Various gels, lotions and creams are used to treat acne. Different preparations work in different ways. The following briefly describes the different types. However, always read the leaflet in the packet, because such things as how to apply it and precautions vary between different preparations. One general point is that you should apply topical treatments to all the affected area of skin and not just to each spot.
Benzoyl peroxide
Benzoyl peroxide is a common topical treatment. It has three actions - it kills germs (bacteria), reduces inflammation and helps to unplug blocked pores. Therefore, it often works well to clear inflamed spots and it helps to clear blackheads and whiteheads (comedones). You can buy benzoyl peroxide at pharmacies, without a prescription. It comes in different brand names and strengths - there is a 2.5%, 4%, 5% and 10% strength. Benzoyl peroxide:
- Works best if you wash the skin 20-30 minutes before use.
- May bleach hair, bed linen, or clothes that come into contact with it.
- Commonly causes mild skin irritation. If your skin does become irritated then stop using it until the irritation goes. Then try again with a lower strength, or reduce the time it is left on your skin before washing off. To prevent skin irritation, the following may help:
- Most people can tolerate the 5% preparation but if it irritates then try the 2.5% once the irritation settles. If you wish to increase the strength, do it gradually.
- Use a water-based preparation (rather than an alcohol-based one).
- Apply once daily at first and wash off after several hours.
- Gradually increase the length of time left on the skin.
- Aim to put on twice daily when you get used to it.
Retinoids
Retinoids are good at unplugging blocked pores. They include adapalene, tretinoin and isotretinoin which come in various brand names. They also have some effect on reducing inflammation. Therefore, one is often used early on in acne to help to unblock pores and to treat blackheads, whiteheads and mildly inflamed spots. You need a prescription for all retinoid preparations. When you use a topical retinoid:
- You may develop some skin redness and skin peeling. This tends to settle over time.
- The spots sometimes become a little worse before improving.
- Your skin may be more sensitive to sunlight. Therefore, it is best to apply at night and wash off in the morning. A sun protection cream may also help if you are out in the sun.
- The most common side-effects are burning, irritation and dryness. Therefore, you may be advised at first to use a low-strength, less frequent application and for a shorter duration.
- You should not be pregnant, or intend to become pregnant, as there is a slight risk of harm to unborn babies. Discuss contraception with your doctor if necessary.
Topical antibiotics
There are various topical antibiotic preparations. They reduce the number of bacteria and reduce inflammation. However, they have little effect on unplugging blocked pores. So, they are usually good at treating inflamed acne but blackheads and whiteheads may remain. You need a prescription to obtain a topical antibiotic. They may cause mild irritation but generally cause fewer side-effects than the other topical preparations. Topical antibiotics are usually prescribed in combination with other medicines (see below). Using them alone can increase the risk that the germ will become used to the antibiotic and make the treatment less effective.
Azelaic acid
Azelaic acid is an alternative that mainly works by unplugging blocked pores. So, like retinoids, it is good at clearing blackheads and whiteheads. It has some effect on reducing inflamed acne too but probably not as much as antibiotics or benzoyl peroxide. However, it may cause less skin irritation than benzoyl peroxide.
Combinations
Some preparations contain a mixture of ingredients. For example, benzoyl peroxide plus an antibiotic, or a retinoid plus an antibiotic. These may work better than either ingredient alone.
Tablets that can treat acne
Antibiotic tablets
Antibiotics work by killing germs (bacteria) that contribute to the cause of acne. They also have a direct effect of reducing inflammation. Antibiotics usually work well to clear inflamed acne spots and any surrounding skin inflammation.
However, they have little effect on unplugging blocked pores - which you can see as blackheads and whiteheads (comedones). So, if you only have mild acne with just blackheads and whiteheads, you are better off using a topical treatment that unblocks holes in the skin (pores). If you have a lot of blackheads and whiteheads as well as inflamed acne spots, you may be advised to use a topical treatment such as benzoyl peroxide in addition to taking an antibiotic tablet.
