There is nothing better in the world, than curing someone's acne. It is such an awesome feeling to help people feel more comfortable and confident in their skin. Nothing brings me greater joy. Unfortunately, the internet is awash with misinformation on acne (P.S. - fungal acne is not a thing - it's called pityrosporum folliculitis and we usually only see it after using antibiotic acne treatments). Here is my take on acne and acne treatments:
Acne is a very common skin condition, particularly in teenagers, that appears as blackheads, whiteheads, red bumps, pus bumps and, sometimes, deeper red nodules (called acne cysts). Acne occurs when hair pores become blocked with dead skin (not dirt and not oil). We do not understand why some hair pores become blocked, and we do not understand why this happens mostly on the face, back, and chest. Patients with more severe, deeper acne often have inherited the tendency.
Acne is not related to germs or dirt. It is related to hormones, grease on the skin, and anything that might occlude the skin, such as chin straps on athletic gear, or a wet shirt that sticks to the skin. Therefore, frequent scrubbing and washing of the skin are not useful for acne. In fact, over-washing and scrubs can irritate the skin so that topical acne treatments are not tolerated. Moisturizers, sunscreens, and makeups used in areas of acne should be labeled "oil free" or "will not cause acne" or "non-comedogenic."
Teenage acne usually goes away in adulthood. However, adult-onset acne, particularly in women, is fairly common and often does not clear until menopause or later. Treatments for acne are very good, but they are very slow. Normally, a month is required for improvement, and three months for maximal improvement. Many patients discontinue their medication after several weeks because they believe it is not working, and don't understand that medications must be used longer to see a good effect. Also, once the skin clears, the medication should be continued.
Over the counter (OTC): Benzoyl peroxide 10% wash used in the shower. Make sure to wash off completely as it can bleach towels and clothing. Use on face, chest, and back. This wash works well with prescription topical antibiotics as it helps prevent bacterial resistance.
Generally, I recommend a topical medication for use in the morning. Usually this is an antibiotic for the red bumps and pustules. This antibiotic kills normal irritating skin bacteria, but more importantly, some antibiotics have a direct effect on irritation, even when it is not from germs. Therefore, these medications must be used long-term and ongoing, rather than for the usual one-two weeks to cure an infection. In addition, the effect is slow in onset. Topical antibiotic clindamycin solution, lotion, or gel, is the most commonly used. It can be applied to the face, chest, and back. Clindamycin is not absorbed very much through the skin, so even people with a history of bowel problems and C. diff are OK to use topical clindamycin.
At night time, it is vital to use a topical medication to unclog the pores. These medications remove blackheads and whiteheads, which often turn into the "pus bumps." The most common medications used are tretinoin (Retin-A®), adapalene (Differin®) (over the counter), trifarotene (Aklief®), or tazarotene (Tazorac®). These are applied very, very sparingly at night. These not only strip dead skin cells from the pores, but also dead skin cells from the surface of the skin, making the skin more prone to drying, peeling, irritation, and sunburn. An oil-free, very strong (high SPF - sun protection factor - of 30 or higher) sunscreen should be applied each morning to any treated skin not covered by clothing. Cerave AM, SkinMedica Essential Defense - Everyday Clear, and La Roche Posay Antihelios are good choices for this. People using these medications should not get a facial wax for hair removal as it can cause significant irritation. Start by applying the medication every other night, or every third night with a pea sized amount to the whole face. If the skin becomes irritated, the frequency of application of the medication can be decreased even further and then gradually increased to daily use. Using a smaller amount of medication can help as well. You can also try applying a light moisturizer such as SkinMedica HA5 Rejuvenating Hydrator prior to applying the topical retinoid and another layer of moisturizer such as Cerave PM or La Roche-Posay Toleraine Double Repair Moisturizer right after (a retinoid sandwich).
Doxycycline is an oral antibiotic used to treat acne. It is taken once or twice daily. It works best for the red bumps and pus bumps. It can cause heartburn if not taken with food and a full glass of water. It also makes the skin very prone to sunburn, so sunscreen needs to be applied to the face daily. Oral antibiotics are generally only used for a maximum of three months due to concern about harming the healthy bacteria in the body. Other treatments are considered if acne is still persistent after a course of doxycycline.
Other treatments for patients not adequately controlled with these therapies include treatments that affect hormones such as birth control pills or a medicine called spironolactone people with uteruses. Spironolactone works as a mild diuretic (water pill). Its main side effects are increased urination, and rarely dizziness, breast tenderness, or irregular periods. People with uteruses taking spironolactone should be careful to avoid pregnancy as it can make a male fetus develop female genitalia. Most people tolerate this medicine very well. Acne can sometimes return after stopping spironolactone as it is not a “cure.”
Isotretinoin (Accutane®) is the most effective medication for acne and is the only curative acne medication available. It is used in people with severe scarring acne, and people who have tried many other treatments but still have continued acne. It causes birth defects if a person gets pregnant on the medication, so it is regulated by the government program called iPledge. People with uteruses who are sexually active must use two forms of birth control for the time that they are on the medication and for one month after stopping the medicine. The medicine leaves the system in 30 days, so it does not cause any long term problems with birth defects. People with uteruses also have to wait one month before starting the medicine. Accutane’s main side effect is dryness of the skin, eyes, lips, and nose. It can cause nosebleeds due to the dryness as well as irritation with contact lenses. Saline eye drops, saline nasal spray, Ayr nasal moisturizing gel, and Vaseline are the best treatments for the eyes, nose, and lips. Accutane can also cause sore muscles and joints. Blood work is checked while on Accutane because in people who are prone to having high cholesterol, it tends to make their cholesterol increase. Acne can get worse before it gets better on Accutane as well. Most people notice the greatest improvement at 3 or 4 months into treatment. Blood should not be donated and pills should not be shared while on Accutane. People on Accutane should not get their skin waxed for hair removal as it can cause a rash. Sometimes minor cuts and scratches take longer to heal while on Accutane.
Occasionally, I will use other topical medications such as azelaic acid, dapsone gel or topical spironolactone. Azelaic acid is great for people who are pregnant or people who are prone to redness/rosacea. Topical dapsone seems to help people who develop more inflammatory or hormonal acne, but it's not my favorite product. I find topical spironolactone to be most effective in patient's who have PCOS or strictly hormonal acne. I'll go into greater depth on PCOS in a future post!