Acne, also known as acne vulgaris, is a skin condition that affects
millions of teenagers and adults alike. In fact, more than 80% of people
worldwide have some form of acne between the ages of 11 and 30. While
usually not serious, acne can cause negative psychological issues and,
while not as common, long lasting scars. There are many different
factors to why people get acne including an increase in hormone levels,
excess oil (or sebum) in the skin, bacteria and more. Acne itself has
many different varieties including whiteheads (closed comedo),
blackheads (open comedo) and inflammatory papules. (Fortunately, there
are many different products available on the market that can help
prevent acne and treat it once someone already has it.
Acne is
classified clinically as being mild, moderate or severe. This grading
scale is somewhat subjective but how severe your acne is will determine
the type of treatment you will be taking. Mild acne is usually self
medicated with over the counter products which we will discuss. Mild
acne that doesn't improve or worsens is typically treated with
prescription products. In terms of medications, this article will
discuss over the counter, prescription and supplemental products used to
treat acne.
Over The Counter(OTC)
Salicylic Acid
When To Use/Place In Therapy
Mild
acne in patients with sensitive skin. This medication is usually used
by patients to self treat their acne and is typically one of the first
medications people will try.
How To Apply
Apply 1 to 3 times per day, massage into skin and rinse off.
Important Additional Information
Not as effective as OTC benzoyl peroxide but is usually better tolerated, especially in those with sensitive skin.
Benzoyl Peroxide
When To Use/Place In Therapy
Benzoyl
peroxide is actually available as both an over the counter product and
as a prescription. It ranges in strength from 2.5% to 10%. Along with
salicylic acid, it is very commonly used to self treat acne. It is used
for mild to moderate acne and is almost always used in combination with a
prescription product to clear up more moderate to severe cases of acne.
How To Apply
Applied
every other day to twice daily. Depending on the specific product you
get, be it a gel, creamy wash, foam, be sure to read the package
directions for application. Some products you apply and keep on while
others you apply and wash off.
Important Additional Information
The
most common side effect is redness of the skin, especially when you
first start using the product. In fact, it's very common that your acne
may appear worse because of the redness. This typically gets much better
though as you continue to use the product. You should start once daily
or even once every other day to become accustomed to the product to
reduce the possibility of the redness. It is also recommended to start
with either the 2.5% or the 5% benzoyl peroxide strength. Benzoyl
peroxide is know to cause bleaching of towels and other fabrics so be
aware of this! Benzoyl peroxide also can cause sun sensitivity.
Prescription Products
The "Retinoids"
When To Use/Place In Therapy
The
retinoids are the most commonly used prescription products for acne,
and there are a lot of them! They can either be used alone for mild acne
or in combination with other products for more moderate to severe acne.
Retinoid Products - Generic name followed by brand names in parenthesis
Tretinoin (Retin-A, Retin-A Micro,? Tretin-X)
Adapalene (Differin gel/cream)
Tazarotene (Tazorac)
All of these formulations come in a variety of different vehicles including creams, gels, and solutions.
How To Apply
Start
with the lowest strength to avoid possible irritation. Typically it is
recommended to start dosing at three times weekly, progressing to
nightly use as tolerated. All retinoids are applied in the evening
before going to bed. Ideally, you should wash the face with a
non-medicated soap or gentle cleanser (such as Cetaphil), then apply a
thin film of the cream, lotion, or gel to cover the entire face. Do not
rinse off afterwards.
Important Additional Information
All
of the retinoid products work in the same way, but certain products and
formulations are either better tolerated or more effective. If what
your doctor prescribed you isn't having the desired effect, it usually
helps to change the retinoid product, strength or formulation.
Tretinoin
creams are the most commonly prescribed since they are available
generically and are less expensive than other products. They do tend to
cause the most irritation in the retinoid class however. There is a
tretinoin product known as Retin-A micro which is the best tolerated of
the retinoid bunch. Tretinoin is deactivated by sunlight and therefore
should be applied at bedtime.
Adapalene (Differin) products are
considered to be slightly more efficacious than tretinoin products and
certainly cause less skin irritation. Some formulations of adapalene are
available generically just as tretinoin products are but in general
does cost more. Sunlight deactivates adapalene just like tretinoin and
therefore should be applied at bedtime.
Tazarotene (Tazorac) is
considered the most effective retinoid of all but is typically more
irritating that the others. It commonly causes redness and scaling.
Also, tazarotene is absolutely to be avoided in pregnancy or in those
who wish to become pregnant.
For all the retinoid products, as the
strength increases so does the possibility of redness, flaking, and
irritation. Ideally you want to start at a couple of times per week and
move up to nightly dosing.
In terms of picking a product
formulation (cream vs gel etc.), the general recommendation is to pick a
formulation based on your skin type. For people with more oily skin, it
is recommended to go with a gel or solution because they contain more
alcohol and tend to be a little bit more drying. In people with dry,
flaky skin, cream is usually the best choice as it won't dry as much.
