoyl peroxide along with oral antibiotics may reduce the risk of developing antibiotic

resistance.

Antibiotics may cause side effects, such as an upset stomach and dizziness. These drugs also

increase your skin’s sun sensitivity. They can cause discoloration of developing permanent teeth and

reduced bone growth in children born to women who took tetracyclines while pregnant.

Combined oral contraceptives. Combined oral contraceptives are useful in treating acne in women

and adolescent girls. The Food and Drug Administration approved three products that combine

estrogen and progestin (Ortho Tri-Cyclen, Estrostep and Yaz).

The most common side effects of these drugs are headache, breast tenderness, nausea, weight

gain and breakthrough bleeding. A serious potential complication is a slightly increased risk of

blood clots.

Anti-androgen agent. The drug spironolactone (Aldactone) may be considered for women and

adolescent girls if oral antibiotics aren’t helping. It works by blocking the effect of androgen

hormones on the sebaceous glands. Possible side effects include breast tenderness, painful periods

and the retention of potassium.

11 Acne Treatment

Isotretinoin. This medicine is reserved for people with the most severe acne. Isotretinoin

(Amnesteem, Claravis, Sotret) is a powerful drug for people whose acne doesn’t respond to other

treatments.

Oral isotretinoin is very effective. But because of its potential side effects, doctors need to closely

monitor anyone they treat with this drug. The most serious potential side effects include ulcerative

colitis, an increased risk of depression and suicide, and severe birth defects.

In fact, isotretinoin carries such serious risk of side effects that women of reproductive age

must participate in a Food and Drug Administration-approved monitoring program to receive a

prescription for the drug.

Therapies Chapter 5

These therapies may be suggested in select cases, either alone or in combination with medications.

Acne Treatment 12

13 Therapies

Light therapy. A variety of light-based therapies have been tried with success. But further study is

needed to determine the ideal method, light source and dose. Light therapy targets the bacteria

that cause acne inflammation. Some types of light therapy are done in a doctor’s office. Blue-light

therapy can be done at home with a hand-held device. Possible side effects of light therapy include

pain, temporary redness and sensitivity to sunlight.

Chemical peel. This procedure uses repeated applications of a chemical solution, such as salicylic

acid. It is most effective when combined with other acne treatments, except oral retinoids. Chemical

peels aren’t recommended for people taking oral retinoids because together these treatments can

significantly irritate the skin.

Chemicals peels may cause temporary, severe redness, scaling and blistering, and long-term

discoloration of the skin.

Extraction of whiteheads and blackheads. Your dermatologist uses special tools to gently remove

whiteheads and blackheads (comedos) that haven

Steroid injection. Nodular and cystic lesions can be treated by injecting a steroid drug directly

into them. This improves their appearance without the need for extraction. The side effects of this

technique include thinning of the skin, lighter skin and the appearance of small blood vessels on the

treated area.

Child Acne Chapter 6

Most studies of acne drugs have involved people 12 years of age or older. Increasingly, younger

children are getting acne as well. In one study of 365 girls ages 9 to 10, 78 percent of them had acne

lesions. If your child has acne, you may want to consult a pediatric dermatologist. Ask about drugs to

avoid in children, appropriate doses, drug interactions, side effects, and how treatment may affect a

child’s growth and development.

Treatment of children with acne is often complicated by their family situation. For example, if a child

moves between two homes due to divorced parents, it may help to use two sets of medications, one

in each home. [5]

Teen Acne Tips Chapter 7

Acne, a skin problem that typically affects teenagers, develops when pores become clogged by the

oil and other substances on the skin.

Jennifer Lucas, MD, a dermatologist at Cleveland Clinic, says your first line of defense is a good

cleaning regimen. Here are some other tips to keep acne at bay:

1. Look for salicylic acid in acne washesIf you use an over-the-counter acne wash, choose one with salicylic acid listed as an ingredient. “All

of these work very well,” says Dr. Lucas. “You just need to be cautious because they can dry your

skin.”

2. Shower immediately after working outSweat can clog pores. Get in the habit of showering immediately after a practice, game or workout.

3. Use non-acne-forming makeupIf you use makeup, look for the “non-comedogenic” kind, which means non-acne-forming.

Teen Acne Tips 16

4. Consult a dermatologist for serious casesIf over-the-counter remedies and cleaning aren’t getting the job done, a dermatologist may be able

to help. “We can’t necessarily make it go away, but we can certainly make it more mild and keep it

from leaving you with permanent effects” like scarring, says Dr. Lucas.[6]

Healthy Skin Diet Chapter 8

Glowing, radiant, clear — those are the words you want to use to describe your skin, your body’s

largest organ. But what do you do when the words that come to mind are tired, stiff, irritated or dry?

