A recent Google™ search for “acne medications” returned about 1,000,000 “hits.” This article tries to give an organized sense to all this information. As always recommended, a personalized treatment and comprehensive care plan should be designed in consultation with a trusted board-certified physician, even when considering the use of over-the-counter products to treat acne. This article is for educational purposes only and is not intended to be a substitute for sound medical care, serve as medical advice, or represent a sole guide to treatment.

I. Mild to Moderate Acne – Topical Medications

“Over the counter” (OTC) topical medications are generally successful for treating mild to moderate acne. Over-the-counter products often include one or more of the following ingredients: benzoyl peroxide, alpha hydroxy acids, salicylic acid, retinoids, nicotinamide, tea tree oil, sulfur, resorcinol

Benzoyl Peroxide (BP) – OTC concentrations of 2.5%, 5% and 10% BP are available in creams, gels or as a component of a soap/face wash. Even higher concentrations of BP are used to whiten hair and teeth! Better results will be obtained using the 10% concentration for acne. BP probably represents the best and most successful acne medication out there. Allergic-type reactions (occurring in approximately 3% of the population) are possible and are characterized by significant itching, scaling, and/or swelling. But BP can cause these effects to some extent even when it’s running normally and doing what it’s supposed to do! Building a tolerance to a topical acne medication so it can do its job: This is a theme/strategy with almost all topical acne medications. So start slowly and at a lower force, then progress to the most effective strength and tolerable treatment schedule. BP is broken down deep in the skin into its component parts. The “benzoyl” part is benzoic acid; this helps penetration deep into the pores where the oxidative action of the “peroxide” kills bacteria. Since clogged pores filled with debris, sebum, and bacteria lie below the skin’s surface, washing alone is simply not effective. Aggressively rubbing while washing or blotting might “feel good,” but it only leads to even more inflammation, further perpetuating the effects of acne. Using a cleanser that contains BP, gently washing, then patting dry is a good option. You can also leave a BP cleanser on for a few minutes for prolonged application on stubborn areas (such as your back) just like you would a gel or cream. BP is a key ingredient in the ProActive line of acne treatment products.

alpha hydroxy acids(ahah) – These act as exfoliants that promote the loosening and shedding of dead and near-dead skin cells, decreasing surface sebum and helping to empty pore-clogging debris in the process. Examples: glycolic acid, lactic acid, citric acid, malic acid and mandelic acid. Glycolic acid appears to be the most clinically effective of this class. Mandelic acid is probably the mildest. Opening pores and enhancing skin cell turnover rejuvenates the look and feel of skin while simultaneously targeting acne. AHAs also have antibacterial properties against acne. Household products often have AHA concentrations of 10% or less, while estheticians often use 30-40% AHA concentrations when performing in-office “chemical peel” treatments. A series of 5-6 monthly chemical peels can be a very effective means of breaking the acne “cycle,” especially for people over the age of 20-30. Doctors will use AHAs up to 70% for certain chemical peels or treatment situations. .

Salicylic acid– The main anti-acne action of salicylic acid is through its exfoliating properties, as seen with AHAs. Several Noxzema acne products use salicylic acid. Salicylic acid has been in medical use for over 100 years; it is more commonly known as “aspirin”!

retinoids– They are derivatives of vitamin A that act simultaneously due to their exfoliating effects and their stimulating effects on collagen and skin cell growth. Dead skin cells, pore debris and sebum are loosened and removed. Extractions will become easier or even avoided. Retinoids increase the opening of pores and skin cell turnover, generally rejuvenating the appearance of the skin. But they can also reduce the oiliness of the skin to an excessive degree and make the skin too dry. However, the skin usually adapts to this after 1-2 weeks of use and better results will be seen if treatment is not interrupted. Vitamin A derivatives encourage skin cell growth, “plumping” and strengthening skin cells, and also increase collagen production. Retinoids can be found in a very wide variety of anti-acne and general cosmetic skin care products. Caution: Retinoid-treated skin is generally more sensitive: waxing, laser treatments, chemical peels, and similar procedures should be performed very conservatively, if at all. Retinoid use is associated with birth defects.

Nicotinamide– This is vitamin B3 and acts as an anti-inflammatory, serving to reduce acne activity.

tea tree oil– This “alternative” topical treatment, also known as “Melaleuca oil” (from the Melaleuca Alternifolia plant) has some antibacterial and antifungal properties that add to its anti-acne effects. Tea tree oil 5% is thought to be comparable in action to BP’s 5%, but seems to work in a much more “gentle” way.

