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Making Sense Of Acne Medications
A recent Google™ search for “acne medication” turned up approximately 1,000,000 “fresh”. This article tries to make some organized sense of all this information for you. As always recommended, a personalized treatment and comprehensive care plan should be designed in consultation with a trusted and certified physician, even when considering the use of over-the-counter acne products. This article is for educational purposes only and is not intended to replace proper medical care, serve as medical advice or represent as a sole guide to treatment.
I. Mild to Moderate Acne – Topical Medications
Typically, “over the counter” (OTC) topical medications are adequate for treating mild to moderate acne. OTC products will usually contain one or more of the following ingredients: benzoyl peroxide, alpha hydroxy acid, salicylic acid, retinoid, nicotinamide, tea tree oil, sulfur, resorcinol.
Benzoyl Peroxide (BP) – OTC concentrations of 2.5%, 5%, and 10% BP are available in creams, gels or as a component of a facial soap/wash. Even higher concentrations of BP are used for hair bleaching and teeth whitening! The best results will be obtained using 10% concentration for acne. BP probably represents overall the single best and most successful anti-acne medication there is. Allergic-type reactions (which occur in about 3% of the population) are possible and are characterized by significant itching, scaling, and / or swelling. But BP can cause these effects to some degree even when it is working normally and doing what it is supposed to do! Build tolerance to a topical anti-acne medication so it can do its job – this is a theme/strategy with almost every topical anti-acne medication. So start slowly and at a lower strength, then advance to more effective strength and tolerable treatment schedule. BP breaks deep into the skin into its component parts. The “Benzoyl” part is benzoic acid – this helps deep penetration into the pores where the oxidative action of the “Peroxide” kills the bacteria. Since clogged pores, filled with debris, sebum and bacteria lie beneath the surface of the skin, washing alone is simply not effective. Aggressive scrubbing while washing or rough drying may “feel good” but only results in creating even more inflammation, further perpetuating the effects of acne. Use a cleanser that contains BP, wash gently and then pat dry is such a good choice. A BP cleanser can also be left on for a few minutes for an extended application to more resistant areas (such as the back) just as you would with a gel or cream. BP is a key ingredient in the ProActive line of anti-acne treatment products.
Alpha Hydroxy Acid(the AHAs) – These act as exfoliants promoting a detachment and shedding of dead and almost dead skin cells, reducing surface sebum and helping to empty the clogged pores debris in the process. Examples: glycolic acid, lactic acid, citric acid, malic acid and mandelic acid. Glycolic acid appears to be the most clinically effective of this class. Mandelic acid is probably the mildest. Opening pores and improving skin cell turnover rejuvenates the look and feel of the skin while simultaneously attacking acne. AHAs also have antibacterial properties against acne. Home use products typically have AHA concentrations of 10% or less, while beauticians will often use AHA concentrations of 30 – 40% in office “chemical peel” treatments. A series of 5 or 6 chemical peels every month can be a very effective way to break the “cycle” of acne, especially in people over 20 or 30 years old. Doctors will use AHAs up to 70% for certain chemical peels or treatment situations. .
Salicylic acid-The main anti-acne action for salicylic acid is in its exfoliating properties as seen with the AHA. Several Noxzema anti-acne products use salicylic acid. Salicylic acid has been used medically for over 100 years; it is more commonly known as “aspirin”!
Retinoids– These are Vitamin A derivatives that together act through their exfoliation effect and their stimulatory effect on collagen and skin cell growth. Dead skin cells, pore debris and sebum are loosened and removed. Extraction will be easier or even avoided. Retinoids increase pore opening and skin cell turnover, generally rejuvenating the look and feel of skin. But they can also reduce the oil in the skin to an excessive degree and make the skin too dry. But the skin will usually adapt to this after 1 -2 weeks of use and better results will be seen if the treatment is not interrupted. Vitamin A derivatives promote skin cell growth, “plumping” and strengthening of skin cells, and increase collagen production as well. Retinoids can be found in a very wide variety of anti-acne and general skin care cosmetics. Caution – retinoid treated skin is generally more sensitive – hair removal, laser treatment, chemical peels and similar procedures should be done very conservatively if at all. Retinoid use is associated with birth defects.
Nicotinamide– This is Vitamin B3 and it acts as an anti-inflammatory, serving to reduce acne activity.
