Hormonal or bacterial? How to tell what your breakouts actually are

You cannot treat a breakout properly until you have some idea what is driving it. The same spot cream that calms one kind of blemish will do almost nothing for another, and you can spend a year and a lot of money learning that the slow way.

So here is the version I wish someone had given me, with the actual research underneath it rather than a caption.

The kind driven by your hormones

It sits low. Jawline, chin, along the sides of your neck, sometimes down onto your shoulders. It tends to be deeper and sorer than it looks, the kind you can feel under the skin for days before anything surfaces.

It also keeps time. If your breakouts arrive on a schedule, in the same week of your cycle, that is your answer. Androgens like testosterone push your oil glands to produce more sebum, and the clinical literature on adult female acne describes exactly this pattern: lower face, often persistent into your thirties and beyond, and closely tied to hormonal shifts (Anais Brasileiros de Dermatologia, 2019).

This one is not really a skincare problem. It is worth a conversation with a doctor, because the treatments that work on it are usually internal (Indian Journal of Dermatology, 2014).

The kind driven by what is on your skin

This one behaves differently. It is shallower, more scattered, and it turns up where oil and dead skin have somewhere to collect. Blackheads, whiteheads, small pustules. It is less about the week you are in and more about what your face has been in contact with.

Your pillowcase. Your phone. Your hands. Makeup brushes you have been meaning to wash. And the towel you dry your face on, which is the one nobody ever gets to.

Hormonal acne follows your cycle. The other kind follows your habits.

The honest part, which most articles skip

Dermatologists do not actually split acne into two tidy boxes. Acne vulgaris has several drivers running at once: too much sebum, pores plugged with dead skin, bacteria, and inflammation on top of all of it (CMAJ, 2011).

So hormonal and bacterial is a useful shorthand, not a diagnosis. Most of us have some of both. What the shorthand is genuinely good for is telling you which lever is worth pulling first.

What this has to do with your towel

Only one of these two is in your hands. You cannot talk your hormones down. You can absolutely control what touches a freshly cleaned face, and a reusable towel is the least examined thing in the whole routine.

To be clear about what I am and am not claiming: a clean towel will not treat acne. Nothing about it touches the hormonal side at all. What it does is remove one variable from the side that is actually yours to remove, which is worth doing precisely because so little else on that list is in your control.

Why gentleness matters more than you think

This is the part that changed how I think about the whole thing. A 2024 study measured skin barrier function in 316 people and found that those with acne had significantly higher water loss through the skin than those without, meaning a measurably weaker barrier. The people on acne treatment had the weakest barrier of all (Clinical, Cosmetic and Investigational Dermatology, 2024).

Read that again, because it is the whole argument. If you are breaking out, your barrier is probably already struggling. If you are treating the breakouts, it is struggling more. That is exactly the moment when dragging rough terry cotton across your face twice a day stops being neutral.

Soft, clean, and used once. Not because it is a cure, but because your skin has enough to deal with.

One more thing worth knowing

Diet does appear to play a part, particularly high glycaemic load foods, though the evidence is stronger for some links than others (American Journal of Clinical Dermatology, 2021). It is a real factor, not the whole story, and anyone selling it as the whole story is selling something.

If your skin is painful, scarring, or not shifting, please see a dermatologist rather than another product. I am a founder who reads a lot of studies, not a doctor, and there is a real difference.

Written after reading this piece from OneSkin, which sent me back to the original research.

Elle x