There are plenty of foods — rich in vitamin A,vitamin C, vitamin D, omega-3 and zinc — that will help

prevent inflammation, reduce acne breakouts and leave your skin looking its best. Unfortunately,

there are also culprits in our daily diets that do the opposite. Many trigger acne,

17 Healthy Skin Diet

a skin disease that results from clogging of the oil glands at the base of hair follicles. Others affect

collagen formation, a process that is critical to keeping your skin healthy and elastic.

If you deal with skin irritations, breakouts or other concerns, take a look at your diet. Are the

following foods culprits?

1. SugarAdd one more strike against eating too much

sugar. Studies have found that diets high in

glucose or fructose affect what’s called “skin

collagen crosslinking.” That sounds complicated,

but it breaks down like this: Collagen is

responsible for your skin’s strength and elasticity.

Too much sugar can disrupt the balance in your

body’s proteins, including collagen. When that

happens, your skin’s softness and elasticity

go downhill — leading to stiff, rigid skin and,

ultimately, wrinkles.


2. Foods with a high glycemic index

That means white bread, white pastas and

potatoes, as well as sugary drinks and snacks.

Preliminary research suggests foods with ahigh

glycemic index cause acne breakouts for many

people — and keep in mind acne isn’t just a

problem for adolescents. When you eat a diet

rich in these foods, your

body produces higher levels of insulin. Insulin

spikes can set off a chain reaction associated

with developing acne. On top of that, an insulin

spike inevitably leads to an insulin crash —

leaving your skin and the rest of you looking and

feeling drained.

3. Salt

Salt and other forms of sodium may add flavor

to your food — but too much sodiumcan sap

the life out of your skin. This occurs in a couple

of different ways. For one, too much sodium

dehydrates you, which means it sucks vital

moisture from your skin. Too much sodium also

can cause you to retain water, resulting in “bags”

under your eyes and other visible signs.


4. Dairy

The typical Western diet includes many dairy

sources that contain hormones, including

certain types of steroids and growth hormones.

Unfortunately, these stimulate acne, too. The

same has been found for protein powder shakes

that contain casein and whey, as well; if you’re

using these shakes as substitutes for food, be

wary. If acne is a concern for you, organic dairy

products may offer an alternative.


5. Saturated Fats

Red meat, cheese, butter and hydrogenated

oils — all are high in saturated fats. And foods

that are high in saturated fat are associated with

high concentrations of insulin growth factor.

Unfortunately, insulin growth factor stimulates

the production of the sex hormones that

increase acne production. On the flipside,plant-

based diets, low-fat diets, high-fiber diets and

vegetarian diets reduce blood concentrations of

insulin-like growth factor. [7]


Acne Myths Chapter 9

When pimples start popping up, so does the advice about treating and preventing acne. But it isn’t

always backed by medical evidence, so it’s important to be able to separate fact from fiction.

We asked dermatologist Jennifer Lucas, MD, to address these commonly held acne beliefs:

1. Putting Listerine or toothpaste on a zit will clear it upMaybe, but don’t do it. These dental products might dry up a pimple, Dr. Lucas says, but they can

also make the skin dry, scaly and inflamed. In other words, don’t try it at home, opting instead for a

salicylic acid wash.

2. Eating chocolate makes me break outMaybe — avoid it if you wish. The verdict is still out on this one. Further studies are needed to know

for sure, but foods containing dairy and high sugar content may be associated with worsening your

acne. Therefore, if you feel like it makes your acne worse, avoid it, Dr. Lucas says. Also, people tend

to eat chocolate when they are stressed, and this may also play a role.

23 Acne Myths

3. Popping a zit will make it clear up fasterMaybe, but don’t do it. Even though we all do it sometimes, and it may appear to make it go away

faster, you are also setting yourself up for scarring. When you express the content of the pimple out,

you’re also pushing it in, Dr. Lucas says.

4. Working out makes me break outTrue, but it doesn’t have to. Acne is worsened by sweat and dirt being left/trapped on your skin. Make

sure you cleanse your face (chest and back if they are prone to breakouts) as soon as possible after

every workout, especially when you’re wearing helmets, hats, etc. that physically trap the sweat

against your skin.

5. I break out more around my periodTrue. “Hormones do play a role in acne,” Dr. Lucas says. That can mean flare-ups during your

monthly period or during pregnancy. Birth-control pills are a treatment she sometimes turns to when

a hormone imbalance is responsible for acne.

Acne Myths 24

6. Adults aren’t supposed to get acneFalse. “I hear that all the time, and I would love for that to be true,” Dr. Lucas says. Not only can acne

continue into adulthood, but some people experience adult onset acne, usually driven by hormonal

imbalances.

