By the time many people consult a doctor for their acne, they usually have tried a drawerful of over-the-counter (OTC) medications. Acne is often treated by a dermatologist, a doctor who specializes in diseases and disorders of the skin. Dermatologists treat all kinds of acne, particularly severe cases. Doctors who are general or family practitioners, pediatricians, or internists may treat patients with milder cases of acne.
The main goal of acne treatment is to prevent scarring. Additional goals are to reduce the number of painful lesions and to minimize the psychological stress and embarrassment caused by this disease. Doctors often use drug therapy as the first choice for treating acne. Drug therapy is aimed at reducing several problems that play a part in causing acne: abnormal clumping of cells in the follicles, increased oil production, the bacterium P. acnes, and inflammation. Depending on the severity of the person's acne, the doctor will recommend one of several OTC or prescription topical medications (medication applied to the skin) or a prescription systemic medication (medication taken by mouth). The doctor may suggest using more than one topical medication or using both an oral medication and a topical medication at the same time.
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Treatment for Blackheads, Whiteheads, and Mild Inflammatory Acne
Doctors usually recommend an OTC or prescription topical medication for people with blackheads, whiteheads, and mild inflammatory acne. Depending on the type of medication, a topical drug is applied directly to the acne lesions or to the entire area of skin affected. The medication helps limit the formation of new blackheads and whiteheads and decrease inflammation.
Treatment for Moderate to Severe Inflammatory Acne
Patients with moderate to severe inflammatory acne may be treated with an OTC or prescription topical medication, a prescription oral medication, or a combination of these.
Topical OTC Medications
Benzoyl peroxide, resorcinol, salicylic acid, and sulfur are the most common topical OTC medications used to treat acne. Each works a little differently. Benzoyl peroxide is best at killing P. acnes and may reduce oil production. Resorcinol, salicylic acid, and sulfur help break down blackheads and whiteheads. Salicylic acid also helps cut down the shedding of cells lining the follicles of the oil glands. Topical OTC medications are available in many forms, such as gel, lotion, cream, soap, or pad.
In some patients, OTC acne medications may cause side effects such as skin irritation, burning, or redness. Some people find that the side effects lessen or go away with continued use of the medication. Severe or prolonged side effects should be reported to the doctor.
OTC topical medications are usually moderately effective in treating acne when used regularly. Patients must keep in mind that it can take between 4 and 8 weeks before they notice an improvement in their skin.
Prescription Topical Medications
Several types of prescription topical medications are used to treat acne, including benzoyl peroxide, antibiotics, tretinoin, adapalene, and azelaic acid. Prescription and OTC benzoyl peroxide work in the same way. Many doctors prescribe benzoyl peroxide instead of recommending OTC versions to make sure patients get the most desirable formulation (cream, gel, or lotion).
Common Prescription Topical Medications Used To Treat Acne
- Benzoyl peroxide
- Adapalene gel (Differin)
- Clindamycin phosphate (Cleocin T)
- Azelic acid (Azelex)
- Erythromycin
- Benzoyl peroxide and sulfur
- Tetracycline HCL
- Erythromycin and benzoyl peroxide
- Tretinoin (Retin-A, Avita)
- Sulfur and resorcinol
Antibiotics and azelaic acid help stop or slow the growth of P. acnes and reduce inflammation. Tretinoin, a type of drug called a retinoid that contains vitamin A, is the most effective topical medication for stopping the development of new comedones. It also fights acne by increasing cell turnover, which helps unplug existing comedones, and thereby allows other topical medications, such as antibiotics, to penetrate the follicles better. The doctor may also prescribe a newer drug called adapalene gel, a retinoidlike compound that helps decrease microcomedone formation.
Prescription topical medications come in a variety of products. The doctor will consider the patient's skin type when prescribing a product. Creams and lotions are moisturizing and tend to be good for people with dry skin. Gels and solutions are generally alcohol based and tend to dry the skin, so patients with excessively oily skin or those who live in hot, humid climates may prefer a gel. The doctor will tell the patient how to apply the medication and how often to use it.
Some people develop side effects from using prescription topical medications. Common side effects include stinging, burning, redness, peeling, scaling, or discoloration of the skin. With retinoids, these side effects usually decrease or go away after the medication is used for a period of time. Patients should report prolonged or severe side effects to their doctor. Between 4 and 8 weeks will most likely pass before patients see improvement in their skin.
