About acne medications
Acne is a very common skin disorder affecting the hair follicle. Acne is often inflammatory and is characterized by comedones (clogged pores) and pimples (papules and pustules), due in part to the excessive production of sebum (skin oil) by the sebaceous glands in the follicle. Acne is not a serious medical condition, and can usually be kept under control with treatment. Although scarring is common, treatment during and after an outbreak can help.
Acne medications heal existing acne lesions, prevent lesions from recurring and prevent scarring. They are available in both topical and oral forms. Topical treatments include gels, lotions and creams. Gels are typically alcohol–based and may dry the skin, making them better for patients with very oily skin or those who live in hot, humid climates. Lotions and creams provide moisture and are generally better for patients with sensitive skin. In some cases, a dermatologist will recommend a combination of two or more treatments.
Many acne medications focus on preventing future eruptions instead of treating current lesions, and may take eight weeks or more to work. Often, the skin may look worse before it starts getting better. Individuals should be patient during this time, and not discontinue the medications. However, those who do not see any improvements after eight weeks should discuss possible treatment changes with their dermatologist.
Acne medications treat acne in five ways:
- Exfoliation and normalizing of skin cell production. The abnormal shedding of skin cells lining the hair follicles is addressed. Retinoids (both topical and oral) are used in treatment.
- Elimination or reduction of the acne-producing bacteria. These bacteria induce inflammation. Treatments include benzoyl peroxide and antibiotics (both topical and oral).
- Removal of materials that clog the pores. This actually addresses current blemishes. Hardened skin cells are loosened and pores are unclogged. Medications that do this are referred to as comedolytics and include retinoids, salicylic acid, alpha hydroxyl acids and azelaic acid.
- Elimination or reduction of inflammation. Current inflammation is addressed, reducing acne lesions. Salicylic acid and corticosteroid injections accomplish this. In some cases, oral nonsteroidal anti-inflammatory drugs (NSAIDs) may be used along with antibiotics.
- Reduction of sebum secretion. Sebaceous gland activity is decreased using retinoids. In hormonal forms of acne in women, certain oral contraceptives may prove useful.
In many cases, acne can be treated without a prescription. The most powerful over-the-counter acne medication is benzoyl peroxide, which reduces acne-causing bacteria within the follicle. It also helps to normalize skin cell production. Benzoyl peroxide is generally more effective when combined with topical antibiotics, particularly erythromycin. However, benzoyl peroxide can bleach fabric, hair and other colored materials.
Other acne drugs available without a prescription include salicylic acid and sulfur. These are less effective than benzoyl peroxide, but have comedolytic effects. They help to break down blackheads and whiteheads and dry up sebum in active lesions. Some of these medications also have mild anti-inflammatory effects.
For patients with more serious forms of acne, or mild acne that does not respond to over-the-counter treatments, physicians may prescribe a stronger medication. Prescription acne medications include retinoids, which are derived from vitamin A. They normalize skin cell production inside the hair follicles by slowing the growth and regulating the shedding of these cells as well as preventing them from sticking together to form plugs. Many retinoids have significant anti-inflammatory properties.
Retinoids are available in topical and oral forms. Topical forms (e.g., tretinoin) have fewer negative side effects, but relapses may occur. Isotretinoin is an oral retinoid. It is the only medication that alters the natural course of acne by decreasing the size and activity of the sebaceous glands. Due to the decrease in sebum, there is a reduction of acne-causing bacteria in the follicles. Isotretinoin also has anti-inflammatory effects and normalizes skin cell metabolism. It is typically used for four to five months.
According to the National Institutes of Health (NIH), after 15 to 20 weeks of isotretinoin treatment acne goes away in up to 90 percent of patients. However, due to the potential for serious birth defects, female patients of reproductive age must sign an informed consent that they will use two different, effective forms of contraceptives for one month before treatment begins, during the entire course of treatment and for one month afterward. Monitoring with monthly pregnancy tests is also required.
Other prescription acne drugs include:
- Antibiotics. These have antibacterial and anti-inflammation effects. Prescriptions may be given for topical or oral forms. Oral forms are more rapid and effective, but produce more serious side effects. One of the most effective antibiotic acne medicines is tetracycline. Others include clindamycin and erythromycin.
- Azelaic acid. Has comedolytic and antibacterial effects. Azelaic acid is used topically.
- Hormonal therapy. Corticosteroids may be injected directly into lesions to help reduce the size and pain of inflamed cysts and nodules. Also, some forms of acne that affect women are hormonal, with acne flares prior to the menstrual period. Increased androgen (male sex hormone) levels are believed to be the cause. Antiandrogen drugs (e.g., spironolactone) work by blocking androgen receptors.