Sulfur– Sulfur is antibacterial and has both a “peeling” and a drying action on acne-affected skin. However, sulfur can have a particularly unpleasant odor, can cause skin discoloration and, paradoxically, can sometimes induce the formation of blackheads.

resorcinol – This works mainly through its exfoliation properties as described above. Several Clearasil products use a combination of resorcinol and sulfur compounds.

II. Moderate Acne: Topical Medications

Prescription topical medications are generally the best options for moderate acne. A regimen would generally include one or more of the following: antibiotics/antimicrobials, retinoids, azeleic acid.

Antibiotics/antimicrobials – Clindamycin is one among many of a wide variety of topical antimicrobials that directly kill bacteria on the skin such as Propionibacterium acnes, the most commonly identified bacteria associated with acne lesions. P. acnes actually “lives” on sebum, but it is less clear whether it is P. acnes itself or other “opportunistic” bacteria on the skin that directly cause acne lesions. Many combinations of topical antimicrobials are available, often combining one or more with BP and/or a retinoid. Allergic-type reactions can occur, and topical antimicrobials can also be very irritating and harsh on the skin, especially with prolonged use.

retinoids – Vitamin A derivatives in strong concentrations (prescription level) are commonly used today for moderate acne and generally work as described above for retinoids. Tretinoin 0.1% (Retin-A) is the most widely used and well-known, but this category also includes adapalene (Differin) and tazarotene (Tazorac). Retin-A has become so famous for its anti-aging and wrinkle-smoothing effects that its great value as a powerful and reasonably inexpensive weapon against acne can be overlooked! Dead skin cells, retentions and sebum are more easily removed. It facilitates the opening of pores and the renewal of skin cells. Enhanced collagen production occurs, plumping up skin cells and strengthening and rejuvenating the skin. Common side effects can include excessive redness, peeling, and irritation. But again, these effects are usually temporary; the skin generally settles and better results will be seen if use is continued rather than discontinued. Recommended use is once a night, but tolerance may need to be built (using a lower concentration to start and/or using every other night for the first two weeks, for example). Proper use of a high-quality moisturizer every day (preferably one that also contains sunscreen) will soothe the skin, offset the effects of drying, and limit skin’s sensitivity to the sun and elements.

azeleic acid– A natural compound found in wheat, barley and rye plants with anti-acne properties. It cleanses the pores, decreases inflammation and limits bacterial growth.

3rd Moderate to Severe Acne – Prescription Drugs:

oral antibiotics– Examples: minocycline, doxycycline, tetracycline, Bactrim and erythromycin. Common side effect: hypersensitivity to sunlight. Prolonged use often results in decreased effectiveness.

Oral contraceptives (OCs)/birth control pills – Oral contraceptives are used to control/stabilize hormone levels and decrease androgen hormone stimulation – Androgens (such as testosterone) increase acne and sebum production. People with conditions such as Polycystic Ovarian Syndrome (PCOS) will greatly benefit from using this strategy to manage acne. Possible dangerous complication of oral contraceptive use: blood clots in the legs, with a significantly higher risk in smokers. Spironolactone is a diuretic medication that has also been used for many years to help control acne due to its anti-androgen effects (by blocking receptors).

Oral retinoids – The best known of these is Accutane, which is often used as a “last resort” for the most severe and stubborn forms of acne. Accutane literally “shuts down” the function/production of the sebaceous glands while increasing skin cell turnover, opening pores, loosening plugs and clearing blockages. The drying effects on the skin can be quite severe and can also affect the lips, eyes and mucous membranes. There are many possible serious side effects. Blood tests are needed to check safety before, during, and after treatment, which is usually 4 to 6 months. Hair loss and toxic effects on the liver, muscle tissue, and bones are possible. Accutane (like all retinoids) is associated with birth defects: prevention of pregnancy while taking Accutane is a must. Unfortunately, depression and suicidal thoughts are also well-recognized potential side effects of Accutane use. Patients desiring certain types of facial cosmetic procedures (such as laser facial resurfacing or chemical peels) must wait a full year after completing Accutane treatment before undergoing such procedures or significant complications related to abnormal scarring may arise. or deficient.

steroid injections– It is often used for inflamed, nodular or cystic acne (acne vulgaris) lesions. Not only does it speed recovery and healing from injury, it also serves to limit the potential for scarring that these injuries can leave behind when left untreated. Possible side effects: thinning of the skin (atrophy), loss of pigment (hypopigmentation), and the appearance of small “broken capillaries” (telangiectasia).