Treatment of Acne
The list of treatment options for acne is long, and it grows longer each day. On the one hand this is a good thing, because there is a good chance our Houston dermatologists can find something that works for you. On the other hand, the sheer number of options can overwhelm patients when they try to navigate through all the over the counter preparations without the guidance of a dermatologist. Patients often spends hundreds of dollars on ineffective skin regimens or topical remedies that don't suit their skin. The best thing you can do for your skin is educate yourself and schedule an appointment so that we can tailor a regimen to your needs.
The table below summarizes various acne treatment options. Below the table are more detailed explanations. Your Houston acne specialists will review these options with you and formulate a plan to treat your acne.
COMPARISON OF ACNE TREATMENT OPTIONS
Minimal internal side effects
No drug interactions
Can be used long-term
Can be expensive
Can be time-consuming to apply to large surface areas
Take 3 months to have full effect
Some can bleach/stain clothing
Often cause dryness and irritation
Often work more quickly than topicals
Usually do not require lab monitoring
Can have internal side effects (stomach upset, sun sensitivity, autoimmune reactions)
Can severely affect gut flora (kill good bacteria in the GI tract which can predispose to other diseases)
Not meant for long-term use (ie. not meant for use longer than 3 months)
Can lead to resistance, or "super-bugs"
Can result in yeast infections in women
Not meant to be used alone -- must be used in conjunction with topicals to prevent resistance
May be associated with the development of IBS (irritable bowel syndrome)
Possibly associated with the development of IBD (inflammatory bowel disease)
Extremely effective -- the most clinically effective acne treatment that exists to date
The only medication that impacts all of the underlying causes of acne
Reduces P. acnes bacteria though is NOT an antibiotic
Has anti-inflammatory properties
Decreases oil (sebum) production
Chance of long-term "remission" from acne
Fewer than 30% relapse after an appropriate course
Synthetic vitamin A - side effects predictable and dose-dependent
Used for a finite period of time (about 6 months)
FDA-approved in 1982 -- over 35 years on the market
Covered by insurance in most cases
Causes birth defects if taken in pregnancy
Regulated by iPledge system
Causes dryness of skin and lips, lip chapping, occasional nosebleeds
Requires blood work monitoring - occasional abnormalities in liver tests and triglycerides
Can cause aches in the joints and muscles
Occasionally causes hair shedding
Requires monthly follow-up for about 6 months
Controversial association with depression
Can cause pseudotumor cerebri (swelling around the brain - rare, also associated with oral antibiotics used for acne)
With proper monitoring, can be done safely and effectively
Easy, minimal effort at home
Effective in decreasing inflammation
Can help treat scarring and post-inflammatory hyperpigmentation
Results are not permanent
Not covered by insurance
Females only: Birth control pills (oral contraceptives)
Can be effective -- a few birth control brands are FDA-approved for acne
Long-term use is acceptable
May cause weight gain, mood symptoms
Not safe if you are a smoker or have a history of blood clots
If over 35 or 40, increased risk of heart attack or stroke
Acne will likely recur once it is discontinued
Females only: Spironolactone
Can work for hormonal and adult female acne
Minimal lab monitoring needed
Minimal dryness and irritation
No risk of resistance
Cannot be used in males
Females should not take if planning pregnancy
Can cause breast tenderness and menstrual irregularity
Only effective while on it - no sustained benefit
Not approved for acne - used off-label
Can cause elevated potassium, which is not common in young, healthy individuals
Not to be used in patients on Bactrim, other potassium-sparing diuretics, ACE inhibitors, or angiotensin-receptor blockers. In some cases, can still be used with close monitoring
Boxed warning by FDA - linked to tumor formation based on studies in rats where they were given chronically toxic doses
We often use a step-wise approach when treating acne.
If acne is mild or if a patient cannot take any medications by mouth for various reasons, we may begin with topical medications alone. If these are not effective, or if acne is a little more extensive, we often will begin with a combination of topical medications and oral antibiotics. If this does not work, or if patients cannot take oral antibiotics, in females we may consider hormonal acne therapy. If acne is severe, nodulocystic, scarring is present, or patients have not responded to other treatment options, isotretinoin (Accutane) is often considered, or it is considered if there are concerns of antibiotic resistance.
Topical Medications: These are medications that are applied to your skin (as opposed to being taken by mouth). Some are available over the counter while some are available by prescription. The most important thing to consider is the active ingredient, which may include:
- Benzoyl peroxide: While some benzoyl peroxide preparations may be found over the counter, prescription-strength preparations are sometimes more effective. Benzoyl peroxide works by releasing free oxygen radicals that oxidize bacteria thereby killing the bacteria that cause acne. It is effective both alone and in combination with other topical medications. To date, bacterial resistance of P. acnes (the bacteria that cause acne) to benzoyl peroxide has not been reported. Benzoyl peroxide comes in many formulations: lotions, washes, gels, foams, creams, and pads. It can cause bleaching when it comes in contact with clothing or towels.
