Poole Dermatology

Acne

Acne Treatment

Health Tips from Poole Dermatology

Tips for using Topical Retinoids

by Jeffrey C. Poole, MD

Topical retinoids (Differin®, Epiduo®, Retin-A®, Tazorac®, .... etc) are a must in most all acne treatment regimens.

They are part of the foundation for most acne treatment. All acne lesions start as a clogged pore (comedone), and effective acne therapy requires the removal of this clogged orifice (comedolysis). Retinoids continue to be our most effective topical medicines for this. Additionally, they have anti-inflammatory properties that further help to decrease the red pimples and pustules of acne.

The first 1-2 months of starting any retinoid will be an adjustment period for your skin. Most people's skin will get dry, red, and mildly irritated. For some people, this can be quite severe. I tell my patients to follow these steps:

At night, after brushing your teeth, wash your face and pat dry. Sunlight may breakdown retinoids, so they are best to apply at night. I find medicine spreads easier and is less irritating on moist skin.

While your face is still moist, apply a small "finger tip" amount of medicine in small dots around the face, then spread over the whole face to a thin film. Be careful to avoid the sensitive skin under the eyes, next to the nose, and the in corners of the mouth.

After rubbing the medicine in well, apply a moisturizer of your choice. Reapply the moisturizer in the morning, along with a daily sunscreen.

If you find your skin becoming very irritated, hold the medicine for a few days, then start applying it only 2-3 times per week. Increase application by 1 day per week every few weeks as tolerated. For patients with sensitive skin, I often start them at this 2-3 times per week regimen.

For some very sensitive skin, we may use short contact therapy. This means applying the medicine for 15 minutes before washing it off, and slowly increasing over time as tolerated.

Remember -- this is medicine, not magic. Acne may initially get a little worse in the first 2-4 weeks of treatment. Continued improvement may occur for up to 4-6 months! So be patient and persistent!

Many people may become dry, red or peeling during the first 1-2 months until they fully adjust to the retinoid. This is a sign of the medicine working effectively. Be sure to moisturize regularly with a ceramide containing moisturizer (such as Cerave®, Cetaphil Restoraderm and Aveeno® Eczema Therapy.

Almost all cases of acne can be effectively treated. The goal of treatment is to promote the healing of existing acne lesions, stopping new lesions from forming, and preventing the formation of acne scars.

Acne treatment aims to control one or more of the underlying causes of acne. For instance, topical retinoids unclog sebaceous glands and keep pores open, while antibiotics are used to fight the P. acnes bacteria. Isotretinoin (Accutane) and hormonal agents, such as birth control pills, are used to reduce sebum (oil) production.

What is the best acne treatment plan?

Your doctor will recommend an acne treatment plan based on these factors:

  • Severity of your acne. Mild acne may respond well to the use of benzoyl peroxide or a topical retinoid only. Moderate acne may require a combination of acne medications, such as topical retinoid with an antibiotic. Severe acne with scarring may require treatment with an oral retinoid (Accutane, Sotret).
  • Results of previous acne treatments. Stronger acne medications may be added to the treatment plan if previous medication do not bring acne under control.
  • Degree of acne scarring. More aggressive therapies may be started earlier if acne scars have already started developing.
  • Gender. Some treatments are available only for females, such as birth control pills.
Boy with acne before treatment Boy with acne AFTER treatment

Whatever your treatment plan, it is important that you give it enough time to work.

This may mean waiting 6 to 8 weeks to see results. While the older acne lesions are healing, the medication is hard at work keeping new lesions from forming.

Staying on your medication is the most important step to getting acne under control.

Acne Medications

Many people will first attempt to treat their acne with an over-the-counter acne medication. Many brands of acne treatment share the same active ingredients. For instance, benzoyl peroxide is the active ingredient of both ProActiv™ and Clearasil™.

