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Of all the skin concerns I’ve seen during the practice of being a dermatologist, acne-sufferers are probably my most frequent visitors. According to the American Academy of Dermatology, nearly 85% of all Americans have suffered from acne at some point in their lives, with some not even experiencing it until their adulthood. With over $2.2 billion spent on acne treatment in 2004, this is not a problem that presents an easy solution. Below, I’ll discuss a wide variety of topical treatments available over the counter and through prescriptions to treat acne. Let’s start with the prescription-only options.
Vitamin A Derivatives (Retinoids): Tretinoin, Adapalene, and Tazarotene
Tretinoin is a derivative of vitamin A that increases and normalizes cellular turnover to chemically exfoliate your skin while forcing the cells to function better. Because it is keratolytic, it binds to the proteins in cells and causes your skin to shed dead keratinocytes (surface cells) faster, which will unclog your pores to reveal smoother skin. When using tretinoin, your skin may appear worse in the first seven to 10 days — red, scaling, and an increase in acne lesions — but should improve in a matter of two to three weeks. However, a good dermatologist will be able to guide you in using these medications to prevent this uncomfortable flare entirely. Side effects may include warmth and stinging; lightening or darkening of skin; swelling and crusting; and an increase in acne. Like all vitamin A-derived retinoid products, tretinoin will degrade in sunlight, so patients should apply this only at night.
Adapalene is a synthetic retinoid derived from napthoic acid. It has similar biological processes to tretinoin, but a greater ability to dissolve in lipids, which is great for those with particularly oily skin. Unlike tretinoin, adapalene doesn’t bind to proteins, but to specific retinoid receptors RAR-ß and RAR-y. Adapalene is marketed as gentler for your skin than tretinoin, and causes less dryness and irritation.
Tazarotene is the most potent of topical vitamin A treatments. It’s prescribed for patients with severe blackheads, and has the most potential for irritating side effects, so its use should be monitored closely with your dermatologist.
Azelaic acid was first investigated for its treatment of hyperpigmentation when researchers accidentally noticed that it was an effective treatment for acne. Azelaic acid has been prescribed for mild to moderate acne since 1996 and is usually not associated with troubling side effects. Its mechanisms of action are still unknown, but it possesses both antibacterial and anti-keratinizing activities. Because of its ability to treat hyperpigmentation, those with darker skin tones should be cautious using this as it could have adverse bleaching effects.
Topical antibiotics work by directly killing the bacteria that causes acne, P. acnes, which allows a slowing of the process of comedogenesis (clogging of pores). Different antibiotics may work for different people, so it’s important to discuss potential use with your dermatologist. Many doctors believe that use of a topical antibiotic alone without other treatment may promote antibiotic resistance, so be aware of this and ask your dermatologist.
Combination topical therapy is often used when patients have both comedonal and inflammatory acne. Clinical studies are few, so it’s difficult to compare the effects of the various treatments. One particularly effective treatment is a combination of antibiotic erythromycin and benzoyl peroxide. The combined treatment gel has shown greater efficacy than either product alone or when compared with clindamycin, one of the stronger antibiotics.
Another combination is benzoyl peroxide and adapalene, the synthetic vitamin A responsible for increasing cellular turnover. Benzoyl peroxide helps to dry out the skin while also providing an antibacterial effect. Side effects are similar to other vitamin A treatments in that it can cause irritation, dryness, and photosensitivity.
A third popular combination is tretinoin with clindamycin. Each of these combination treatments works well for different people.
Over the Counter: Salicylic Acid, Benzoyl Peroxide
Salicylic acid is a beta hydroxy acid that increases cellular turnover by softening the keratin protein in your skin, which allows it to slough off dead skin cells and clear acne. It is also lipid-soluble, making it an effective treatment for oily skin. In OTC products, salicylic acid cannot exceed 2% concentrations.
As noted above, benzoyl peroxide has bactericidal properties against P. acnes and will dry your skin to decrease the amount of oil that can clog your pores.
There’s no one specific way to treat acne, and what works for you may not work for your friend. The above are just a sampling of topical treatments available, and other options exist in both oral and laser treatments, which we will discuss over the next few weeks. As always, discuss your options with your dermatologist to figure out what will work best for you and your skin.