Oral contraceptives contain estrogen and/or progestin and work by employing these two female sex hormones to counterbalance the effect of androgens. As a result, birth control pills may be prescribed for the sole purpose of treating acne. However, there are a wide variety of types available and not all are effective in reducing or preventing acne. Some may actually make acne worse. Oral contraceptive pills may be recommended as an acne treatment when other forms of treatment fail to improve the condition.
It is important to note that patients should not stop their medication without instruction from their physician. Many patients cease using their medication once their skin clears only to have their acne flare up a few weeks later.
Types and differences of acne medications
Many factors influence which type or combination of acne medications are prescribed. Dermatologists will consider the severity of the condition and the types of lesions present, as well as the patient’s age, skin type and lifestyle.
Acne medications available without a prescription include:
Generic Name Brand Name
benzoyl peroxide (topical)
salicylic acid (topical)
Prescription medications for acne include:
Category Generic Name Brand Name
azelaic acid (topical)
clindamycin (topical or oral)
trimethoprim/ sulfamethoxazole (oral))
There are a wide variety of oral contraceptive pills that contain estrogen and/or progestin. Physicians will decide which type is most appropriate for use on an individual basis. These medications are often used in combination with other forms of acne treatment.
Conditions treated with acne medications
Different acne medications are used to treat different types and degrees of acne, including:
- Mild to moderate acne. Treated with over-the-counter medications, topical retinoids and azelaic acid.
- Moderate to severe acne. Topical retinoids and topical antibiotics may be used.
- Severe acne. Oral antibiotics may be used.
- Severe cystic acne that does not respond to other treatments. Isotretinoin is the standard treatment.
- Hormonal acne. Treatment includes antiandrogens and oral contraceptives.
Conditions of concern with acne medications
Acne medications are usually not recommended if patients are known to be sensitive to similar medications. In general, when using topical treatments patients are advised to avoid contact with the eyes, mouth, nostrils, mucous membranes, open wounds or red or raw skin. Other conditions of concern vary by medication, including:
- Benzoyl peroxide. Not recommended for patients with dermatitis or eczema.
- Salicylic acid. Not recommended for patients with blood vessel disease, influenza (flu), varicella (chickenpox), or kidney or liver disease. Use on inflamed, irritated or infected skin may cause severe irritation.
- Retinoids. Many retinoids (e.g., isotretinoin) should not be used in women of childbearing age who are or may become pregnant.
- Clindamycin. Caution is recommended for patients with asthma, impaired kidney or liver function, or a history of gastrointestinal disorders or diseases.
- Erythromycin. Not recommended for patients with porphyria or liver disorders or disease.
- Tetracyclines. Not recommended for patients with impaired kidney or liver function, pregnant women in the second or third trimester or children under the age of 8.
- Antiandrogens (e.g., spironolactone). Not recommended for pregnant women.
- Side effects
Potential side effects of acne medications
Side effects of acne medications vary depending on the type of medication. Common side effects of nonprescription acne medications include erythema (reddening), edema (swelling), dry skin, burning sensations, itching and peeling skin.
Topical retinoids may increase susceptibility to sunburn. It is recommended that patients use a sunscreen with a skin protection factor (SPF) of at least 15 and avoid unnecessary sun exposure. Other common side effects include skin irritation involving scaling, redness, dryness, erythema, burning sensations, itching and peeling skin.
Isotretinoin is associated with numerous side effects, including severe birth defects or miscarriages when used during pregnancy. Women of reproductive age are required to use two separate, effective forms of birth control for one month before treatment begins, during the entire course of treatment and for one month after treatment ends. Pregnancy tests are typically performed every month during treatment. Other side effects include:
- Dry skin and cheilitis (inflammation and redness of the lips). These are common, occurring in nearly all patients.
- Mood changes. Depression, sadness and irritability are very common during isotretinoin treatment. This drug has been linked to numerous suicide attempts. Physicians will monitor patients for depression.
- Vision impairment. Opacities of the cornea and poor night vision may occur during this treatment.
The following side effects may also occur:
- Fragile skin
- Nausea and vomiting
- Abdominal pain
- Lack of appetite
- Dry eyes and mucous membranes
- Muscle and joint aches
- Liver damage
- Bone marrow suppression
Common side effects of topical antibiotics include skin irritation involving itching, burning or stinging sensations, dryness, erythema and redness. When antibiotics are taken orally, side effects may include headaches, dizziness, nausea, vomiting, vaginal yeast infections, abdominal pain, jaundice or diarrhea. Tetracyclines are not recommended for use in children under the age of 8. They may cause permanent discoloration and enamel defects in developing teeth and retard bone growth.
