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Medications For Acne

​     Acne, also known as acne vulgaris, is a skin condition that affects millions of teenagers and adults alike. In fact, more than 80% of people worldwide have some form of acne between the ages of  11 and 30. While usually not serious, acne can cause negative psychological issues and, while not as common, long lasting scars. There are many different factors to why people get acne including an increase in hormone levels, excess oil (or sebum) in the skin, bacteria and more. Acne itself has many different varieties including whiteheads (closed comedo), blackheads (open comedo) and inflammatory papules.  (Fortunately, there are many different products available on the market that can help prevent acne and treat it once someone already has it.

    Acne is classified clinically as being mild, moderate or severe. This grading scale is somewhat subjective but how severe your acne is will determine the type of treatment you will be taking. Mild acne is usually self medicated with over the counter products which we will discuss. Mild acne that doesn't improve or worsens is typically treated with prescription products. In terms of medications, this article will discuss over the counter, prescription and supplemental products used to treat acne.

Over The Counter(OTC)

Salicylic Acid       


When To Use/Place In Therapy


Mild acne in patients with sensitive skin. This medication is usually used by patients to self treat their acne and is typically one of the first medications people will try.

How To Apply


Apply 1 to 3 times per day, massage into skin and rinse off.


Important Additional Infomation


Not as effective as OTC benzoyl peroxide but is usually better tolerated, especially in those with sensitive skin.

Benzoyl Peroxide


When To Use/Place In Therapy


Benzoyl peroxide is actually available as both an over the counter product and as a prescription. It ranges in strength from 2.5% to 10%. Along with salicylic acid, it is very commonly used to self treat acne. It is used for mild to moderate acne and is almost always used in combination with a prescription product to clear up more moderate to severe cases of acne. 

How To Apply


Applied every other day to twice daily. Depending on the specific product you get, be it a gel, creamy wash, foam, be sure to read the package directions for application. Some products you apply and keep on while others you apply and wash off.


Important Additional Information


The most common side effect is redness of the skin, especially when you first start using the product. In fact, it's very common that your acne may appear worse because of the redness. This typically gets much better though as you continue to use the product. You should start once daily or even once every other day to become accustomed to the product to reduce the possibility of the redness. It is also recommended to start with either the 2.5% or the 5% benzoyl peroxide strength. Benzoyl peroxide is know to cause bleaching of towels and other fabrics so be aware of this! Benzoyl peroxide also can cause sun sensitivity.


Prescription Products

The "Retinoids"


When To Use/Place In Therapy


The retinoids are the most commonly used prescription products for acne, and there are a lot of them! They can either be used alone for mild acne or in combination with other products for more moderate to severe acne. 


Retinoid Products - Generic name followed by brand names in parenthesis


Tretinoin (Retin-A, Retin-A Micro, Tretin-X) 

Adapalene (Differin gel/cream)

Tazarotene (Tazorac)


All of these formulations come in a variety of different vehicles including creams, gels, and solutions.

How To Apply


Start with the lowest strength to avoid possible irritation. Typically it is recommended to start dosing at three times weekly, progressing to nightly use as tolerated. All retinoids are applied in the evening before going to bed. Ideally, you should wash the face with a non-medicated soap or gentle cleanser (such as Cetaphil), then apply a thin film of the cream, lotion, or gel to cover the entire face. Do not rinse off afterwards.


Important Additional Infomation


All of the retinoid products work in the same way, but certain products and formulations are either better tolerated or more effective. If what your doctor prescribed you isn't having the desired effect, it usually helps to change the retinoid product, strength or formulation.


Tretinoin creams are the most commonly prescribed since they are available generically and are less expensive than other products. They do tend to cause the most irritation in the retinoid class however. There is a tretinoin product known as Retin-A micro which is the best tolerated of the retinoid bunch. Tretinoin is deactivated by sunlight and therefore should be applied at bedtime.


Adapalene (Differin) products are considered to be slightly more efficacious than tretinoin products and certainly cause less skin irritation. Some formulations of adapalene are available generically just as tretinoin products are but in general does cost more. Sunlight deactivates adapalene just like tretinoin and therefore should be applied at bedtime.


 Tazarotene (Tazorac) is considered the most effective retinoid of all but is typically more irritating that the others. It commonly causes redness and scaling. Also, tazarotene is absolutely to be avoided in pregnancy or in those who wish to become pregnant.


