It’s important – though hard sometimes – to keep acne in perspective. At some time everyone will have a spot or two: it’s normal to have a few spots breaking out. However, if they persist, or more develop, then it really is worthwhile making an appointment to see your doctor, who will be able to determine whether you have acne, and if so which type, as this will help you to decide on the best treatment available.
There are numerous over-the-counter products for acne. Some offer a ‘quick-fix’ solution, but do be aware that in most cases acne is not something that can be lured overnight. Because of the complexity of acne and the numerous reasons for its occurrence, most successful acne treatments have to be continued for many weeks before improvements can be seen.
The successful treatment approach varies from person to person, as each individual’s skin is unique. Therefore, a treatment which might work for one will not necessarily work for another. Even your age may be a factor in determining how long your acne lasts and how your skin reacts to one product.
Some individuals may have to try several products before they find the one most suitable and successful for them. Bear in mind, too, that most products take 8-12 weeks before improvement can be seen. Rather than prolong the period of trial and error, it is more effective, both physically and emotionally, to make an appointment to see your dermatologist.
He or she can advise you on the best treatments for your skin and your acne type, which may also include prescription medication.
Before you begin
Before you see a doctor, it is worth knowing as much as you can about your acne. This will help you, and your doctor, to choose the most suitable medication.
- Draw up a daily acne log. You need to chart your spots. Counting spots can be difficult, so always start on the same side of the face.
- Keep a chart of your skin. You may find it changes during the month, or it may be oily in certain areas, such as the T-zone, along the forehead and nose, and dry in others.
- Identify any other factors that make your acne worse. For example, if you know stress affects your skin and there are reasons for the increase in your stress levels, you can identify a pattern to your acne breakouts.
- Do ask your doctor to tell you which type of acne you have. This way, you will have a better idea of which types of treatment are available.
- Make sure you understand how long your treatment should be used for, and then follow it up with another appointment so you can determine how successful the treatment has been.
- Ask what treatment will help stop new lesions from appearing.
- Make sure you decide the course of action that suits you; it is no good agreeing to a treatment if you know you won’t follow it through for the required period of time.
- Inform yourself about the side-effects of any medication you are offered.
- Realize your treatment may last months, in some cases even years.
- Understand what you need to do in order to help prevent acne from scarring your skin.
- Continue your daily log for as long as your medication is prescribed.
- If you feel your acne is not responding to treatment, ask to be referred to a dermatologist.
The most usual treatment for mild acne generally begins with over-the-counter products available at a pharmacy or supermarket. Any treatment applied directly to the skin is known as topical treatment, and includes washes, gels, solutions, creams and ointments. Read more about topical antibiotics.
Most of these will contain one or more of the active ingredients benzoyl peroxide, alpha-hydroxy acids and salicylic acid. Topical treatments must be applied to all the skin, not just to the spots. They must also be continued, even if the acne is clearing up, for a period of time afterwards, to keep the lesions under control.
Choosing your treatment comes down to your skin type, the type of acne you have and its severity, and your own personal preference. Washes, for example, are quick and can be used in the shower, and while they are sometimes slightly drying they rarely cause any irritation.
In general, creams and ointments tend to be more moisturizing, so they are good for sensitive and dry skin. Gels and solutions are more suited to oily skin, particularly as they help to dry out the skin. Ointments can be very greasy, so they may be more suited to those who prefer to use them at night, and a wash, gel or lotion in the morning.
Combination treatments, when one agent is used in the morning and another at night, tend to be much more successful, especially with regard to adult acne. However, it can take several attempts to find the right combination for any significant improvement of the skin to take place.
Very often doctors will prescribe a topical treatment containing an antibiotic combined with benzoyl peroxide or zinc in order to improve its effectiveness. Many teenagers find these combination types of products the easiest to use, as they are less willing to adhere to strict regimes where a combination of treatments is given.
The most common side-effects of over-the-counter products include the drying or irritation of the skin. Excessive redness, itching or burning are possible signs of an irritant reaction, so either go back to the pharmacist or see your doctor as soon as you can, and stop the application of the product immediately.
As treatment can take several weeks before an improvement is seen, any disruption will increase the length of time it takes. Acne treatments are categorized into those that:
– Kill bacteria;
– Normalize pore lining cells;
– Decrease inflammation;
– Alter hormones or hormone effects;
– Decrease oil gland production;
– Use laser, ultraviolet and intensive light therapies.
Treatments that kill bacteria
There are a wide variety of treatments which kill the bacteria in the pore and on the skin.
