Some old wives’ and doctors’ tales are pretty harmless. Behind the myths about blackheads and acne, though, it gets very ugly. And what the truth shows us about how superficial we can be isn't pretty either.

The sisters in this cartoon are very unusual. They're blasé about their blemishes and the rather untoward experience they're having in a type of clinical trial favored by some dermatologists. But blackheads, pimples and the adverse effects of acne treatments often cause a lot of misery. And lingering misunderstandings that are taking too long to die out contribute to that.

Most adolescents don't have "clear" skin - less than 20% in fact. It's pretty much the luck of the draw. Genes may be involved. More often than not, for as much as a decade or longer from the age of 15, people are going to have at least some blackheads and pimples to deal with, if not full-blown acne. Acne might be getting more common and may be starting younger - a sign of puberty starting earlier, perhaps.

Around one in five adolescents will have moderate to severe acne, and about the same number will have scarring. For those with dark skin, post-inflammatory hyper-pigmentation can follow acne lesions - and even common treatments might make the pigmentation worse. Although to add insult to injury, that's not an issue that's gotten all that much study.

Acne is so common, and it's only "skin deep" after all. It just shouldn't be a big deal, right? It is, though. It's such a big deal, that the effects on young people - sometimes out of proportion to the objective severity of their skin's condition - go all the way to a higher risk of self-harm and getting suicidal. As Darwin's contemporary, Herbert Spencer, said: "The saying that beauty is but skin deep is but a skin-deep saying."

Blackheads and pimples are only skin conditions, caused by oil and a specific bacterium that doesn't make people sick. But we didn't always know that - and some time-honored myths remain deeply entrenched.

The technical word for blackhead is comedo (plural - comedones, adjective - comedonal). It comes from the Latin for gluttony, which was used to describe parasitic worms ... and for the wormy look of a squeezed blackhead. Revolting, eh? And revolting imagery and explanations for skin problems is a large contributor to the misery they cause. We've historically had a lot of disgust for our own body products.

In 1930, seeing blackheads, pimples and oily skin on others' faces had all made it to an academically derived list of people's greatest annoyances (along with "to see a woman drinking liquor" and "to just miss a streetcar"). In the 1960s, blackheads even managed to rank as the most repulsive of all bodily excretions - yes, all - in some surveys of disgust.

We assign a disproportionate amount of disgust, in fact, to skin conditions - including something so inherently trivial as blackheads. A blackhead is simply a pore clogged with a bit of oil that's open to the air - oxidation turns it black. (If skin covers the oil and any pus from infection with Proprionibacterium acnes, that's a whitehead, pimple or zit.)

Blackheads do not mean that skin is clogged with dirt, and acne isn't a sign of lesser hygiene. Although reducing oil gets at the problem, very abrasive scrubbing can damage the skin and actually increase the inflammation that causes pimples.

Yet people are still marketing their products with this "dirt" myth. It's a hard notion to dispel. Here are snippets from the packaging of products currently on sale in my local drugstore:

Washes away problem-causing dirt…

Clear breakouts and blackhead-causing impurities.

Deep cleans even dirt and oil you can’t see.

Which brings us inevitably to an industry that has a lot at stake in making us unhappy enough about our skin that we'll be hooked onto skin products our whole lives. More than $300 million will be spent on over-the-counter acne products alone in the US each year. Skin-care and cosmetics are chewing up an increasing proportion of teenagers' budgets (around 20% for those with an average or high amount of cash).

Women in particular are manipulated emotionally with claims of “flawless” skin, and products that do all sorts of often biologically impossible things for the skin, especially “revitalize”. It’s the language of a previous medical tradition – of humors - lingering still.

In The Beauty Myth, Naomi Wolf points out that the language of skin care - “calm,” “soothe,” and “nourish” - are claims on women’s emotional needs, not their skin. They prey on women’s feeling of vulnerability, and weaken self-esteem while offering a way to restore it. Wolf gathered some amazing claims. My personal favorite? “When your skin is acting confused.”

Even though acne affects far more young men than women, women have been bombarded with messages about the importance of "clear" skin for a long time. Consider this advertisement from 1909: "Every woman strives to acquire and preserve a clear, faultless, rose-and-lily complexion. This is apparently the height of the feminine ambition." Racism, sexism and commercial exploitation rolled into one: now that's gross.

There's more behind all this, however, than money, specific notions of beauty and squeamishness about body excreta. Faces are critically important to us. We judge others by them, and know we are judged in turn. Moral judgments also accrue to the way we see those we find beautiful - or those we judge to be contagious.

Facial disfigurement has been seen as a mark placed by the devil in the past. An analysis of cinema showed we still have an association between skin conditions, scars and evil. As dermatologist Hywel Williams points out, even children know if you're drawing a witch, she's gotta have warts.

Robert Kurzban and Mark Leary argue that our tendency to stigmatize others has evolutionary origins. We need to choose mates, avoid many people and protect ourselves from contagious disease. Social exclusion, then, would be an adaptive response to living closely with people in large groups. That could explain, they write, why "an inherently social species with a strong need for social acceptance should be inclined to reject members of its own kind."

In 1613, the man who probably first committed the concept of beauty being "only skin deep" to print, was apparently murdered by the woman he was describing - thus rather decisively proving his point. We've made a lot of progress on skin diseases in those four hundred years. But how can we move faster towards the time when we narrow down our social choices by things that aren't so literally superficial as blemished skin? Doing more to scrub away the remnants of old ways of thinking about skin conditions as a sign of poor hygiene might help, at least a little.

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For more information about acne, check out this evidence-based information for people with acne and this dermatology overview. There's more specific information about blackheads in a Wikipedia article (to which I contribute).

The cartoon is original, from my post about within-person trials at Statistically Funny (Creative Commons, non-commercial, share-alike license). My sketch of the ancient Egyptian hieroglyph, Aku-t, is based on the representation from Budge's "An Egyptian hieroglyphic dictionary" in Grant's article on the history of acne.

The advertisement clippings come from: The Portsmouth Daily Times (1900), The Pittsburgh Press (1919) and The Milwaukee Journal (1930).

The thoughts Hilda Bastian expresses here are personal, and do not necessarily reflect the views of the National Institutes of Health or the U.S. Department of Health and Human Services.