For all the retinoid products, as the strength increases so does the possibility of redness, flaking, and irritation. Ideally you want to start at a couple of times per week and move up to nightly dosing.


In terms of picking a product formulation (cream vs gel etc.), the general recommendation is to pick a formulation based on your skin type. For people with more oily skin, it is recommended to go with a gel or solution because they contain more alcohol and tend to be a little bit more drying. In people with dry, flaky skin, cream is usually the best choice as it won't dry as much.


Lastly, as will many different drug products, acne does tend to get worse when you start a medication before it gets better. It can sometimes take around a month to start seeing the positive effects of medication.


Azelaic Acid


When To Use/Place In Therapy


Azelaic Acid (Azelex) is often used for patients with mild to moderate acne. It tends to be less irritating than other products

so it is good for those with sensitive skin.

How To Apply


Azelaic Acid is usually gentle enough where is can be applied twice daily, in the morning and in the evening, at the start of therapy. Gently wash the face, pat dry and apply the product. Do not wash the face afterwards.


Important Additional Information


Azelaic Acid (Azelex) is usually considered slightly less effective than the retinoid products but again, it is great for people with sensitive skin. In those people with darker complexions, it has been know to cause hypopigmentation, also known as a loss in skin color.


Dapsone (Aczone)


When To Use/Place In Therapy


Dapsone (Aczone) is a topical antibiotic formulation indicated for mild, moderate or even severe acne. It usually is used in combination with other products. Though Dapsone is classified as an antibiotic, it appears to work by preventing and treating the inflammatory process. It is usually very well tolerated and typically is regarded as a good option for patients that can't tolerate other medications well.

 

How To Apply


Dapsone should be applied to a clean and dry face. Dapsone does tend to be a little bit gritty so you can expect to feel that when you rub it in. Do not rinse your face afterwards.


Important Additional Information


Two things are important to know about Dapsone. First, it is usually fairly well tolerated and should not make acne worse before it gets better, unlike the retinoid products. Secondly, it usually is not used with benzoyl peroxide products as the combination of both can cause a temporary orange staining on the skin. 


Spironolactone (Aldactone)


When To Use/Place In Therapy


Spironolactone is an oral therapy and is usually reserved for more moderate to severe cases of acne where other treatments haven't worked. It is almost always used in combination with topical products and is almost exclusively used only in females with either excess androgenization (i.e. excess male hormones) or acne that comes and goes in cycles. Excessively oily skin, abnormally excessive hair growth and menstrual irregularities sometimes signal excess androgen in women.


How To Apply


The dosage for spironolactone is individualized in each patient with typical dosages ranging from 25 to 200 mg. Ideally you want the lowest effective dose. It should be taken in the morning because it is a mild diuretic (causes a loss of water through urination).


Important Additional Information


Spironolactone is know as an anti-androgen and is very effective in reducing sebum (oil). It works by blocking the conversion of testosterone to dihydrotestosterone. Excess Dihydrotestosterone can cause many dermatological issues such as clogged pores and inflammation. Studies have shown that spironolactone reduces sebum excretion in the skin by about 30-50 percent and therefore is very effective in those with oily skin.


Being an oral medication, it has the possibility to cause more side effects than topical treatments. The most common side effects are excess urination, menstrual irregularities (spotting etc.) and low blood pressure. The menstual irregularities are usually decreased in woman who are also taking oral hormonal contraceptives.


Many compounding pharmacies make topical spironolactone which can sometimes help reduce side effects. It is not commercially available though at retail pharmacies.







Antibiotics (Topical)


When To Use/Place In Therapy


As part of combination therapy for mild to severe acne. Topical antibiotics should never be the sole treatment for several reasons including the extended time it takes to see positive effects and the fact that bacterial resistance can occur. It's important to note that acne is not an infection. Everyone carries a bacteria in their skin known as P. Acnes. The problem is when the bacteria overgrows in the skin. Some byproducts of the metabolism of the P. Acnes bacteria are irritants to the skin and lead to microcomedo formations and results in inflammatory lesions. Decreasing the amount of P. Acnes via antibiotic therapy is usually associated with acne improvement. 


Topical antibiotics include, erythromycin and clindamycin.


How To Apply


Topical antibiotics are applied usually once to twice daily. Apply to a clean, dry face and do not wash off after application.