7. Shaving my face makes me break outFalse. What looks like pimples are probably ingrown hairs, but sulfur and salicylic acid products

recommended for acne can often help. Dr. Lucas tells patients to switch to an electric razor,

although some patients say razor-shaving more frequently can eventually ease the irritation.

8. Going tanning will help my skin clear upMaybe, but don’t do it. “I don’t see it helping people,” she says. “Putting yourself at increased risk of

melanoma as an alternative to acne is not worth the risk.”

When is it time to see a dermatologist?“When you’ve tried simple things and haven’t gotten results, it’s time to see a dermatologist,” Dr.

Lucas says. [8]

25 Acne Myths

When you have big, deep nodules that are painful, it’s setting you up for scarring. If you notice your

acne leaving more permanent marks or scars, she suggests making an appointment.

Who Gets Acne? Chapter 10

If you have a bad case of acne, you may feel like you are the only one. But many people have acne. It

is the most common skin problem in the United States. About 40 to 50 million Americans have acne

at any one time.

Who Gets Acne?

What Causes Acne?

Most people who have acne are teenagers or young adults, but acne can occur at any age. Newborn

babies can get acne. Men and women get acne. Some women get acne when they reach middle age.

Acne appears when a pore in our skin clogs. This clog begins with dead skin cells. Normally, dead

skin cells rise to surface of the pore, and the body sheds the cells. When the body starts to make lots

of sebum (see-bum), oil that keeps our skin from drying out, the dead skin cells can stick together

inside the pore. Instead of rising to the surface, the cells become trapped inside the pore.

Who Gets Acne? 26

Sometimes bacteria that live on our skin, p. acnes, also get inside the clogged pore. Inside the pore,

the bacteria have a perfect environment for multiplying very quickly. With loads of bacteria inside, the

pore becomes inflamed (red and swollen). If the inflammation goes deep into the skin, an acne cyst

or nodule appears.[9]

Skincare Chapter 11

Dry skin is defined as flaking or scaling of the skin when there is no evidence of dermatitis

(inflammation). It is most prominent on the shins, hands, and sides of the abdomen, and can be

associated with itching. It is more common during the winter months, when humidity is low, and

improves in the summer time. Some people also have a genetic tendency to develop dry skin. In

Dry Skin Care

addition, elderly people tend to have more trouble with dry skin due to the natural changes in skin

that occur with age.

Treatment is important because extensively dry skin can lead to dermatitis or eczema. Dry skin may

be prevented or treated by:

• Taking lukewarm baths or showers

• Limiting baths/showers to 5 to 10 minutes

• Applying a moisturizer right after drying off from a shower or washing your

hands

• Using a moisturizing body soap and hand soap

• Using heavier creams or ointments during the winter months and lighter

lotions in the summer

If the above regimen does not improve the condition of the dry skin, it is possible that the flaking is

a sign of underlying dermatitis (which is also called eczema). There are different types of dermatitis

that may cause dry, itchy, flaking skin. They include:

27 Skincare

• Seborrheic dermatitis — a red, scaly, mildly itchy rash on the scalp, eyebrows, and sides of the nose

in areas that contain many oil glands.

• Allergic contact dermatitis — a rash that results when the skin comes in contact with a substance

that causes an immune reaction, such as poison ivy. Allergic contact dermatitis of the hands often

causes scaling on the palms or fingers.

• Atopic dermatitis — long-lasting type of dermatitis usually starting in childhood that tends to run in

families. It also may cause excessively dry, itchy skin on the face and body.

• Athlete’s foot — dry flaking skin on the soles and/or sides of the feet and between toes caused by a

fungus.

Sun ProtectionProtecting your skin from the sun is important because the sun emits ultraviolet radiation (UVR).

Over time, UVR exposure causes many changes in the skin, including wrinkles, discoloration, age

spots, benign (non-cancerous) growths, and pre-cancerous, or cancerous growths. In fact, most skin

cancers are related to sun exposure.

Skincare 28

UVR consists of two main subtypes: UVB and UVA. UVB rays are responsible for sunburns and

tanning. UVA rays are believed to be responsible for photoaging - the damage that occurs to the skin

from many years of exposure to the sun. Both types have been implicated in promoting cancer. Most

sunscreen products available prevent sunburns by blocking UVB rays. Newer sunscreen products are

also successful in blocking UVA rays. For that reason, sun protection recommendations emphasize

certain behaviors, as well as the use of sunscreens. The recommendations include:

• Avoiding midday sun between 10 a.m. and 3 p.m.

• Wearing wide-brimmed hats, long long-sleeved shirts, and pants

• Using a generous amount of sunscreen and reapplying it frequently (every 2 to 3 hours)

• Using sunscreens that have a sun protection factor (SPF) greater than 30, and that have

• UVA and UVB coverage

• Avoiding tanning beds

Protecting the skin from excessive sun exposure may decrease vitamin D levels. A higher dose of

vitamin D intake may be necessary for individuals with known risk factors for vitamin D deficiency,

such as dark skin, older age (elderly), photosensitivity, obesity, or those with fat malabsorbtion.

