A dermatologist has numerous topical and oral prescription options to treat acne, from retinoids like tretinoin or Differin® to antibiotics and oral vitamin A (isotretinoin, formerly sold under the brand name Accutane). Each has its share of pros and cons, which you should discuss with your doctor. Following is an overview that will help you understand the options your doctor may suggest.
Important reminder: Using prescription-only products for your acne doesn’t change the basic skincare routine you need to follow. Bar soaps, harsh cleansers, abrasive scrubs, and products that contain irritating ingredients or overly waxy products will still harm your skin and increase the likelihood of your skin not being able to tolerate these prescription treatments.
Prescription topical antibiotics are an option if you haven’t gotten good results using over-the-counter treatments containing salicylic acid and benzoyl peroxide.
There are several topical antibiotics to consider; the main ones to discuss with your dermatologist are erythromycin, clindamycin, minocycline, and tetracycline. These can be used alone, but a good deal of research indicates that you can derive greater benefit without some of the side effects by combining one of these antibiotics in lower doses with benzoyl peroxide to create a far more potent and effective treatment.
Dapsone is a topical disinfectant gel available by prescription in 5% strength. The brand name for this anti-acne drug is Aczone. A recent study involving 347 adolescents and 434 adult women showed dapsone 5% gel used twice daily was effective in reducing inflammatory and noninflammatory acne lesions in both adolescent and adult women, but was even more effective for adult women. [73]
Retinoids, such as prescription tretinoin (Retin-A, Avita, Atralin, and generics) and other vitamin A derivatives, such as tazarotene (Tazorac®, Avage®) and adapalene (Differin®), can play a significant role in an anti-acne treatment routine. [74]
Retinoid is the name of the general category for any and all forms of vitamin A. Prescription retinoid options are viable treatments for breakouts because they change the way skin cells are formed in the layers of skin as well as in the pore, improving how skin cells shed while unclogging pores, thereby significantly reducing inflammatory lesions. Retinoids also have anti-inflammatory action, making them even more compelling.
Topical tretinoin and many antibacterial agents have complementary actions, and they work well together, but applying both at the same time increases the chance of side effects such as dryness, redness, and/or peeling. If you experience side effects, it’s best to use the two separately, applying the antibacterial product in the morning and the prescription retinoid (be it tretinoin or another type) at night. Benzoyl peroxide does not deactivate newer formulations of tretinoin as it did in the past. [75]
Azelaic acid is believed to work against acne-causing bacteria in concentrations of 15%–20%, and it may also pack an anti-inflammatory punch. [76] Azelaic acid was approved for the treatment of acne in the United States in 2002, and also is prescribed to manage the symptoms of rosacea (some of which are similar to those of acne). It’s definitely on the A-list of prescription options for treating acne—no pun intended. (Azelaic acid is not a prescription treatment in most Asian countries.)
Stay the course! For any topical acne treatment to work, whether prescription or over-the-counter, consistency is vital. Unfortunately, because almost all topical options can be hard on skin (at least at first), it’s even more important to follow our suggestions for gentle skincare. Too often, skincare recommendations, even from dermatologists, include using products with irritating, drying ingredients that cause damage and inflammation. This means you’ll struggle with being able to use acne-fighting treatments successfully. Please don’t make the mistake of reverting to an outdated, problematic way of caring for acne- or breakout-prone skin. The research is clear that irritation makes acne worse, but a lot of salespeople, aestheticians, and physicians ignore or aren’t familiar with this—but now you are!
Oral antibiotics can be extremely effective in controlling acne, but they also pose a risk of serious side effects that you must consider. Oral antibiotics do indeed kill the bad bacteria, but they also kill the good bacteria in the body. Thus, ongoing use can lead to chronic vaginal yeast infections as well as stomach problems. In addition, the acne-causing bacteria can become immune or resistant to the oral antibiotic. [77] That means if you’ve been taking an oral antibiotic to treat your acne for longer than six months, it can, and almost always does, become ineffective against the acne, although the negative side effects—killing good bacteria and causing stomach and other problems—could continue.
However, some research has shown that taking low doses (“sub-microbial” or subclinical doses) to fight acne is moderating the concern about bacterial resistance and adaptation. [68] Taking such low doses of oral antibiotics over the long term can improve acne, while minimizing, if not completely eliminating, the problem of the bacteria becoming resistant. It seems that lower doses of oral antibiotics have anti-inflammatory benefits instead of antibacterial benefits, but they still can kill acne-causing bacteria. That doesn’t mean you won’t suffer from possible systemic effects, though; so, whether you opt for regular or low-dose oral antibiotics, be sure to discuss the pros and cons with your dermatologist.
Birth control pills (some types) have been shown to reduce acne lesions and oil production, in part by decreasing androgens (male hormones), which are largely responsible for causing acne.
Birth control pills are a combination of different synthetic estrogens and progestins (female hormones). Some progestins can increase the amount of androgens in the body, while others block the production of androgens. Because androgens stimulate oil production, blocking androgens for those prone to breakouts and oily skin is a good thing.
As a result, some of the birth control pills that block androgens have been approved by the Food and Drug Administration (FDA) and other regulatory organizations for the treatment of acne. These include Ortho Tri-Cyclen (active ingredient: norgestimate/ethinyl estradiol), YAZ (active ingredient: drospirenone/ethinyl estradioland), Estrostep Fe (active ingredient: norethindrone/ethinyl estradiol). Diane-35 (chemical name: ethinyl estradiol cyproterone acetate) has been approved for such use in Canada.
Keep in mind that there are risks associated with taking any type of birth control pill (especially if you smoke), and you should discuss these matters with your doctor. [78] Birth control pills also should not be the sole therapy for acne; think of them as a partner product for use with a skincare routine designed to reduce acne.
Alternative Acne Treatments
The world of alternative acne treatments is wide and varied. It includes options that are easily obtained at the drugstore, some that you can find at your local health supplement retailer, and even options in your grocery store, particularly if you frequent natural markets. We describe some of these options below.
Tea tree oil has some interesting, though minor, research demonstrating that it’s an effective antimicrobial agent, although it’s not without its drawbacks. In a study comparing tea tree oil with benzoyl peroxide, it was found that a 5% concentration of tea tree oil has an efficacy similar to that of 5% benzoyl peroxide. [33] That sounds as if the two are equally effective, but in the world of skincare it doesn’t work that way. It turns out there aren’t any skincare products that contain 5% tea tree oil. The highest concentration of tea tree oil we’ve ever seen in a cosmetic product is less than 0.5%, which likely makes it ineffective for treating acne. [33] “Pure” tea tree oil is typically only a 3% concentration diluted in a carrier oil, so even that isn’t strong enough, despite the “100% tea tree oil” statement you might see on the label.
Niacinamide and nicotinic acid are derivatives of vitamin B3. There are a handful of studies showing they can be helpful for improving the appearance of acne, which most likely is the result of their anti-inflammatory and barrier-restoring properties. [79,80] When included as part of an anti-acne skincare routine, these B vitamin ingredients can be part of a powerful combination of products and ingredients to combat the series of events