However, even some cases of mild acne may require prescription-strength medications for effective treatment. If no improvement is seen after 6 to 8 weeks of using a non-prescription medication, see your doctor about starting other medications. Relying on an ineffective treatment simply means enduring acne for weeks longer than necessary and increases the chances of developing permanent acne scars.

Over-the-Counter Acne Medications

Benzoyl peroxide

Benzoyl peroxide was one of the first medications found to be effective in treating mild acne and has been used safely for decades. It is found in many over-the-counter formulas, as well as in combination with prescription medications. Benzoyl peroxide is available in different concentrations. Its primary side effect is dry skin and higher concentrations are more likely to irritate the skin.

Benzoyl peroxide may be used in combination with other prescription acne medications. For instance, your doctor may recommend that benzoyl peroxide be used along with an oral or topical antibiotic.

Sulfur and salicylic acid

These medications have some mild ability to break down whiteheads and blackheads and are found in many non-prescription acne medications. Like benzoyl peroxide, salicylic acid must be used continuously. Once these medications are stopped, acne lesions are likely to reappear.

Herbal or natural remedies

Over-the-counter products labeled "herbal," "organic" or "natural" are marketed as acne treatments but their effectiveness has rarely been tested in clinical trials. The value of these alternative acne treatments is not known.

Prescription-Strength Acne Medication

Topical Retinoids

Topical retinoids are among the most effective and commonly used prescription acne medications. Topical retinoids are unique in their ability to unclog swollen pores. They may be used alone for mild acne or combined with other medications for moderate to severe acne.

Different topical retinoids are found in a variety of branded acne medications, include:

  • Adapalene (Differin®, Epiduo®)
  • Tazarotene (Tazorac®)
  • Tretinoin (Retin A Micro®, Veltin®, Ziana®)

Topical Antibiotics

Antibiotics applied to the skin, such as clindamycin and erythromycin, kill the P. acnes bacteria that leads to inflammation.

Oral Antibiotics

Antibiotics, such as tetracycline, doxycycline, and minocycline, may be prescribed for oral use. This allows the medication to reach bacteria in the deep layers of the dermis. They are also prescribed for their ability to reduce skin inflammation.

Dapsone

Dapsone is a medication that that may be applied to the skin to reduce the inflammation of acne.

Oral Contraceptives

For women who experience hormonally triggered acne, birth control pills may be prescribed to reduce sebum production.

Isotretinoin

Isotretinoin remains the most effective treatment for severe acne or acne that does not respond to other treatments. Isotretinoin treats all causes of acne: excess sebum, clogged pores, bacterial overgrowth, and inflammation. Most patients take the medicine for periods of 15 to 20 weeks that may be repeated if necessary. Treatment requires monthly office visits, monthly lab tests, and strict contraception. It is critical that women of childbearing age do not get pregnant while taking isotretinoin because of the serious risk of birth defects. The iPledge program was developed to reduce the likelihood of birth defects and other side effects.

Anti-androgen drugs

Some drugs used for other medical conditions are known to reduce androgen levels, such as spironolactone (Aldactone). These may be used in some cases of acne.

Side Effects of Acne Medications

Many of these acne medications have side effects, such as burning, redness, and irritation. With some medicines, such as topical retinoids, these side effects usually decrease or go away after the medicine is used for a period of time. Tell your doctor if side effects are severe or don't go away. 

While the older acne lesions are healing, the medication is hard at work keeping new acne lesions from forming. Staying on your acne medication is the most important step to getting acne under control.

Procedures to Treat Acne.

For persistent acne lesions that are inflamed or unresponsive to medications, some doctors recommend additional methods, including extraction, photodynamic therapy (PDT), or corticosteroid injections.

Talk to your Doctor

It is important to talk to your doctor about the best acne treatment for you.

Ongoing use of your acne medicine may be required for several months, even after the initial acne lesions cleared up, to keep acne under control.


Reference: Vivacare, American Academy of Dermatology

Last updated: January 7, 2017