A recent Google™ search for “acne medications” came up with about 1,000,000 “hits”. This article attempts to make some organized sense out of all this information for you. As is always recommended, a personalized treatment and comprehensive care plan should be designed in consultation with a trusted board certified physician, even when considering the use of over the counter products for treating acne. This article is meant for educational purposes only and not intended to substitute for sound medical care, serve as medical advice or to represent as a sole guide to treatment.
I. Mild to Moderate Acne – Topical Medications
Typically, “over the counter” (OTC) topical medications are satisfactory for treating mild to moderate acne. OTC products will usually include one or more of the following ingredients: Benzoyl Peroxide, Alpha Hydroxy Acids, Salicylic Acid, Retinoids, Nicotinamide, Tea Tree Oil, Sulfur, Resorcinol
Benzoyl Peroxide (BP) – OTC concentrations of 2.5%, 5%, and 10% BP are available in creams, gels or as a component of a facial soap/wash. Even higher concentrations of BP are used for hair bleaching and teeth whitening! Better results will be obtained using the 10% concentration for acne. BP probably represents the overall single best and most successful anti-acne medication that there is. Allergic type reactions (occurring in about 3% of the population) are possible and are characterized by significant itching, peeling, and/or swelling. But BP can cause these effects to some degree even when it is working normally and doing what it is supposed to do! Building tolerance to a topical anti-acne medication so that it can do its job – this is a theme/strategy with almost every topical anti-acne medication. So start slowly and at a lower strength, then advance to the most efficacious strength and treatment schedule tolerable. BP breaks down deep in the skin into its component parts. The “Benzoyl” part is benzoic acid – this helps penetration deep into the pores where the oxidative action of the “Peroxide” kills the bacteria. Since clogged pores, full of debris, sebum and bacteria lie below the surface of the skin, washing alone simply isn’t effective. Aggressive scrubbing while washing or rough drying might “feel good” but only results in creating even more inflammation, further perpetuating the effects of acne. Using a cleanser containing BP, washing gently and then patting dry is such a good choice. A BP cleanser can also be left on for a few minutes for a prolonged application to more resistant areas (such as the back) the same as you would with a gel or a cream. BP is a key ingredient in the ProActive line of anti-acne treatment products.
Alpha Hydroxy Acids(AHA’s) – These act as exfoliants promoting a loosening and shedding of dead and nearly dead skin cells, decreasing surface sebum and helping to empty out pore-clogging debris in the process. Examples: glycolic acid, lactic acid, citric acid, malic acid and mandelic acid. Glycolic acid seems to be the most clinically effective of this class. Mandelic acid is probably the most gentle. Opening of pores and enhanced skin cell turnover rejuvenates the look and feel of the skin while the acne is simultaneously attacked. The AHA’s also have antibacterial properties against acne. Home use products typically have AHA concentrations of 10% or less, while aestheticians will often use AHA concentrations of 30 – 40% in performing office “chemical peel” treatments. A series of 5 or 6 monthly chemical peels can be a very effective means of breaking the acne “cycle”, especially in those over the age of 20 or 30. Physicians will use AHA’s of up to 70% for certain chemical peels or treatment situations.
Salicylic Acid– The primary anti-acne action for salicylic acid is through its exfoliation properties as seen with the AHA’s. Several Noxzema anti-acne products utilize salicylic acid. Salicylic acid has been in medical use for over 100 years; it is more commonly known as “aspirin”!
Retinoids– These are Vitamin A derivatives which simultaneously act via their exfoliation effects and their stimulatory effects on collagen and skin cell growth. Dead skin cells, pore debris and sebum are loosened and removed. Extractions will be made easier or even obviated. Retinoids increase pore opening and skin cell turnover, generally rejuvenating the look and feel of the skin. But they can also decrease the oiliness of the skin to an excessive degree and make the skin overly dry. Nevertheless, the skin will usually adapt to this after 1 -2 weeks of use and better results will be seen if treatment is not interrupted. Vitamin A derivatives encourage skin cell growth, “plumping” and strengthening of the skin cells, and increased collagen production as well. Retinoids can be found in a very wide variety of anti-acne and general cosmetic skin care products. Caution – retinoid treated skin is overall more sensitive – waxing, laser treatments, chemical peels and similar procedures should be done very conservatively if at all. Retinoid use is associated with birth defects.
Nicotinamide– This is Vitamin B3 and acts as an anti-inflammatory, serving to diminish acne activity.
Tea Tree Oil– This “alternative” topical treatment, also known as “Melaleuca oil” (from the Melaleuca Alternifolia plant) has some antibacterial and antifungal properties to add to its anti-acne effects. 5% tea tree oil is felt to be comparable in action to 5% BP but seems to work in a much more “gentle” fashion.