29 Skincare

If you are prone to acne, choose a cleanser specially formulated for acne. These products often

contain salicylic acid or sulfur, which help to clear acne sores. Clean your face gently, as trauma to

the acne breakouts may worsen the acne or cause scarring. Avoid harsh mechanical scrubbing of

skin and picking lesions. If you need to use a moisturizer, use light, non-comedogenic moisturizers,

which do not aggravate acne. Also, women should use an oil-free foundation, as heavy makeup or

other cosmetic products that block pores may worsen acne.

Facial Skin Care For Acne-Prone Skin

Facial Skin Care For Mature SkinPhotoaging refers to the damage that is done to the skin from prolonged exposure to UV radiation,

over a person’s lifetime. Roughness, wrinkling, irregular pigmentation (coloration), inelasticity,

enlarged sebaceous (oil) glands, precancerous and cancerous lesions are all examples of skin

changes associated with photoaging. Sunscreens and sun protection are important to prevent

further progression of photoaging. Furthermore, smoking has been shown to accelerate aging of

skin, so stopping smoking is important for good skin health. In addition, a well-balanced diet allows

the skin get the nutrition it needs to help repair ongoing damage from the sun and other

Skincare 30

environmental elements. Many topical non-prescription and prescription products are currently

available for anti-aging purposes, including:

31 Skincare

Tretinoin (Retin-A® and Renova®) — Retin-A is a prescription medication initially developed to treat

acne. In addition, it was discovered that it also improved skin texture and color when used over an

extended period of time. Tretinoin exfoliates the skin (removes a dead layer of skin cells), helps even

out pigmentation, and minimizes fine lines. Many people can benefit from using Tretinoin or related

products at bedtime. Side effects of Tretinoin include redness, peeling, tightness, and swelling.

You may be able to minimize these side effects by initially using Tretinoin every other night and

then gradually increasing the frequency to nightly as tolerated. Tretinoin also makes the skin more

sensitive to ultraviolet rays from the sun, and therefore we recommend the use of a broad-spectrum

sunscreen each morning.

Alpha hydroxy acids (AHAs) — Alpha hydroxy acids (glycolic, lactic, tartaric, and citric acids) are

found as ingredients of numerous skin products. In the United States alone, there are approximately

185 manufacturers of products containing AHAs. Creams and lotions with AHA may help with fine

lines, irregular pigmentation, age spots, and may help decrease enlarged pores. Side effects of AHAs

include mild irritation and sun sensitivity. For that reason, sunscreen should also be used every

morning.

Beta hydroxy acid (salicylic acid) — Salicylic acid also has been studied for its effect on photoaged

skin. It exfoliates skin, and can improve the texture and color of the skin. It penetrates oil-laden

hair follicle openings and, as a result, also helps improve acne. There are many products available

that contain salicylic acid. Some are available over-the-counter, and others require a doctor’s

prescription.

Hydroquinone — Hydroquinone is a bleaching agent that is used to remove hyperpigmentation (skin

darkening), such as age spots and dark spots related to pregnancy, hormone therapy, or excessive

sun exposure. [10]

Skincare 32

33 References

[1] National Institute of Arthritis and Musculoskeletal and Skin Diseases. http://www.niams.nih.gov/

Health_Info/Acne/

[2] American Academy of Dermatology. https://www.aad.org/dermatology-a-to-z/diseases-and-

treatments/a---d/acne

[3] Prevention. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/acne/basics/prevention/

con-20020580

[4] Treat acne-prone skin with care. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/

acne/in-depth/health-tip/art-20049077

[5] Treatments and drugs. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/acne/basics/

treatment/con-20020580

References

[6] 4 Tips for Teenage Acne. Cleveland Clinic. http://health.clevelandclinic.org/2012/12/4-tips-for-

teenage-acne/

[7] Want Healthy Skin? Limit These 5 Types of Foods. Cleveland Clinic. http://health.clevelandclinic.

org/2014/09/want-healthy-skin-limit-these-5-types-of-foods/

[8] Your 8 Biggest Acne Myths Busted . Cleveland Clinic. http://health.clevelandclinic.org/2014/03/8-

biggest-acne-myths-busted/

[9] Acne Who Gets and Causes. American Academy of Dermatologists. https://www.aad.org/

dermatology-a-to-z/diseases-and-treatments/a---d/acne/who-gets-causes

[10] Basic Skin Care Tips . Cleveland Clinic. https://my.clevelandclinic.org/health/healthy_living/hic_

An_Overview_ofYour_Skin/hic_Basic_Skin_Care_Tips

References 34

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