Important Additional Information


Topical antibiotics typically are used in 3 month spurts and then given a break. They are always to be used in combination therapy with other acne products such as benzoyl peroxide.


Some products do cause sun sensitivity so it is recommended to use sunscreen.








Antibiotics (Oral)


When To Use/Place In Therapy


Antibiotics taken by mouth are typically only prescribed for those who have moderate to severe inflammatory acne and they are always prescribed as past of a combination with topical therapies. They are used to reduce the colonization of a specific bacteria known a P. Acnes. They can take one to two months to begin working and once new acne lesions are no longer forming, the antibiotics are typically stopped.


Antibiotics given for acne are usually one of the following:


Doxycycline

Minocycline

Tetracyclin

Clindamycin

Sulfamethoxazole/Trimethoprim


How To Apply


The usual dose of antibiotics is one to two capsules/tablets per day.


Important Additional Information


The oral antibiotics are never given to children under the age of 8 due to the possibility of serious side effects.


There are some concerns of bacterial resistance in those taking consistent antibiotics for acne. The bacteria that may become resistant however typically don't cause major infections. People may be slightly more susceptible to getting strep throat, but treatment is still fairly easy.


It is usually recommended to use oral antibiotics for 12-18 weeks and to always combine oral antibiotics with other therapies such as benzoyl peroxide to help avoid resistance.

Vitamin A


We've all heard of vitamin A before. It plays a huge role in the treatment of acne. In fact, all of the drugs in the retinoid class we wrote about earlier and the drug isotretinoin are derivatives of vitamin A!


We get vitamin A from two sources, animal and plant. The vitamin A we get from plant sources (such as carrots and certain vegetables) have the most potent forms of vitamin A known as Carotenoids.


In addition to it's use for skin conditions like acne, vitamin A is vitally important for immune system development, vision growth development and much more. Ideally, if you are looking for a vitamin A supplement, you want to go for vitamin A sources as a carotenoid and not a retinol.


Vitamin A supplementation in people can go a long way towards treating and preventing acne. When looking for a vitamin A supplement, you want to look for vitamin A as beta carotene as it is the safest and most effective. You should not consider vitamin A if you are taking isotretinoin products.


​Too much vitamin A for a long period of time can lead to some possible side effects so it's important not to take extremely high doses of vitamin A. Sticking to 10,000 to 25,000 units for a month or so should be perfectly safe.





Omega 3-Fatty Acids



Omega 3-Fatty acids reduce the inflammatory response and may result in a less "waxy" sebum that doesn't get "stuck" in the pore/follicle. Fish is a great source of Omega 3-Fatty acids and they are also available over the counter as a supplement.




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Over The Counter Supplements

Isotretinoin (Accutane/Claravis/Absorica)


When To Use/Place In Therapy


Isotretinoin is a very strong and extremely effective acne medication indicated for acne that leaves severe scarring or for acne that does not respond to other treatments. Among other things, it reduces sebum in the skin, helps regulate your skin cells and reduces the P. Acnes bacteria. While effective, the medication has very serious possible side effects and has a high risk of teratogenicity (birth defects). Because of this risk, isotretinoin is only available under a restricted program under REMS (Risk Evaluation and Mitigation Strategy) and this program is called iPLEDGE. All patients must sign a consent form before beginning therapy and must register in the iPLEDGE program. Patients that are sexually active must use two forms of contraceptive for at least one month before beginning therapy, during the course of therapy and for one month after stopping therapy. Additionally, women of child bearing age must have 2 negative pregnancy tests before beginning the drug.


How To Apply


There are varying strengths of isotretinoin and typically the drug is given orally once to twice daily.  Isotretinoin should be given with food.


Important Additional Information


Isotretinoin can produce remarkable effects in patients with severe acne and may even produce remissions after a single course of therapy. Unfortunately, it's use is limited by the possible side effects. The most common side effects appear on the skin and they include:

Dry skin

​Chelitis (inflammation of the lips)

Nosebleeds

Hair loss (not very common)


Patients taking higher doses are more at risk for these side effects:


Musculoskeletal pain

Mood alterations


Isotretinoin should never be used with the "cycline" (e.g. doxycycline) as there is a major drug interaction between the two.


Isotretinoin is used in millions of patients safely. It is just very important to take the iPLEDGE program seriously and always monitor for possible side effects.