Acne Treatments

Acne is an extremely common skin condition that mainly affects adolescents but may persist or even become more severe in adulthood. Acne may occur on the face, chest, back and sometimes other areas.  Several types of acne spots occur, often at the same time, and include non-inflammatory lesions (comedones) and inflammatory lesions (papules, pustules, and cysts).

• Avoid oily hair products, occlusive items such as hats/bandanas, and frequent touching of face (do not squeeze or pick)
• Irritation from sweat can also be a factor, and patients are encouraged to bathe/shower soon after exercising.
• For females: Avoid make-up or switch to “non-comedogenic” products.  If you have an irregular menstrual cycle and/or excessive body hair growth, discuss this with your clinician.  These signs may indicate a hormonal imbalance.

• Topical retinoids are effective in preventing the development of acne lesions. Note that this medication does little for the acne that you have today.   You need a prescription from your dermatology provider for tretinoin or adapalene.
• Instructions:
  • Apply a pea-sized amount to your entire face. Do not use as a spot treatment for individual bumps.  In order to reduce irritation, start every other night and increase to nightly (after 2-3 weeks) as your skin adjusts to the new medication.  Avoid getting medication into your eyes.
• Cautions / Adverse effects:
  • You may experience dryness/irritation and/or a mild flare of acne in the first 1-2 weeks after starting. Continue treatment through this uncomfortable period.
  • Apply only at night. Application during the day can lead to photosensitivity.
  • Do not use during pregnancy or when attempting to become pregnant.
• Other tips:
  • Do not expect results overnight! It takes at least 6-8 weeks to notice improvement using this medication.
  • If your skin becomes uncomfortably dry, use CeraVe Moisturizing Lotion several times daily to keep skin hydrated. If skin is still dry/irritated after 2-3 weeks of moisturizing, you may decrease the frequency of tretinoin application from every other day to twice weekly.
  • Expect to stay on medication for a long time (often years).

• The anti-inflammatory and anti-bacterial properties of this agent make it an important element of your acne regimen. It is especially effective in reducing the number of pustules, nodules and red bumps.   You do NOT need a prescription from your dermatology provider for most benzoyl peroxide-containing products.
• Products:
  • Wash: Over-the-counter recommendation (for face):  PanOxyl 4% Creamy Wash (or 2.5%, 3.5%, 5% generic wash)
  • Wash: Over-the-counter recommendation (for body):  PanOxyl 10% Foaming Wash (or 10% generic wash)
  • Leave-on product (gel): Over-the-counter recommendation (for face):  La Roche-Posay Effaclar Duo OR other generic 5%
  • Leave-on product (gel): Over-the-counter recommendation (for body):  Any generic 5% or 10% gel
• Instructions for washes:
  • Use as a face and/or body wash once or twice daily. After lathering wash with water onto affected area, wait 1-2 minutes before rinsing off.  For patients with sensitive skin, start with once daily application for 2-3 weeks and increase to twice daily as tolerated.
• Instructions for leave-on products:
  • Apply a very thin film to entire area where you often get acne bumps (not just to individual spots). To cover the entire face with Effaclar Duo, a pea-sized amount is usually sufficient.  For patients with sensitive skin, start with once daily application for 2-3 weeks and increase to twice daily as tolerated.   The best time for the second application is before dinner in order to avoid interfering with topical retinoid (tretinoin or adapalene) at bedtime.  You may also minimize irritation by avoiding application in the creases surrounding your nose and the corners of your mouth.
• Cautions / Adverse effects:
  • May cause dry or irritated skin and may bleach towels/clothes
• Other tips:
  • If you are starting benzoyl peroxide at the same time as a topical retinoid (tretinoin or adapalene), start the retinoid first. After your skin adjusts to the topical retinoid (often 2-3 weeks), then start the benzoyl peroxide.
  • As with tretinoin, it may take your skin a few days to adjust to benzoyl peroxide. If your skin becomes too dry, do not hesitate to use a non-comedogenic moisturizing agent (e.g. CeraVe Moisturizing Lotion) several times daily to keep skin hydrated.

Topical clindamycin or erythromycin are often prescribed for use in acne. These are usually used in conjunction with benzoyl peroxide since use of these agents without benzoyl peroxide often leads to bacterial resistance and sometimes treatment failure.   Side effects are minimal and are often limited to slight drying of the face.

