Monday, April 16, 2012

Acne, Part II

Several weeks ago, we discussed the causes and types of acne.  Today, I am going to cover the various treatments available to the millions of patients with this condition.

Treatment options can be divided into over-the-counter (OTC) and prescription-based.  Here is my personal acne regimen. I would generally recommend that anyone with acne be initially evaluated by a physician such as a dermatologist.  This is important to further classify your subtype of acne and to have individualized recommendations made by your own personal physician.  For example, if acne is primarily inflammatory (many pustules) or nodulocystic (deep, painful bumps), then oral medications such as antibiotics or isotretinoin (Accutane) may be indicated.  In addition, the risk of scarring is greater with these types of acne, and oral treatments may be indicated for this reason as well.  Rarely, acne may be caused by an underlying medical illness and likewise, other medical conditions may mimic acne.  Therefore, I recommend seeing a physician.

General recommendations
Do not pick or squeeze skin lesions.  This does not help them clear faster and can make things worse.

Give treatments time.  It takes at least 28 days for the skin to completely turnover; therefore, treatments take at least that long.  Most treatments take 3-4 months to start seeing improvements, and others can take even longer.  Be patient. 

Do not use scrubs and rough products on the skin.  This damages the skin and makes acne worse.

Use treatments on the entire area affected by acne, not just on active spots.

After you have been evaluated by a physician, you may decide to opt for OTC treatment.  In general, the main active ingredients available OTC are benzoyl peroxide, salicylic acid, sulfur, and retinols.

Benzoyl peroxides are primarily antibacterial, and exert their effect against P. acnes, the acne-causing bacteria.  This is found in ProActiv and several other OTC products.  It is often recommended for patients to use a benzoyl peroxide facial wash (such as PanOxyl) in addition to their other medications.  I have used PanOxyl cream wash, and find it gentle and non-irritating.  It is available at Walgreen's.  AcneFree makes "the Terminator" which is a 5% benzoyl peroxide gel that is also fairly gentle.

Salicylic acid is a beta-hydroxy acid that is considered a keratolytic.  It combats one of the earlier stages of acne, the comedone (whitehead and blackheads).  It is often well tolerated with only some mild irritation as a side effect.  I particularly like the Neutrogena Stress Control Acne cream wash with a 2% salicylic acid.

Retinols fall into the family of retinoids, but are less potent than those prescribed by physicians.  They are keratolytics and combat blackheads and whiteheads.  The brand ROC offers a few different retinols, which are generally marketed more towards anti-aging, but may also be effective against acne.  Retinols are related to dermatologists' most commonly prescribed acne medication, Retin-A or tretinoin.

Sulfur is a keratolytic and also anti-bacterial.  My experience is that it can be somewhat soothing to acne lesions when used in conjunction with other treatments.  It too comes in a prescription strength (often used to treat rosacea) but is available in ProActiv's Refining Mask.

Alpha-hydroxy acids such as lactic acid and glycolic acid are also effective against mild acne. They are keratolytics and help exfoliate the stratum corneum (the most superficial layer of the epidermis).  These are usually marketed towards anti-aging regimens.

If you are undergoing prescription management of acne, gentle cleansers and moisturizers should be used.  Purpose, Cetaphil, and CeraVe are all good options. This is because prescription agents may be drying and irritating to the skin, particularly at first.

Clindamycin solution is an anti-bacterial agent.  It can be prescribed alone, or in conjunction with other agents such as benzoyl peroxide and adapalene (Differin).

Differin, Retin-A, and Tazorac (generic names: adapalene, tretinoin, and tazoratene) are all retinoids.  Retinoids are vitamin A derivatives found to help the surface of the skin turnover and exfoliate, to prevent plugging of pores.  They are often quite drying and irritating to the skin, but are one of the most beneficial longterm management strategies for acne.  They may take many months for full effect.  Retinoids are often not covered by insurance because they are also highly effective for anti-aging, fine lines and wrinkles, melasma, and post-acne dark spots.

Finacea, (generic: azeleic acid) is more commonly used for rosacea, but is also used in acne.  It is a Category B in pregnancy, and is therefore considered one of the safer treatment options during pregnancy.  It works as a keratolytic and anti-inflammatory.  It has also been found effective in fading some of the dark spots left behind in acne.

Antibiotics may be needed if the acne consists of many pustules and deeper nodules ("cystic" acne).  These mostly act as anti-inflammatory agents when treating acne.  The most commonly used agents are doxycycline and minocycline.  Dermatologists often combine oral antibiotics with a retinoid and benzoyl peroxide for maximum benefit.  The goal is to utilize the oral antibiotic for several months, and then control things just through the use of topicals.

Accutane (generic:  isotretinoin) is used in the treatment of scarring, nodulocystic, or acne resistant to treatment.  It is a vitamin A derivative and is absolutely contraindicated in pregnancy.  Because of this, the FDA has the medication highly regulated.  It also comes with many warnings about potential side effects, but the most recent studies have not indicated a clear connection between Accutane and inflammatory bowel disease or psychological illness (such as suicidal ideation).  Accutane is the closest thing to a "cure" for acne that physicians have to offer, and can be a good option for those suffering from scarring acne.

After the acne
Once your acne is under control, patients are often concerned with the pink or dark spots that may be left behind.  These will naturally fade over time.  In general, the darker your skin tone, the longer these spots will take to resolve.  Tretinoin and sunscreen can be two of the best things to help fade these spots.  There are also many OTC creams designed for this purpose.  I have not had the chance to use these personally or to recommend them to patients, but clinique and strivectin both have products which have shown promising results.  I would love to hear results (good or bad) with any of these products in particular.

AcneNet on treatment options
American Academy of Dermatology:  Acne


  1. Really great info. I'm SO glad I finally have gotten a combo of prescriptions that do the job for me! Hey, I made those zucchini noodles tonight and they were so delicious! My two year old even loved them!

    1. I am SO happy you liked the noodles! They are so versatile...I'll probably make them again this week :)

  2. I have tried the Clinique Even Better Clinical and was not impressed with the results. It was also fairly harsh on sensitive skin.

    1. Thanks so much for sharing that...I will pass that along to my patients. Let me know if you find a good one!