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How is acne treated?
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.
Common over-the-counter topical medications used to treat acne
Generic Name Common Brand Names Benzoyl peroxide cream, gel, lotion, or soap Clearasil, Fostex, PanOxyl Dryox, Persa-Gel Salicylic acid PROPApH, Stridex, Oxy Night Watch, Clearasil Clearstick Maximum Strength Sulfur Sulpho-Lac Acne Medication, Liquimat, Therac Lotion, Sulmasque Benzoyl peroxide and sulfur Dryox 10S, Dryox 20S 10, Sulfoxyl Sulfur and resorcinol Sulforcin Lotion, Rezamid Lotion 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 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 one month before therapy begins, during the entire course of therapy, and for one 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 anti-androgen 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 anti-androgen 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.
How should people with acne care for their skin?
Clean skin gently
People with acne may try to stop outbreaks and oil production by scrubbing their skin and using strong detergent soaps. However, scrubbing will not improve acne; in fact, it can make the problem worse. Most doctors recommend that people with acne gently wash their skin with a mild cleanser, once in the morning and once in the evening. Patients should ask their doctor or another health professional for advice on the best type of cleanser to use. The skin should also be washed after heavy exercise. Patients should wash their face from under the jaw to the hairline; rough scrubs or pads should not be used. It is important that patients thoroughly rinse their skin after washing it. Astringents are not recommended unless the skin is very oily, and then they should be used only on oily spots. Doctors also recommend that patients regularly shampoo their hair. Those with oily hair may want to shampoo it every day.
Avoid frequent handling of the skin
People who squeeze, pinch, or pick their blemishes risk developing scars. Acne lesions can form in areas where pressure is frequently applied to the skin. Frequent rubbing and touching of skin lesions should be avoided.
Avoid tanning
A suntan or sunburn that reddens the skin can make blemishes less visible and make the skin feel drier for a little while. But the benefits are only temporary. The sun can seriously damage skin, promote aging of skin, and cause skin cancer. Furthermore, many of the medications used to treat acne make a person more prone to sunburn.
Choose cosmetics carefully
People being treated for acne often need to change some of the cosmetics they use. All cosmetics, such as foundation, blush, eye shadow, and moisturizers, should be oil free. Patients may find it difficult to apply foundation evenly during the first few weeks of treatment because skin may be red or scaly, particularly with the use of topical tretinoin or benzoyl peroxide. Lip products that contain moisturizers may cause small, open and closed comedones to form. Hairstyling products that come in contact with the skin along the hairline can cause burning or stinging in people with acne. Products that are labeled as noncomedogenic (do not promote the formation of blemishes) should be used; in some people, however, even these products may cause acne.
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