• Like benzoyl peroxide, doxycycline has anti-inflammatory and anti-bacterial properties that help to improve acne and rosacea. It is used commonly in patients with moderate disease (with at least several red, inflammatory acne lesions)
• Instructions:
  • Take capsules with food and drink as directed by your provider.
• Cautions / Adverse effects:
  • May cause sun sensitivity. If you are planning for sun exposure, wear protective clothing and sunscreen.  If necessary, you may stop the medication 4 days before significant sun exposure and restart it afterwards.  This medication may also cause stomach discomfort, especially if it is not taken with food.  Do not lie down for 30 minutes after taking the pill, as it can cause inflammation of the esophagus.  If you experience mild diarrhea, this may be improved by eating a daily serving of yogurt or taking an over-the-counter probiotic such as lactobacillus (ask pharmacist).  If you experience persistent diarrhea, blood in your stool, or abdominal pain stop the medication and contact your provider.  Another extremely rare side effect is a severe headache and/or changes in your vision. If you experience a severe headache with or without vision changes, stop taking the medication and contact the office.  Women:  Serious birth defects have been reported if this medication is taken during pregnancy.  If you become pregnant while on the medication, STOP IT IMMEDIATELY and speak with your clinician. If you are using a hormonal contraceptive (e.g. the pill/ring/patch), doxycycline (at least theoretically) can decrease the effectiveness of the contraception. Use a second form of birth control in these cases.  Women using the medication may also develop yeast infections.  If this occurs, contact your primary care clinician.

Minocycline is an oral antibiotic in the same class as doxycycline but with slightly better activity against the bacterium P. Acnes that is implicated as a cause of acne. See Cautions / Adverse effects above for doxycycline.  Minocycline has significantly less risk of photosensitivity than does doxycycline (but does have similar risks in pregnancy, risk of esophageal irritation, risk of headaches/vision changes).  Additionally, patients may experience dizziness for up to 2 weeks after starting the medication.  Minocycline can sometimes lead to skin pigmentation abnormalities.  It can also cause an uncommon connective tissue disorder that usually goes away when the medication is stopped.   Minocycline can rarely can cause a severe life-threatening rash or damage to the liver.  Please report any unusual symptoms to your provider.

Your care provider’s goal will be to get the maximal effect of doxycycline use with the minimal dose and treatment length. Ideally, you should be on oral antibiotics for no more than a year; however, sometimes patients use these medications for longer term. Please report any unusual symptoms to your provider when using these medications.

This medication is used when patients are at high risk for acne scarring or in those who have severe acne resistant to the above treatments. Isotretinoin is an oral medication which shrinks the oil-producing glands in the body (sebaceous glands) by about 90% while you are taking the medication.  Isotretinoin has the potential to result in many side effects that will be reviewed in the iPledge packet that you will receive if you are considering this medication.  Women MUST use two forms of birth control (an oral contraceptive and a barrier method), as isotretinoin has the potential to result in SEVERE fetal abnormalities. You can only get one month prescription at a time and will need monthly blood tests.  The usual length of treatment is 5-6 months.

• Oral contraceptives: We do not prescribe  oral contraceptives (OCPs) in the dermatology clinic but often recommend it, especially if acne tends to worsen during the week before menstrual period.  The potential benefits of OCPs for acne needs to be weighed against the inconvenience of use and the potential side effects.  This is a discussion that is best had with your primary care provider or gynecologist.
• Spironolactone. For females whose acne tends to worsen during the week before menses and for females with acne concentrated on the lower face, spironolactone can be an effective oral therapy.  This medication has the potential to cause severe fetal abnormalities and therefore should always be used with reliable birth control (such an oral contraceptive or IUD).  Unintended pregnancies must be reported immediately to your dermatologist.  Other potential side effects include breast tenderness, menstrual irregularity, increased urination, minor gastrointestinal disturbance, and increased potassium levels.  This is an off-label use of spironolactone and there is a black box warning issued by the FDA which indicates an increased risk for cancer in laboratory animals, although this has not proven to be relevant in humans.  For this reason, spironolactone should not be used in patients with personal or immediate family history of breast, ovarian, or uterine cancer.  Spironolactone should not be taken with other blood pressure medications without consultation with your primary care provider.  Taking this medication with potassium supplements or excessive dietary potassium (e.g. more than one banana per day) may increase the likelihood of dangerous potassium levels that could lead to heart arrhythmias.  Blood tests may be performed before starting the medication and periodically thereafter to monitor potassium levels.

• BLU-U: Treatment with BLU-U (high intensity blue light that kills P. acnes bacteria) can be an effective treatment for inflammatory acne.   Your face will be exposed to a bright blue light for approximately 17 minutes twice weekly for approximately 4 weeks.   You may require additional sessions to maintain the benefits you experience.   This treatment is not covered by insurance.   MassDerm offers one of the only BLU-U treatment devices on the North Shore MA.
• Chemical Peels: In-office treatment with peeling agents such as salicylic acid and glycolic acid can be very effective in reducing acne as well as smoothing out pigmentation and mild acne scarring.  Often 4-6 treatments spaced approximately 3-4 weeks apart are necessary to experience benefits.   You may require additional sessions to maintain the benefits you experience.  These treatments are not covered by insurance.