Prescription Oral Medications
For patients with moderate to severe acne, the doctor often prescribes oral antibiotics (taken by mouth) in addition to topical medication. Oral antibiotics are thought to help control acne by curbing the growth of P. acnes and decreasing inflammation. Common antibiotics used to treat acne are tetracycline, minocycline, doxycycline, and erythromycin. Some people have side effects when taking these antibiotics, such as photosensitivity (higher risk of sunburn), upset stomach, dizziness or lightheadedness, and skin discoloration. Tetracycline is not given to pregnant women or children under 12 years of age because it can discolor developing teeth. Tetracycline and minocycline also decrease the effectiveness of birth control pills, so a backup or alternative form of birth control must be used. Patients usually must take oral antibiotics for as long as 4 to 6 months to effectively treat acne.
Treatment for Severe Nodular or Cystic Acne
People with severe nodular or cystic acne should be treated by a dermatologist. For patients with severe inflammatory acne that does not improve with other medications, such as those described above, isotretinoin (Accutane), a retinoid, may be needed. Isotretinoin is an oral drug and is usually taken once or twice a day for 16 to 20 weeks. It is believed to markedly reduce the size of the oil glands so that much less oil is produced. As a result, the growth of P. acnes is decreased. Isotretinoin also reduces cell shedding and the stickiness of cells in the follicles, which helps prevent the development of comedones.
Advantages of Isotretinoin
Isotretinoin is a very effective medication that can help prevent extensive scarring in patients. After 16 to 20 weeks of treatment with isotretinoin, acne completely or almost completely goes away in most patients (up to 90 percent). For some people, however, the acne will come back, and they will need additional treatment with isotretinoin.
Disadvantages of Isotretinoin
Patients should carefully consider the several disadvantages of isotretinoin. The drug is not only expensive but is also linked to some adverse effects that can be severe. Possible side effects include inflammation of the lip and mucous membrane of the eye; dry mouth, nose, or skin; itching; nosebleeds; muscle aches; photosensitivity; and, rarely, decreased night vision. Other more serious side effects include increased blood cholesterol, lipid, and triglyceride levels and abnormal liver enzymes. To make sure isotretinoin is stopped if these side effects occur, the doctor usually monitors a patient's complete blood count, blood chemistries, cholesterol, triglycerides, and liver enzymes before therapy is started and periodically during treatment. All of these side effects usually go away after the medication is stopped. Patients who experience side effects while using isotretinoin should tell their doctor. The doctor may be able to reduce the dose of the drug so that the side effects are decreased or stopped.
The most serious potential adverse effect of isotretinoin is that it is teratogenic: it can cause birth defects in the developing fetus of pregnant women who take the drug. Therefore, it is crucial that women of childbearing age are not pregnant and do not get pregnant while taking isotretinoin. Women must use an appropriate birth control method for 1 month before therapy begins, during the entire course of therapy, and for 1 full month after therapy stops. Women should talk to their doctor about when it is safe to get pregnant after therapy with isotretinoin has stopped.
Treatments for Hormonally Influenced Acne
For some female patients, treatment-resistant acne is caused by excessive production of hormones called androgens. Clues that help the doctor diagnose hormonally influenced acne are adult-onset acne, hirsutism (excessive growth of hair or hair in unusual places), premenstrual acne flares, irregular menstrual cycles, and elevated blood levels of certain androgens.
The doctor may prescribe one of several drugs to treat women with this type of acne. Low-dose estrogen birth control pills help suppress the androgen produced by the ovaries. Low-dose corticosteroid drugs, such as prednisone or dexamethasone, may have an anti-inflammatory effect and suppress the androgen produced by the adrenal glands. Finally, the doctor may prescribe an antiandrogen drug, such as spironolactone, which helps prevent androgens from causing excessive oil production. Spironolactone also stops androgen production in the ovaries and adrenal glands. Side effects of antiandrogen drugs may include menstrual irregularities, breast tenderness, headache, and fatigue.
Other Treatments for Acne
Doctors may use other types of procedures in addition to drug therapy to treat patients with acne. The doctor may remove the patient's comedones during office visits. Sometimes the doctor will inject a corticosteroid drug directly into lesions to help reduce the size and symptoms of tender and inflamed cysts and nodules. Other patients may benefit from light skin-peeling agents that are prescribed by a doctor or applied in the doctor's office. For some patients, the doctor may suggest a minor surgical or medical procedure to help reduce scarring caused by acne.
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