The most common bacterial treatment for acne, this active ingredient is found in most over-the-counter products. An antimicrobial agent, benzoyl peroxide releases free oxygen radicals in the sebaceous follicles, ensuring bactericidal activity against the acne bacteria, P.acnes (which is anaerobic, meaning that it will only grow in the absence of oxygen).
It also helps to unblock the pores and decreases microcomedone formation, at the same time drying up greasy skin. It is useful for treating blackheads, whiteheads and red inflamed spots, and can be applied directly on the spots.
It is worth noting that this treatment works best if it is applied 20-30 minutes after you have washed your skin.
Benzoyl peroxide is an active ingredient in prescription medication, and is available in 2.5 per cent, 4 per cent, 5 per cent and 10 per cent concentrations. You need to find the strength that suits your skin as the higher concentrations do have significantly more side effects.
Brand names for benzoyl peroxide include Brevoxyl and PanOxyl. Benzoyl peroxide can be combined with an antibiotic, clindamycin, whose brand name is Duac Once Daily. A prescription from your doctor is required for this.
As with any medication, there are side-effects, and benzoyl peroxide typically causes drying of the skin or irritation. Keeping to the lowest preparation, 2.5 per cent may help, and using water-based preparation rather than an alcohol-based one helps to reduce these effects.
You can also limit applications to once a day until your skin becomes more used to the product, washing off the solution after several hours and gradually increasing the amount of time you leave the preparation on your skin.
Your aim is to use the treatment twice a day. Benzoyl peroxide can also induce redness, peeling, burning or itching, and through its bleaching effects can discolour clothes and bedding, especially when applied to the chest or back.
Precautions such as wearing a cotton T-shirt in bed and changing your pillowcases should be taken if you are planning to leave the treatment on overnight. It is wise to avoid direct sunlight when using this product, as you may find it increases your sensitivity to the sun, increasing the chances of sunburn and sun damage.
Salicylic acid is a beta-hydroxy acid, with antibacterial and anti-inflammatory qualities. It is a key ingredient in many acne treatment products, often combined with other agents including zinc, sulphur or coal tar.
It comes in gel, ointment, shampoo or liquid form. Common examples of this treatment include Clearasil, Neutrogena Rapid Clear and Clean and Clear.
Azelaic acid not only helps to destroy bacteria, but also helps to reduce the growth of keratin (surface skin cells), unblocks pores and sebaceous glands, and reduces the formation of comedones. Skinoren cream is a prescription-only preparation containing azelaic acid and should be applied to the affected areas twice a day, except for those with sensitive skin, who should only use it once a day.
Regular use is important, and after four weeks there should be some visible signs of improvement. According to the manufacturer, the cream should be used for a period of several months, but not more than six months, for maximum effects.
It is often used as an alternative if benzoyl peroxide or topical retinoids cannot be tolerated.
As well as killing bacteria, antibiotics help control inflammation. Antibiotics can be used alone or with other topical acne agents. The drugs erythromycin (Benzamycin gel), and clindamycin, (Duac Once Daily gel), for example, are both used with benzoyl peroxide.
These antibiotics can be found in gels, washes, creams, lotions, ointments and solutions.
Topical antibiotics are always preferable to oral antibiotic medication, as they have fewer side-effects or allergic reactions and can be used twice a day.
Despite good skin care, sometimes topical treatments are not enough to control acne, and oral antibiotics may be prescribed. They include the tetracyclines (oxytetracyline, lymecycline, minocycline and doxycycline), macrolides (erythromycin and clarithromycin), and trimethoprim.
They are generally prescribed for mild or moderate acne not responding to topical treatment. Occasionally the acne can start to become resistant to a type of antibiotic, and it may be necessary to change to another.
The side-effects of oral antibiotics can be more severe than for other treatments, and can include sensitivity to sunlight. Oral antibiotics can also affect the effectiveness of the contraceptive pill for up to 3 weeks after starting it, so extra precautions may need to be taken for this period of time.
Usually oral antibiotics and Retin A, a retinoid treatment which helps to normalize pore lining cells, are prescribed together to ensure the best results.
Very occasionally, the injection of corticosteroids into an inflammatory cyst or nodule can dramatically decrease its size, although a repeat injection two to three weeks later may be needed.
It is a form of treatment that is used for acne that flares up now and again, as an additional treatment when the acne cannot be completely suppressed by oral antibiotics or isotretinoin or if you are unable to consider isotretinoin treatment.
Once the cyst or nodule has been injected, the skin will flatten out.
