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.

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:

Prescription medications for acne include:

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.

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.

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 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
• Nosebleeds
• Headaches
• Fatigue
• Nausea and vomiting
• Abdominal pain
• Lack of appetite
• Jaundice
• 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.

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.