Sulfur– Sulfur is antibacterial and has both a “peeling” and a drying action on acne affected skin. However, sulfur can have a particularly bad smell, can cause skin discolorations, and can sometimes paradoxically induce the forming of blackheads.
Resorcinol – This primarily acts via its exfoliation properties as described above. Several Clearasil products utilize a combination of resorcinol and sulfur compounds.
II. Moderate Acne – Topical Medications
Typically, prescription basedtopical medications are the best choices for moderate acne. A regimen would generally include one or more of the following: Antibiotics/Antimicrobials, Retinoids, Azeleic Acid.
Antibiotics/Antimicrobials – Clindamycin is one among many of a wide variety of topical antimicrobials which directly kill skin bacteria like Propionibacterium acnes, the most commonly identified bacteria associated with acne lesions. P. acnes actually “lives” on sebum but it is not all that clear if it is the P. acnes itself or other “opportunistic” bacteria in the skin which directly cause acne lesions. Many combinations of topical antimicrobials are available, often combining one or more with BP and/or a retinoid. Allergic type reactions can occur and topical antimicrobials can also be very irritating and harsh on the skin, especially with prolonged use.
Retinoids – Vitamin A derivatives at strong (prescription level) concentrations are commonly used today for moderate acne and generally work as described for retinoids above. 0.1% tretinoin (Retin-A) is the most widely used and well-known of these but this category also includes adapalene (Differin) and tazarotene (Tazorac). Retin-A has become so famous for its anti-aging and wrinkle smoothing effects that its strong value as a powerful and reasonably inexpensive weapon against acne may be overlooked! Dead skin cells, impactions and sebum are more easily shed. Pore opening, and skin cell turnover are facilitated. Enhanced collagen production, plumping of skin cells, and strengthening and rejuvenating of the skin takes place. Common side effects can include excessive redness, peeling, and irritation. But again, these effects are usually temporary; the skin usually accommodates and better results will be seen if use is continued rather than interrupted. Recommended use is once each evening, but one may need to develop tolerance (by using a lesser concentration to start with and/or by using every other night for the first couple of weeks, for example). Proper use of a high quality moisturizer each day (preferably one containing a sunscreen as well) will soothe the skin, offset the drying effects and limit skin sensitivity to the sun and the elements.
Azeleic Acid– A naturally occurring compound found in wheat, barley and rye plants with anti-acne properties. Clears pores, decreases inflammation, and limits bacterial growth.
III. Moderate to Severe Acne – Prescription Medications:
Oral Antibiotics– Examples: minocycline, doxycycline, tetracycline, Bactrim and erythromycin. Common side effect: sunlight hypersensitivity. Prolonged use often results in a diminishing of effectiveness.
Oral Contraceptives (OC’s)/Birth Control Pills – OC’s are used to control/stabilize hormone levels and decrease androgenic hormone stimulation – androgens (such as testosterone) increase acne and sebum production. Those with conditions like Polycystic Ovary Syndrome (PCOS) will benefit greatly utilizing this strategy for acne control. Potential dangerous OC use complication: blood clots in the legs – with a significantly increased risk for this in smokers. Spironolactone is a diuretic medication which has also been used for many years to help control acne because of its anti-androgen effects (via receptor blocking).
Oral Retinoids – The most well-known of these is Accutane which is often used as a “last resort” for the most severe and otherwise resistant forms of acne. Accutane literally “shuts down” oil gland function/production while increasing skin cell turnover, opening up pores, loosening plugs, and releasing impactions. Drying effects on the skin can be quite severe and can also affect the lips, the eyes and mucus membranes. There are many potential serious side effects. Blood tests are needed for safety monitoring before, during, and after treatment which is typically 4 – 6 months. Hair loss and toxic effects on the liver, muscle tissue and bones are possible. Accutane (as are all retinoids) is associated with birth defects – pregnancy prevention while on Accutane is a must. Depression and suicidal thoughts are, unfortunately, also well recognized potential side effects of Accutane use. Patients who desire certain types of cosmetic facial procedures (such as laser facial rejuvenation or chemical peels) must wait a full year after completing Accutane treatment before having such procedures or significant complications related to abnormal or deficient healing can result.
Steroid Injections– Often used for inflamed, nodular or cystic acne (acne vulgaris) lesions. Not only accelerates the recovery and healing of the lesion but also serves to limit the scar potential these lesions can leave in their wake when left untreated. Potential side effects: thinning of the skin (atrophy), loss of pigment (hypopigmentation) and the appearance of small “broken capillaries” (telangiectasia).