Common side effects of hormonal therapies include irregular menstrual periods, breast tenderness, headache and fatigue.
Patients can lower their risk of side effects by using their medication exactly as directed by their dermatologist. Although many people believe that using their medication more frequently than prescribed will speed up the clearing of their skin, it may actually irritate the skin, delay clearing time, and increase their risk of side effects.
Drug or other interactions
Patients should consult their physician before taking any additional prescriptions, over-the-counter medications, nutritional supplements or herbal medications. Interactions of particular concern to individuals taking acne medications depend on the medication taken and may include:
- Benzoyl peroxide and tretinoin. These medications may neutralize each other.
- Topical retinoids. May cause a cumulative drying effect when used with medicated soaps and cleansers, topical peeling agents (including benzoyl peroxide) or alcohol–containing preparations.
- Isotretinoin and alcohol. Alcohol consumption while taking isotretinoin may increase levels of particular blood fats (triglycerides) and liver enzymes.
- Oral clindamycin and erythromycin. Erythromycin may reduce the effectiveness of clindamycin. Erythromycin may also increase the effectiveness of some anticoagulant medications, requiring reduced dosages.
- Tetracyclines. May increase the effectiveness of some anticoagulants, requiring reduced dosages. May reduce the effectiveness of oral contraceptives, causing breakthrough bleeding and an increased risk of pregnancy. Antacids may reduce the effects of tetracyclines.
Symptoms of acne medications overdose
Symptoms of overdose can be similar to the medication’s side effects, but are usually more severe. It is recommended that patients exhibiting severe burning, itching, swelling or excessive dryness while taking benzoyl peroxide contact their physician immediately. It is also recommended that patients using salicylic acid contact their physician immediately if they exhibit any of the following:
- Fast or deep breathing
- Severe or continuing headache
- Hearing loss
- Nausea or vomiting
Symptoms of overdose with topical antibiotics include severe skin irritation. Symptoms of overdose with oral antibiotics include nausea and vomiting, fever and gastrointestinal distress.
- How to use
Pregnancy use issues with acne medications
Many acne medications should not be used by women who are or may become pregnant. This is particularly true of isotretinoin, an oral retinoid. Isotretinoin is absolutely not recommended for pregnant women because of a very high risk of miscarriage or severe birth defects. The Food and Drug Administration (FDA) strictly monitors isotretinoin and requires women to have two negative pregnancy tests prior to receiving a prescription.
Further, women must have monthly pregnancy tests throughout the course of isotretinoin treatment, as well as additional tests right after finishing the last dose of the drug and one month after finishing the last dose of the drug. It is not known if this medication passes into breast milk and breastfeeding is not recommended during therapy.
Topical retinoids are typically not recommended for women who are or may become pregnant, or those who are breastfeeding. It is currently unknown whether these drugs can have an adverse effect on developing fetuses or nursing children.
Most antibiotics are safe to use during pregnancy when monitored. However, these may enter breast milk and breastfeeding is typically not recommended while taking these medications. The use of tetracycline and its derivatives is not advised during pregnancy or breastfeeding. These drugs can inhibit bone growth and discolor permanent teeth in developing fetuses, as well as in children who are nursing.
Antiandrogens are also considered unsafe to use during pregnancy as they may cause birth defects. These drugs are also not recommended for women who are breastfeeding because it is unknown whether they can be passed through breast milk.
Child use issues with acne medications
Most acne medications do not have established dosages for children. Tetracyclines are not recommended for use in children until after they have all their permanent teeth because it can permanently discolor developing teeth. Care is advised when using salicylic acid on young children because they may be more likely to develop skin irritation. Children using clindamycin, an antibiotic, should be monitored closely, especially for diarrhea.
Elderly use issues with acne medications
Elderly use of acne medications typically poses no additional concerns aside from a slightly increased rate of side effects. However, it should be noted the elderly may not well tolerate certain side effects, such as the diarrhea common to certain antibiotic use. Because of this, elderly medication use often requires close monitoring.
Questions for your doctor on acne medicationsPatients may wish to ask their doctor the following questions about acne medications:
- Which acne medications do you recommend for me?
- When can I expect to see an improvement in my acne?
- What will be the next step if my current form of medication fails?
- How long will I have to use the medication?
- What side effects may this medication cause?
- Which side effects should I immediately report to you?
- How will this medication affect my current medical conditions other than acne?
- How will this medication interact with other medications I am currently taking?
- Can I breastfeed while taking this medication?
- Is it safe to become pregnant while taking this medication?
- Will I have to avoid the sun while using this medication?