Lastly,
as will many different drug products, acne does tend to get worse when
you start a medication before it gets better. It can sometimes take
around a month to start seeing the positive effects of medication.
Azelaic Acid
When To Use/Place In Therapy
Azelaic Acid (Azelex) is often used for patients with mild to moderate acne. It tends to be less irritating than other products
so it is good for those with sensitive skin.
How To Apply
Azelaic
Acid is usually gentle enough where is can be applied twice daily, in
the morning and in the evening, at the start of therapy. Gently wash the
face, pat dry and apply the product. Do not wash the face afterwards.
Important Additional Information
Azelaic
Acid (Azelex) is usually considered slightly less effective than the
retinoid products but again, it is great for people with sensitive skin.
In those people with darker complexions, it has been know to cause
hypopigmentation, also known as a loss in skin color.
Dapsone (Aczone)
When To Use/Place In Therapy
Dapsone
(Aczone) is a topical antibiotic formulation indicated for mild,
moderate or even severe acne. It usually is used in combination with
other products. Though Dapsone is classified as an antibiotic, it
appears to work by preventing and treating the inflammatory process. It
is usually very well tolerated and typically is regarded as a good
option for patients that can't tolerate other medications well.
How To Apply
Dapsone
should be applied to a clean and dry face. Dapsone does tend to be a
little bit gritty so you can expect to feel that when you rub it in. Do
not rinse your face afterwards.
Important Additional Information
Two
things are important to know about Dapsone. First, it is usually fairly
well tolerated and should not make acne worse before it gets better,
unlike the retinoid products. Secondly, it usually is not used with
benzoyl peroxide products as the combination of both can cause a
temporary orange staining on the skin.
Spironolactone (Aldactone)
When To Use/Place In Therapy
Spironolactone
is an oral therapy and is usually reserved for more moderate to severe
cases of acne where other treatments haven't worked. It is almost always
used in combination with topical products and is almost exclusively
used only in females with either excess androgenization (i.e. excess
male hormones) or acne that comes and goes in cycles. Excessively oily
skin, abnormally excessive hair growth and menstrual irregularities
sometimes signal excess androgen in women.
How To Apply
The
dosage for spironolactone is individualized in each patient with
typical dosages ranging from 25 to 200 mg. Ideally you want the lowest
effective dose. It should be taken in the morning because it is a mild
diuretic (causes a loss of water through urination).
Important Additional Information
Spironolactone
is know as an anti-androgen and is very effective in reducing sebum
(oil). It works by blocking the conversion of testosterone to
dihydrotestosterone. Excess Dihydrotestosterone can cause many
dermatological issues such as clogged pores and inflammation. Studies
have shown that spironolactone reduces sebum excretion in the skin by
about 30-50 percent and therefore is very effective in those with oily
skin.
Being an oral medication, it has the possibility to cause
more side effects than topical treatments. The most common side effects
are excess urination, menstrual irregularities (spotting etc.) and low
blood pressure. The menstual irregularities are usually decreased in
woman who are also taking oral hormonal contraceptives.
Many
compounding pharmacies make topical spironolactone which can sometimes
help reduce side effects. It is not commercially available though at
retail pharmacies.
Antibiotics (Topical)
When To Use/Place In Therapy
As
part of combination therapy for mild to severe acne. Topical
antibiotics should never be the sole treatment for several reasons
including the extended time it takes to see positive effects and the
fact that bacterial resistance can occur. It's important to note that
acne is not an infection. Everyone carries a bacteria in their skin
known as P. acnes. The problem is when the bacteria over grows in the
skin. Some byproducts of the metabolism of the P. Acnes bacteria are
irritants to the skin and lead to microcomedo formations and results in
inflammatory lesions. Decreasing the amount of P.Acnes via antibiotic
therapy is usually associated with acne improvement.
Topical antibiotics include, erythromycin and clindamycin.
How To Apply
Topical antibiotics are applied usually once to twice daily. Apply to a clean, dry face and do not wash off after application
Important Additional Information
Topical
antibiotics typically are used in 3 month spurts and then given a
break. They are always to be used in combination therapy with other acne
products such as benzoyl peroxide.
Some products do cause sun sensitivity so it is recommended to use sunscreen.
Antibiotics (Oral)
When To Use/Place In Therapy
Antibiotics
taken by mouth are typically only prescribed for those who have
moderate to severe inflammatory acne and they are always prescribed as
past of a combination with topical therapies. They are used to reduce
the colonization of a specific bacteria known a P. Acnes. They can take
one to two months to begin working and once new acne lesions are no
longer forming, the antibiotics are typically stopped.
Antibiotics given for acne are usually one of the following:
Doxycycline
Minocycline
Tetracyclin
Clindamycin
Sulfamethoxazole/Trimethoprim
How To Apply
The usual dose of antibiotics is one to two capsules/tablets per day.