- Topical retinoids: These are vitamin A derivatives that help the skin turn over more quickly, resulting in the unclogging of pores and follicles, reducing the numbers of comedones and inflammatory lesions. They include Differin (adapalene), Retin-A and Atralin (tretinoin), and Tazorac (tazarotene). Skin irritation, dryness, redness, and peeling can sometimes be seen during the initial weeks of use. Washing your face with a mild cleanser and limiting the use of other drying agents can help minimize these effects. If the irritation persists, using the topical retinoids every other day or every third day can also be helpful. Sun sensitivity may be increased while on these medications
- Topical antibiotics: Topical antibiotics are effective against P. acnes and also help reduce the inflammation associated with acne. The most common agents include topical clindamycin and topical erythromycin. These are sometimes combined with benzoyl peroxide (as seen with Benzaclin, Duac, and Benzamycin) to reduce the possibility of bacterial resistance. Topical dapsone is also available (Aczone gel), and it tends to be well-tolerated.
- Sulfur-based medications: Sulfur is thought to help acne through its antibacterial and keratolytic properties. It helps the skin turn over, resulting in fewer clogged pores and follicles. It is believed that when sulfur reacts with cysteine in the skin, it produces hydrogen sulfide which helps break down keratin. It also produces pentathonic acid, an agent that is toxic to fungus and inhibits P. acnes. Sulfur-based medications are most commonly seen in combination with sodium sulfacetamide, as seen in Plexion, Clenia, Avar, and Ovace.
- Glycolic acids: Glycolic acids belong to the family of acids known as α-hydroxy acids. Glycolics have excellent skin penetrating capabilities and the ability to help break down the lipids that hold dead skin cells together. With regular application, gentle exfoliation of the stratum corneum is achieved, and live, healthy skin cells are exposed, improving the tone and texture of the skin. They play a role in both anti-aging as well as acne, and they are felt to be safe for use in pregnancy.
Oral Antibiotics: Oral antibiotics have been shown to be helpful in the treatment of inflammatory acne, though they are used somewhat less than they were previously used. We use these primarily in patients with moderate inflammatory acne, though sometimes we will also use them in milder acne on the trunk for which it is difficult to apply topical medications. Oral antibiotics improve inflammatory acne by inhibiting the growth of P. acnes within the pilosebaceous unit. The tetracycline antibiotics have the added benefit of having direct anti-inflammatory properties. Antibiotics by mouth can provide more rapid results than topical medications alone; however, there is also the chance of having an allergic reaction or a yeast infection as a result. In addition, antibiotic resistance is becoming a major problem. For this reason, it is not recommended to use these for longer than a few months. Some of the common antibiotics considered include:
- Tetracyclines: This category is the most commonly prescribed antibiotic for acne. In the past, tetracycline was used, but now newer derivatives such as doxycyline and minocycline are used a little more commonly. Doxycycline and minocycline both have great efficacy against P. acnes, and they also have very significant anti-inflammatory properties that can decrease the redness and pain associated with inflammatory acne. We can't use these medications in pregnant women or in children under the age of 9, because it stains the teeth and interferes with bone development at a young age. In older children this is not a concern.
- Macrolides: These include erythromycin and azithromycin. Erythromycin is not used as often because it causes gastrointestinal side effects and because antibiotic resistance develops quickly. Azithromycin also can result in antibiotic resistance, but we occasionally use it for short periods of time in patients who cannot receive a tetracycline.
- Sulfa drugs: Trimethoprim-sulfamethoxazole (Bactrim or Septra) can be effective in the treatment of severe acne. However, it can cause severe drug reactions such as toxic epidermal necrolysis. In addition, it is very effective in the treatment of MRSA, or methicillin-resistant staphylococcus aureus, infections, which is a much more serious condition. We try to avoid prescribing these for acne if possible, so that they will work for you if you really need it for a life-threatening infection.
- Clindamycin: We occasionally see other doctors prescribe this for acne. We prefer to avoid this by mouth, because of the chance of developing pseudomembranous (C. dificile) colitis. Topical clindamycin is far less likely to cause this, and it is still used quite a bit in the treatment of acne.
- Cephalexin: This does not really penetrate the pilosebaceous unit effective, so it does not tend to work as well for acne.
Hormonal acne therapy: Since acne is often influenced by hormones, various medications that target hormones can be used to treat acne. These include birth control pills and spironolactone. Hormonal acne therapy is discussed further here.
Oral retinoids: This is a class of medications derived from vitamin A, and it includes isotretinoin, which is highly effective in the treatment of acne. Isotretinoin is used so commonly in acne, it deserves its own page, and you can read more about it here.
Surgical acne treatment: Some patients benefit from physical extraction of comedones, injection of steroids into large acne cysts, chemical peels, medical facials, and laser therapy. These are great options in patients who wish to avoid systemic medications.
Learn more about acne: