Dear doctor – I eat healthily, wash my face regularly and drink plenty of water. Why am I still suffering acne breakouts?

While influencers share their endless ‘secrets’ to skincare online, many average people are left asking questions about why their skin doesn’t seem to behave.

Across the internet, people are asking, why do I still have acne if I’m doing everything right? 

‘I cleanse, moisturize, and use SPF every day. I change my pillowcase every 3 days. I pretty much only drink water. I get at least 7 hours of sleep every night,’ one Reddit user shared. 

They added that they also avoid eating food like meat and dairy and don’t drink anything besides water, ‘and yet, I am still stuck with consistent breakouts,’ the post says.

User thisisausername10000 isn’t alone. Roughly 50 million Americans deal with some form of acne – be it black heads, white heads, pustules or pimples.

That’s about 85 percent of people between 12 and 24 years old, according to the American Academy of Dermatology (AAD).  

Despite what you might think, zits aren’t reserved for teenagers either. The AAD wrote that adult acne has been increasing over the past few decades, and currently affects about 15 percent of women in their 30s and 40s. 

For some people, this condition does resolve itself with age. For others, a solid skin care routine – washing your face daily and using moisturizer – takes care of most pimples. 

And for others yet, changing your diet to avoid your personal irritants or high sugar foods will clear up your skin. 

But for many people, acne persists despite best efforts. 

‘Sometimes it takes a little bit of hunting to solve what’s causing your acne, Dr Anthony Rossi a professor of dermatology at Memorial Sloan Kettering in New York, told DailyMail.com.

Acne can be caused by your hormones, genetics or can be lurking in the skincare routine you think is helping. 

Top dermatologists told DailyMail.com six things that you could be doing that is making it harder for you to reach your glassy skin dreams. 

 You’re washing too much

Washing your face is the best way to removes dirt, oil and dead skin that might clog your pores and lead to black heads or pimples.

But the top layer of your skin is also home to a bunch of good bacteria, oils and proteins that protect it, Dr Rossi said. 

This is known as the skin barrier. 

If you wash your skin more than twice a day, you might disrupt or completely strip your skin of these delicate defenses. 

Our doctors advised washing your face once or twice daily- most importantly at night, to get the grime from your day off your skin. This can be done in the shower at the sink. 

Without a robust barrier, your skin has a hard time keeping water in, which can make it dry, irritated and sometimes, full of little red bumps that look like acne. 

Other times, in response to over washing, people’s skin begins overproducing oil in a desperate attempt to keep lubricated, which can also lead to acne, Dr Rossi said.

‘Cleansing is really a delicate balance between hygiene and barrier damage,’  Amy Gordinier-Regan, the founder of skincare brand Skinfix, told The New York Times.

Hence why doctors generally recommend washing your face no more than  two times a day. 

You’re using dud products

Just as washing too often can disrupt your skin barrier, so can using the wrong products, Dr Rossi said. 

Many people shop for their skincare products based on the recommendations of their favorite wellness influencer, which can lead them to selecting products that aren’t right for them. 

This trend is increasing, especially amongst young people, Dr Rossi said. 

One example is that a lot of people seem to be using products with retinol in them.

Retinol is an over the counter form of vitamin A often added to face creams that causes the skin to shed dead layers and bring up new cells. 

Some common products include CeraVe’s Resurfacing Cream, La Roche Posay Pure Retinol Face Serum and The Ordinary’s retinol serum. 

Retinol is best used in older people who are looking to decrease scars or wrinkles, Dr Rossi said. 

However, it can be an irritating product that disrupts the skin barrier, especially in younger people who shouldn’t need help clearing their top layer of skin. 

This, like over washing, can lead to a dried-out, irritated texture that looks like acne. Or it can lead to actual pimples if your skin overproduces oil to compensate. 

‘I think people are over retinizing themselves’, he said. 

Other popular products, like Vitamin C serum, can have similar effects, he said. 

A safe bet when shopping for skin care is to pick products that include terms like ‘non-comedogenic’ or ‘oil-free’ , which essentially means the product is designed to not clog pores. 

Dr Rossi also recommends products with peptides, which can support the skin barrier. In addition, it’s important to have a strong broad spectrum sunscreen, which will protect from UV damage and improve skin health overall.  

Also, this might not end with the products you’re slapping on your face. Sometimes hair care products can also block up your skin, the AAD wrote. 

So if you have persistent acne around the forehead and have tried everything else, you might want to look at the shampoo or hairspray you are using. 

Or at least, be careful not to let it drip onto your skin. 

Your hormones are out of whack

Many different hormones have an influence on how our skin looks, feels and behaves, Dr Rossi said. 

Hormonal acne isn’t caused by a lack of hygiene or by using the wrong face wash.

Instead, it happens when hormones in your body increase the amount of oil your skin produces, which clogs your pores, according to Cleveland Clinic. 

This can involve the balance between estrogen and testosterone, commonly thought of as the female and male hormones, respectively. 

Hormonal acne can affect any gender, but is more common in women, Dr Rossi said. 

That’s because as women age, they slowly produce less and less estrogen. 

As the effects of estrogen wean, the effect of male hormones become more evident – which can increase oil production and make your pores seem larger, according to Johns Hopkins dermatologist Mary Sheu. 

Aside from age related changes, women might see their skin change in accordance with their menstrual cycle each month. 

This kind of hormonal acne usually takes up camp around the mouth and chin, Dr Rossi said. 

Hormonal acne can be stubborn, so dermatologists often turn to medications or topical treatments to help patients. This might include birth control, Isotretinoin, popularly known as Accutane. 

But if you suspect that hormones may be causing your acne, you should talk with your doctor to figure out what treatment is best for you. 

Outside of medication, some of the best ways to mitigate the effects of hormonal acne are reducing your stress when possible and getting quality sleep, according to Cleveland Clinic. 

Blame your family

Sometimes you might be able to blame your acne on your genes. 

Dr Joshua Zeichner, the Director of Cosmetic and Clinical Research in Dermatology at Mount Sinai Hospital told DailyMail.com that sometimes, your genetics matter more than your skincare routine. 

‘Acne is caused by your genetics, not from not washing your face. In fact, you can break out but have clean skin, or you can be acne free but still have dirty skin,’ Dr Zeichner said by email. 

It’s not that acne is as simply inherited as things like eye color, but generally, scientists agree that if your family has a history of acne, you’re more likely to develop pimples. 

‘If you had parents that had really bad acne as well, like this inflammatory sort of acne, that can in a way be in inherited,’ Dr Rossi said. 

Some studies have found that people with a familial history of acne are three times more likely to develop it themselves than people without a family history. 

Doctors aren’t entirely sure how genetics might affect this. Some people’s genes might make them produce more oil than other people – leading to acne. 

Other people’s genetics might make their skin  more prone to inflammation – meaning that its easier for them to get angry, red looking spots on their face.

If this is what’s causing your acne, then doctors will likely recommend continuing a normal skin care routine, but might also prescribe medication. It depends on your unique needs, which a dermatologist should be able to asses, Dr Rossi said. 

You’re not laundering enough

Sometimes, what’s affecting your acne might be part of a routine that seems far away from a skincare regime. One avenue that people often neglect is regular laundering, Dr Rossi said. 

Consider, as an example, your bed sheets. Every time you lay on your pillow, it soaks up oil, dirt and dead skin cells. Even if you wash your face before plopping down each night – your sheets are still soaking in whatever sits on your skin. 

This quickly causes a lot of build up on the sheets, which you essentially soak in each night until you wash them again.  ‘In this scenario it’s like sleeping with your makeup on, it’s not going to allow the skin to breathe,’ Dr Rossi said. 

This can clog pores – causing little red eruptions to form on the skin.  

Proper laundering hygiene is therefore incredibly important in skincare. This also involves washing clothes, towels and makeup tools regularly, he said. 

Stress 

One final place to look when searching for a cause of acne is within. There is a strong connection between the brain and the skin, Dr Rossi said. 

This is evident when you think about what happens when many people get embarrassed- the skin flushes. Blushing is evidence of the complex connection between your emotions and your skin.  

Stress can therefore play a big role in acne flare ups. When your body is stressed, your tissues are likely more inflamed, which could cause more acne. The red, swollen appearance of a pimple is after all, inflammation. 

Also, stress interrupts sleep quality. Sleep is crucial to skin health because without a full eight hours, our skin can’t adequately repair itself, Dr Rossi said.

Doctors have increasingly identified stress as a contributor to a host of unpleasant things- like cancer, a shorter life span and dementia. 

If you can do your best to reduce your day to day stress, this may help reduce acne.