This is the term used when the closed comedones are opened and the contents expressed in the hope of speeding up the resolution of acne. Very often, purulent nodules can be incised and drained of pus.
There are various types of comedone extractors; each is a small instrument that applies pressure to the surface of the comedone. However, this treatment is rarely used by doctors now as topical retinoids are a much popular option.
Treatments that normalize pore lining cells
The most important category of these treatments includes retinoids, which are vitamin A-based medications. Topical retinoids include tretinoin (Retin A), adapalene (Differin) and isotretinoin (Isotrex), and are available in different formulations and concentrations.
They have been found to be effective for mild to moderate acne, reducing the number of inflamed and non-inflamed lesions in 8-12 weeks. According to research, adapalene and tretinoin are proven to be effective in reducing inflammatory acne by 47 per cent and 50 per cent respectively, and non-inflammatory acne by 57 per cent and 54 per cent.
Adapalene is significantly the more effective of the two, benefiting two out of three people.
Retinoids work by normalizing the follicular lining cells, loosening the cells in the skin and unblocking the pores, allowing the natural oil-producing glands to work properly. They also help decrease inflammation and act as a natural exfoliant, removing dead skin cells.
The gel is considered more suitable for oily skin, and the cream for dry skin. These products can be bought over the counter, but generally those prescribed by a doctor are more effective, at they have a higher retinal concentration level.
Initially when these products are used they may turn the skin red or irritated, which is often the reason so many people stop their treatment, mistakenly believing this sensitivity to be an allergy or an adverse reaction to the product.
However, most people find that with regular use these effects subside, and in most cases the treatment goes on to be very successful. Tretinoin has more adverse effects than do other topical retinoids. There are some other side-effects with retinoid treatments, which include an increased sensitivity to the sun and UV light, but your doctor or dermatologist will offer guidance if you use this product.
Adapalene (brand name Differin)
Adapalene is a retinoid-like drug and affects the growth of skin cells, reducing the production of keratin. It is more suited to those with dry or fair skin, and is available in a gel or cream form. The cream is less irritating than the gel and thus suitable for sensitive skin, but less effective in comedonal acne.
Regarded as the most effective retinoid acne treatment, isotretinoin is available as a gel (Isotrex gel) or in the stronger oral form; in the UK the most widely prescribed form is known as Roaccutane.
Capsules are only available on prescription, and can be supplied by your dermatologist. If you are a woman of childbearing age, European legislation means that you can only be prescribed the drug for 30 days at a time and will be checked to make sure you are not pregnant before a further prescription is given.
Isotretinoin is considered to be the best treatment available for treating severe acne that has not responded to conventional treatment and/or oral antibiotics. It takes at least six to eight weeks before a beneficial effect can be seen, and in the first seven to ten days the acne can actually get worse.
The drug should be prescribed until all spots are clear and for a minimum of four months and you will be kept under close supervision during this time. In most cases the acne will completely clear up, and skin may remain acne-free for some considerable time.
It is not always a cure for acne and 50 per cent of people will relapse some time after the treatment is stopped.
Isotretinoin is an anti-inflammatory agent derived from vitamin A and works by reducing the size and activity of the sebaceous glands in the skin, which reduces the production of sebum. It prevents the glands from becoming blocked, so that bacteria are unable to thrive, and it reduces inflammation.
This drug does have a number of side-effects, which include drying of the skin, aching joints and muscles, lip soreness and reddening, and scaling of the skin.
Some severe side-effects of this drug include depression, which has been associated with suicide. You cannot use this treatment if you are pregnant or considering becoming pregnant as it can cause major deformities for the foetus.
Should you require further treatment then at least eight weeks have to pass before you can start another course. Oral isotretinoin also reduces skin healing and increases skin fragility so operations and laser treatment of the skin should be avoided for 6 months after stopping the drug and while on treatment, women should avoid waxing.
Treatments that decrease inflammation
Red bumps and tender red spots are a direct result of inflammation, which can lead to scarring. Controlling inflammation is a necessary part of acne treatment. Antibacterial agents, such as benzoyl peroxide, salicylic acid and retinoids, all demonstrate some anti-inflammatory properties, but oral antibiotics are even better at controlling inflammation.
The inflammation occurs as the body’s immune system reacts to increasing levels of P.acnes in the follicle.
Treatments that exfoliate
As clogged pores play such a major role in acne, removing the dead skin cells and unclogging the pores is an important approach to treatment. With acne-prone skin, the process of producing and removing dead cells becomes abnormal.
Dead cells build up on the surface, preventing moisture, oxygen and nutrients from reaching the new cells that are forming underneath. Exfoliation using alpha-hydroxy acids, beta-hydroxy acid or microdermabrasion can be used.