Always read the leaflet that is in the packet of antibiotics. Things such as precautions and possible side-effects vary between antibiotics. The following are some general points.
Tetracycline-based antibiotics are the most commonly used antibiotics to treat acne. These include: oxytetracycline, tetracycline, doxycycline and lymecycline.
- Children aged under 12 years should not take tetracycline-based antibiotics.
- Do not take tetracycline-based antibiotics if you are pregnant, breast-feeding or intend to become pregnant. Discuss contraception with your doctor if necessary.
- Food and milk affect the absorption of oxytetracycline or tetracycline. Therefore, take these tablets on an empty stomach, between meals, with a glass of water (not milk). Doxycycline and lymecycline can be taken with food.
Other antibiotics that are sometimes used include erythromycin and trimethoprim. You may be advised to take one of these if one of the above has not worked well or is unsuitable.
The pill (a hormone treatment)
The combined contraceptive pill (the pill) may help some women if their acne seems to be partly related to their hormonal changes. For example, acne that began or became worse in adulthood, or if acne seems to flare up around the time of a period. It is the oestrogen part of the pill that is thought to help. A variety of the pill, called co-cyprindiol, may be especially useful where a sensitivity to androgen hormone is thought to be making acne worse. For example, for women with excess facial hair growth in addition to acne. Co-cyprindiol contains a combination of an oestrogen plus cyproterone (an anti-androgen).
Isotretinoin tablets
Isotretinoin greatly reduces the amount of oil (sebum) made by your sebaceous glands. It works very well and usually clears spots even in severe cases. However, it is normally used only on the advice of a specialist after other treatments have been tried first. This is because there is a risk of serious side-effects with isotretinoin tablets.
How long is treatment needed?
Whatever treatment is used, it is normal to take up to four weeks for there to be any improvement that you can see. There is often a good response to treatment by six weeks. However, it can take up to four months (sometimes longer) for maximum response to a treatment and for the skin to be generally free of spots. Note: the most common reason for a treatment failure is because some people think that treatment is not working after a couple of weeks or so and give up.
Therefore, continue with any treatment for at least six weeks before deciding if it is working or not. If there is no improvement after six weeks of taking a treatment regularly and correctly, do not despair. Adding in another treatment or a change to a different or more powerful treatment will usually be advised and is likely to work. Although treatment can usually clear most spots, there is no treatment that will make your skin perfect and the odd spot may remain.
Will acne return after treatment?
Once the spots have cleared, acne commonly flares up again if you stop treatment. Therefore, after the spots have gone or are much reduced, it is common to carry on with a maintenance treatment to prevent acne from flaring up again. It is common to need maintenance treatment for 4-5 years to keep acne away. This is typically until the late teens or early 20s. In a small number of cases, acne persists into the 30s, or even later. For these people it is possible to continue to treat the skin to keep it under control.
Maintenance treatment is usually with either benzoyl peroxide or a topical retinoid. These can both be used indefinitely. The dose used to prevent spots from returning is often lower than that used to treat acne. For example, one application to the skin every other day with a low-strength preparation may be sufficient to keep spots from returning.
It is not usual to use topical antibiotics or antibiotic tablets as maintenance treatment once the spots have cleared. This is because long-term use of antibiotics can lead to resistance of germs to the antibiotics. Also, azelaic acid, another topical treatment, is only licensed for treatment periods of six months. Also, it is best not to take the pill long-term solely to prevent acne. Therefore, if at first you are treated with an antibiotic, azelaic acid or the pill, you may be advised to switch to benzoyl peroxide or a topical retinoid for maintenance treatment.
Does acne ever need hospital treatment?
If you have severe acne which does not respond to the treatments usually prescribed by GPs, you may need to see a hospital specialist. In particular, if your doctor believes you would be helped by isotretinoin tablets. You may also need hospital treatment for acne scars. Options available for scarring include laser resurfacing of the skin, mechanical or chemical peeling of the skin, breaking the scar tissue down with a sterile needle (subcision) and injection of collagen filler.
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