Tea tree oil-This “alternative” topical treatment, also known as “Melaleuca oil” (from the Melaleuca Alternifolia plant) has some antibacterial and antifungal properties to add to its anti-acne effects. 5% tree oil felt to be comparable in action to 5% BP but seems to work in a much more “gentle” mode.
breath– Sulfur is antibacterial and has both a “peeling” and a drying action on skin that affects acne. However, sulfur can have a particularly bad smell, can cause skin discoloration, and sometimes can paradoxically induce the formation of blackheads.
Resorcinol – This primarily acts through its exfoliating properties as described above. Several Clearasil products use a combination of the compounds resorcinol and sulfur.
II. Mild acne – Topical medication
Typically, prescription-based medications are the best choice for mild acne. Generally, a regimen would include one or more of the following: Antibiotics/Antimicrobials, Retinoids, Azeleic Acid.
Antibiotics/antimicrobials – Clindamycin is one of many in a wide variety of topical antimicrobials that directly kill skin bacteria such as Propionibacterium acnes, the most commonly identified bacteria associated with acne lesions. P. acnes actually “lives” on sebum but it is not entirely clear whether it is P. acnes itself or other “opportunistic” bacteria in the skin that directly causes acne lesions. Many combinations of topical antimicrobials are available, often combining one or more with BP and/or a retinoid. Allergic type reactions can occur with topical antimicrobials and can also be very irritating and harsh on the skin, especially with prolonged use.
Retinoids – Vitamin A derivatives in strong concentrations (prescription level) are commonly used today for moderate acne and generally work as described for retinoids above. 0.1% tretinoin (Retin-A) is the most widely used and well known of these but this category also includes adapalene (Differin) and tazarotene (Tazorac). Retin-A has become so popular for its anti-aging and wrinkle smoothing effects that its great value as a powerful and reasonably inexpensive weapon against acne can be overlooked! Dead skin cells, impurity and sebum are shed more easily. Pores open, and skin cell turnover is facilitated. Strengthening the production of collagen, strengthening the skin cells, and strengthening and rejuvenation of the skin takes place. Common side effects may include excessive redness, peeling, and irritation. But again, these effects are usually temporary; the skin usually accommodates and better results will be seen if they continue to use rather than cutting. Recommended use is once every evening, but one may need to develop tolerance (for example by using a smaller concentration to start and/or by using every other night for the first two weeks, for example). Using a good quality moisturizer every day (preferably one that also contains a sunscreen) will soothe the skin, offset the drying effects and limit the skin’s sensitivity to the sun and the elements.
Azeleic acid– A compound naturally found in wheat, barley and rye plants with anti-acne properties. Clears pores, reduces inflammation, and limits bacterial growth.
III. Moderate to severe acne – Prescription drugs:
Oral antibiotics– Examples: minocycline, doxycycline, tetracycline, Bactrim and erythromycin. Common side effects: hypersensitivity to sunlight. Prolonged use often results in a decrease in effectiveness.
Oral Contraceptives (OC’s)/Pill Control – OCs are used to regulate/stabilize hormone levels and reduce androgenic hormone stimulation – androgens (such as testosterone) increase acne and sebum production. People with conditions like Polycystic Ovary Syndrome (PCOS) will greatly benefit from using this strategy for acne control. Potential dangerous complications for the use of OC: blood clots in the legs – with a significantly increased risk for this in smokers. Spironolactone is a diuretic medication that has also been used for many years to help control acne due to its anti-androgen effects (via receptor blocking).
Oral retinoids -The most well-known of these is Accutane which is often used as a “last resort” for more severe and otherwise resistant forms of acne. Accutane literally “shuts down” oil gland function/production while increasing skin cell turnover, opening pores, unclogging plugs, and releasing breakouts. The effects of drying on the skin can be severe and can affect the lips, eyes and mucous membranes. There are many potential serious side effects. Blood tests are needed to monitor safety before, during, and after treatment which is usually 4 – 6 months. Hair loss and toxic effects on the liver, muscle tissue and bones are possible. Accutane (like all retinoids) is associated with birth defects – pregnancy prevention while on Accutane is a must. Depression and suicidal thoughts are, unfortunately, also well-recognized potential side effects of Accutane use. Patients who want certain types of facial cosmetic procedures (such as facial laser rejuvenation or chemical peels) must wait a full year after completing Accutane treatment before having these procedures or significant complications related to abnormal or deficient healing may result.
Steroid injection– Often used for inflamed lesions, nodular or cystic acne (acne vulgaris). It not only speeds up the recovery and healing of the wound, but also serves to limit the potential scars these wounds can leave in their wake when left untreated. Potential side effects: thinning of the skin (atrophy), loss of pigment (hypopigmentation) and the appearance of small “broken capillaries” (telangiectasia).
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