Naturally occurring organic fruit acid and water-soluble alpha-hydroxy acids (AHAs) are available in many cosmetic products, including cleansers, toners, moisturizers and chemical peels.
Applied topically, they increase the rate of cell turnover, decrease the stickiness of the cells and exfoliate the skin. As a result, the pores are unclogged and the skin is smoother and thinner. They are beneficial for some types of acne.
Some dermatologists in the USA will offer AHA peels as part of their treatment, using glycolic acid.
Otherwise known as salicylic acid, it is keratolytic, which means it will dissolve dead skin cells and thus exfoliate the surface and will help unblock skin pores.
Allergic reactions to salicylic acid are quite common. Peels that contain salicylic acid in combination with citric acid and linoleic acid are now available and have been shown to be effective in the treatment of acne.
This is a procedure where a suction tip gently lifts the skin while a fine jet of minute crystals is sprayed across the face, using a hand-held instrument which vacuums the loose dead skin. The skin is left softer, and collagen and elastin formation is stimulated.
There is slight stinging during the procedure but side-effects are mild, although they may include redness and mild skin irritation. Microdermabrasion is a very different procedure to dermabrasion, which is not performed on active acne skin.
Microdermabrasion can be used to treat superficial acne scars. Unfortunately, this is not available on the NHS.
Treatments that affect hormones
The oral contraceptive pill
According to the British Association of Dermatologists, ordinary contraceptive pills have little or no effect on acne. However, prescription of one particular contraceptive pill, Dianette or Diane 35, may be helpful, and anti-androgens that block testosterone are often prescribed alongside, to boost results.
The pill works by reducing testosterone production and activation. Side-effects of Dianette are very similar to those of other contraceptive pills and may include weight gain, bleeding and mood changes.
In practice it is only effective in clearing acne in 40 per cent of women. It may cause a flare-up of acne in the first month and almost invariably stopping Dianette leads to a flare-up of acne.
It is only licensed for women with severe acne who are resistant to conventional forms of acne treatment and should not be given to women with mild acne who want a contraceptive pill. Spironolactone is a potassium-sparring diuretic, with anti-androgenic effects; it has been used in some cases to treat acne, but is not common.
You would need to discuss this treatment option with your doctor.
Treatments that decrease oil production
The only topical agent that significantly reduces oil production is Aknicare lotion (Skinmed), where clinical trials have demonstrated up to 70 per cent reduction in oil production. Anti-androgens in women – Dianette and spironolactone – reduce oil production which is androgen driven.
Oral isotretinoin will decrease oil production, but because of its potency it is used for the treatment of severe acne only.
Intensive light therapy and pulsed dye laser treatment
It has been known for some time that sunlight can help improve acne, at least for a while, but the improvement is short-lived and the potential risk of skin cancer from the ultra violet rays negates the potential short-term effects.
However, the development of light therapy – that is, visible light directly applied to acne skin – is a relatively new treatment. Laser treatment has been around for approximately 20 years, and a new yellow pulsed dye laser treatment – the NLite – has produced some impressive results.
According to British dermatologists, this development is the most exciting to arise during the last 30 years in their search for a successful acne treatment.
Recent trials using the NLite laser treatment and led by Professor Tony Chu, consultant dermatologist at Hammersmith Hospital, have recorded a 50 per cent improvement in acne spots for 58 per cent of people, suppressing acne for three months with no side-effects from a single NLite.
The NLite pulses a beam of yellow light from a hand-held laser pen onto the skin, where it penetrates the outer layer and, when absorbed by the skin, generates heat and produces chemical changes within the cells. Prof. Chu thinks it is the biological change in the reactivity of skin that is so effective.
The skin, believing it is under attack, releases an enormous amount of a chemical called transforming growth factor beta, which done regulates inflammation and increases collagen production. Collagen is required for the repair of the skin and improves acne scarring, at the same time increasing the production of oxygen, which is toxic to bacteria.
According to Prof. Chu it is this ‘would-healing cascade’ that mysteriously switches off the acne, which he thinks is caused by hypersensitivity to testosterone, and is good news for all those with acne, especially those who feel they are running out of treatment options.
The treatment is painless, although there may be a mild warm tingling sensation, and those being treated have to wear an eye mask for the ten-minute sessions, which are given to the whole affected areas – face, back or chest. With antibiotic resistance increasing from 30 per cent in 1992 to 70 per cent in 1997, the use of Roaccutane, a vitamin A derivative, has up until now been considered a last-resort treatment for acne, with its side-effects well documented.
