You thought you left your breakouts behind in high school, along with your teenage angst and poorly conceived fashion choices. But, now, they’re suddenly back with a vengeance. Or maybe you escaped the agony of acne in your teen years (lucky you!) only to be curiously plagued by pimples now that you’re a grownup. What gives? First off, know that you’re far from alone: According to the Journal of American Academy of Dermatology, up to 54 percent of women over the age of 25 experience some degree of facial acne. It can be a pretty upsetting, not to mention baffling, skin condition to contend with, especially if you’re also dealing with the signs of aging such as fine lines and wrinkles.

So, why do breakouts happen to adult skin? And how can you get a handle on them? We spoke with Acne Store advisory board member Linda Stein Gold, M.D., a dermatologist based in Bloomfield, Michigan, who is on the forefront of clinical research on acne, to help us get clear about adult acne—the causes, the contributing factors, and the treatments.

Q: Is adult acne different from teenage acne?

A: It’s not. We tend to think of acne as a teenage thing, but it can persist well into adulthood. We know that about half of adult women in their 20s still have acne, a third in their thirties, and a quarter of women in their forties are still experiencing breakouts. Of those, 25 percent of adults with acne didn’t experience it at all as a teen.

Q: What causes adult acne?

A: There are four main components that play a role in the development of acne at any age. The first is inflammation. We have a lot of inflammatory cells in the skin that can cause the redness and swelling associated with pimples. Second, there’s a strain of bacteria called cutibacterium, or C. acnes, that’s a culprit in causing breakout. Sebum, the oil that’s secreted by the sebaceous glands, is also a factor—in patients with acne, sebum production is excessive and abnormal. We also know that sebum is affected by hormones, which is why many women see a breakout around their menstrual cycle. Finally, there's a clog of a hair follicle that occurs underneath the skin, causing a pimple to erupt. When trying to get acne under control, we try to hit as many of these components as possible with treatments. Understanding why you have acne can help you determine whether your adult acne will go away on its own, or whether it needs an intervention via acne products and medication.

"Up to 54 percent of women over the age of 25 experience some degree of facial acne."

Q: Are there any lifestyle factors such as diet that could be contributing to my breakouts?

A: When I was growing up, we were told that pizza, French fries, and chocolate—all of the things I lived on—contributed to acne. Then the pendulum swung the other way, and we started to think that was a myth. Now we’ve come full circle with some studies showing that diet does contribute to the development of acne, or at least exacerbates it.

Q: What foods cause acne in adults?

A: One of things we believe makes acne worse is a high glycemic index diet—one high in sugar, white bread, and processed fats. We don’t fully understand the connection yet, but it seems that anything that increases your sugar and insulin levels quickly may potentially increase hormone levels and sebum production. Conversely, eating a low-glycemic diet, one that’s rich in whole grains, vegetables, and fruits, keeps sugar and insulin levels fairly low and constant. That’s been shown to be better for patients with adult acne.

Q: We’ve all heard about adult stress acne—does tension play a role?

A: Stress is absolutely another factor. It doesn’t cause breakouts, per se, but can certainly make them worse. When people who are prone to acne are stressed out, their acne tends to flare. Adult stress acne is a real phenomenon that does occur, but it’s unlikely to cause acne on its own.

Q: What are the best acne treatments for adults?

A: We used to think that adult acne was an entirely different entity from the type of acne that teenagers get and, therefore, should be treated differently. But the truth of the matter is that it’s very similar to teenage acne, and the medications that we use usually work both. I lean toward things like adapalene, which is available over the counter without a prescription, which prevents acne from forming and has anti-inflammatory properties, and benzoyl peroxide, which kills bacteria, including C. acnes bacteria.

Q: Can those treatments dry out adult skin, which tends to be drier anyway?

A: It’s certainly a consideration because, yes, as we get older, the skin does tend to dry out a bit. You just need to balance acne treatments with good skin care. In addition to your acne treatments, you want a gentle cleanser (harsh soaps and scrubbing can increase inflammation and make acne look worse), an oil-free moisturizer, and lightweight sunscreen that says non-comedogenic on the label, which means it won’t clog your pores.

Q: I have acne and wrinkles! What are my options?

A: It’s really frustrating for adults who are dealing with acne and skin aging, but there are ways that we can address both concurrently. The best way is with a topical retinoid [a form of vitamin A], which you can get both over the counter [retinol, adapalene] and in a prescription strength [tretinoin, tazarotene, or trifarotene for example]. Topical retinoids fight acne very effectively, but also work to stimulate skin’s production of collage, smoothing fine lines and wrinkles. And, of course, you want to wear a great sunscreen to protect skin from future damage. Wear one with at least SPF 30 and reapply every two hours when you’re in the sun. If you're using any type of a topical retinoid, you're more likely to burn.