Why does acne get worse before it gets better?

This is a common warning I give my patients after starting them on a new skin care regimen that often involves prescription medication.

To understand why acne gets worse before getting better, let's talk a bit about the different type of acne lesions on your face. Some of your pimples are very young; babies not yet "hatched", so you can't see them yet. Some of your pimples are elderly, having risen to the surface and erupted, creating a large red papule or goo-filled pustule that is visible from across the room. Delicious, I know.

When you start on a proper skin care regimen, you start to age every pimple on your face. Old ones die sooner than they otherwise would have, middle-aged ones become large elderly inflamed pimples, and all the babies start aging quickly and coming up to the surface. For the first month you are seeing every microscopic pimple erupt to the surface and join their elderly brothers. The result is an acne flare.

The good news is that once the first month or so is behind you, the pimple pipeline is mostly empty. You will start to grow fewer pimples, and the pimples that you do see will be less severe (small flesh-colored bumps instead of big angry red nodules).

The difficult part is sticking to the plan, and convincing yourself that even though your skin may look worse in the short-term, it will all be worth it in the end.