Watch how the NLite Laser Treatment is Performed
While the N-Lite may not be a cure, it does offer significant management and control for this increasing skin disease. You will need to check with your dermatologist whether referral through the NHS is possible for this treatment; private treatment is expensive.
Julie, a 16-year old teenager from London, had been plagued with acne since the age of ten. Her mother had taken her to the doctor on numerous occasions and treatment had varied from benzoyl peroxide to several courses of antibiotics, but nothing had prevented the acne from recurring and unfortunately scarring.
There are other forms of light treatment for acne that have been used for the last few years. Blue light treatment was the most usual light treatment people could expect to receive. The blue light, which has none of the UV rays that cause irritation and can damage the skin, could not be used by anyone using medication that increased sensitivity to light.
It was mainly used for mild to moderate acne, and was not suitable for severe acne as it could actually make the nodules worse! Furthermore, treatment was not effective for everyone. But scientists then discovered that a blue light combination, where the UV rays were again removed, was the most effective treatment for mild to moderate acne, with significant improvements in inflammatory acne.
Although the red light is able to penetrate the tissue more deeply than the blue light and has anti-inflammatory properties, it was the combination of the blue light and red light that produced the most dramatic results.
The trial, led once again by Prof. Tony Chu, demonstrated that people with acne experienced a 76 per cent reduction of spots after a 12-week period. The blue and red light wavelengths are produced by a light box, used for approximately 15 minutes a day, and visible improvements have been seen within six weeks.
These light boxes, available from Goldstaff by mail order have the added benefit of being portable, which means they can be sued within the comfort of your home. However, it is worthwhile discussing this treatment with your doctor, as it may be possible for you to be referred to a hospital or clinic specializing in this treatment.
Very often it is a combination of treatments which seems to produce the most beneficial effects when treating acne, and determining the type of acne you have will help you to choose the best treatments.
As a general rule, retinoids then salicylic acid, azaelaic acid and benzoyl peroxide are thought to be the most effective for comedones, while benzoyl peroxide, azelaic acid and topical antibiotics are considered the most effective treatments for inflammatory lesions.
Retinoids and combination products – topical antibiotics and benzoyl peroxide, for example – are considered effective for both non-inflammatory and inflammatory lesions. However, there is no apparent benefit in combining antibiotic topical treatment with oral antibiotic treatment, and there is the opportunity for the bacteria to become resistant to the treatment.
Mild acne treatment
Mild acne comprises whiteheads, blackheads, small red bumps or a combination of all three. There is no inflammation.
– Begin treatment with a mild over-the-counter topical product: a wash, cream or gel containing benzoyl peroxide or salicylic acid.
– Chart your acne on a weekly basis.
– Consider gentle facials and extractions by a qualified therapist.
– If acne continues, try a low-dose antibiotic product such as clindamycin and benzoyl peroxide.
– If acne still persists, seek a prescription-based antibiotic.
– The alternative may be an oral contraceptive.
– Consider a change in dietary habits, reducing sugar and refined carbohydrates, and if necessary use stress-reducing techniques.
– If acne persists, consult your GP, who will be able to prescribe topical retinoids, antibiotics and antibiotic combinations with benzoyl peroxide or zinc.
Moderate acne treatment
Moderate acne consists of whiteheads, blackheads, raised inflamed red bumps and some pustules and nodules.
– Book an appointment with your doctor, who may prescribe a topical agent containing a retinoid, an antibiotic or a combination product.
– Use a topical wash cream, lotion or gel containing benzoyl peroxide or azelaic acid, or a topical antibiotic.
– Keep a weekly acne chart.
– It may be necessary to use a combination therapy. Oral antibiotics may be prescribed, along with use of topical retinoid.
– An oral contraceptive may be prescribed.
– If acne still persists, then you may be referred to a dermatologist for consideration of oral isotretinoin.
– Consider a change in dietary habits, reducing refined carbohydrates and sugar, and if necessary use stress-reducing techniques.
Severe acne treatment
Severe acne causes deep painful cysts and scarring.
– Referral to a consultant dermatologist will be required.
– Surgery or drainage of large cysts may be required. Your doctor or dermatologist will perform this.
– An intralesional injection may be given to help lessen the inflammation and prevent scarring.
– Oral antibiotics may be prescribed.
– Oral contraception may be prescribed.
– Isotretinoin may be prescribed; this is taken for 16-20 weeks and usually only one treatment is required.
– A dermatologist will continue to monitor you during your treatment.