Over-the-Counter Acne Treatments
When considering acne treatments, most people’s first stop is the drug store. There are a huge variety of over-the-counter (OTC) acne products available, including cleansing lotions, gels, foams, towelettes, leave-on products, treatments, and kits, most of which are fairly effective at combating mild to moderate acne.
These products work in a few different ways. Some OTC acne treatments work by killing the excess bacteria that cause inflammation, others remove extra oil from the skin, or speed up the growth of new skin cells while removing dead cells. Others combine all these techniques.
A 2013 study on acne vulgaris found that in most cases, a multidimensional approach to acne is necessary because most people have a combination of symptoms. Look for these 4 common active ingredients in OTC acne products.
Benzoyl Peroxide
This ingredient is found in a huge variety of washes and scrubs, and works by killing the bacteria that causes acne, helps remove excess oil from the skin, and gets rid of dead skin cells. OTC benzoyl peroxide products come in a range of strengths, from 2.5 to 10%. This option is best for mild to moderate acne, but it can be combined with other treatments for more severe cases.
While this option is very good at reducing the number and severity of acne blemishes, it can also lead to irritated skin, dryness, or peeling. This chemical is also often used to bleach hair, so be sure to keep it away from your hair and clothing.
Salicylic Acid
This OTC treatment (a Beta Hydroxy Acid) option works to remove the outer layer of skin by causing the cells to shed more readily, opening clogged pores, and killing the bacteria inside. This helps prevent your pores from clogging and allows more room for new, healthy cell growth, as well as strong anti-inflammatory effects.
Salicylic acid is usually found in wipes or towelettes. High concentrations of the chemical can lead to a darkening of the skin in people with darker skin types, unless properly applied or prescribed by the appropriate and well-trained provider. This acid is one of the most commonly found in chemical peels which aid in reducing pore size, evening out skin tone/texture, and correcting dark marks and subtle acne scars.
Alpha Hydroxy Acids
There are two types of alpha hydroxy acids (AHA’s) used in OTC products and/or chemical peels: glycolic acid and lactic acid. Each of these chemicals treat acne by helping your body remove dead skin cells and reducing inflammation. This treatment has the additional bonus of encouraging the growth of healthy, smoother skin, which in turn improves acne scars and makes pores look smaller.
On the other hand, common side effects include mild skin irritation, redness and flaking, and less commonly blistering, burning, or skin discoloration if the concentration is too high, though these are usually mild and fade after a day or two. If the AHA’s are applied properly by a trained professional, be sure to ask about what to expect during/after the application of these acids either through washes, creams, or peels.
Sulfur
Usually found combined with benzoyl peroxide or salicylic acid, sulfur removes dead skin cells and helps wash away excess oil. Sulfur is found in a wide variety of OTC products, from washes and scrubs to peels. Bear in mind sulfur can cause dry skin, and these products might have an unpleasant smell.
Prescription Acne Medications
If your acne doesn’t begin to improve after a few weeks of drugstore treatments, it might be time to visit your dermatologist. There are a wide variety of prescriptions available for all acne types, ranging from simple topical regimens to oral medications that must be taken several times a day.
Topical Prescriptions
These make up the majority of prescription acne medications, and are usually applied directly to the areas of the breakouts. There are many options to choose from, but the most common and effective treatments include topical antibiotics like clindamycin, anti-inflammatories like benzoyl peroxide, and the all-powerful comedone-fighting/anti-aging retinoids.
Prescription strength topical medications include:
Dapsone
Dapsone is a topical gel used to treat acne, although its action is not well understood. It is believed that it works to stop the bacterial growth that causes acne, as well as fighting against many of the acids that lead to acne synthesis.
Available only by prescription in 5% and 7.5% strength, a brand name for this drug is “Aczone.” This drug has been found to be quite effective, bringing “clinically meaningful” improvements to acne blemishes after 12 weeks.
More recent data from the newly released 7.5% formulation also suggests its improvement of dark marks associated after active acne marks begin to heal. The most common side effects, although the medication is fairly well tolerated by even the most sensitive of skin types, are dryness, oily skin, peeling, redness.
Rarely, the topical application can be associated with methemoglobinemia, and is used with caution in individuals with a G6PD deficiency.
Retinoids
Retinoids make up a general category for any and all forms of vitamin A, and despite their still unproven method of action, it is known that retinoids enhance epithelial cell turnover. Essentially, this means that it exfoliates your skin from the inside-out.
Retinoids improve how your skin cells are shed, while also unclogging pores and significantly reducing inflammation. Prescription tretinoin include name brands like Retin-A, Avita, and Atralin, vitamin A derivatives like tazarotene (brand names Tazorac and Avage), and adapalene (brand name Differin).
Side effects of retinoids include dry skin and increased sun sensitivity. Be sure to follow proper sunscreen/block protocol as advised by your provider before going on your Caribbean vacation.
Azelaic acid
In 15-20% concentration, Azelaic acid works against acne-causing bacteria while also carrying an anti-inflammatory one-two punch. Used in topical gels and foams, this naturally occurring acid is found in whole grain cereals and animal products. It is sold under the brand names “Azelex” and “Finacea”.
Side effects associated with Azelaic acid are short term, and in rare cases can include discomfort like burning, tingling, stinging, dryness, or redness. Some studies have supported Azelaic Acid as improving rosacea-type acne by reducing redness and papules.
Oral Prescriptions
Used somewhat less frequently than topical treatments, the most common oral prescription medications for acne are antibiotics, spironolactone, isotretinoin (Accutane), and some types of birth control pills.
Oral antibiotics
Oral antibiotics are usually extremely effective treatments, but they also carry a risk of some more serious side effects than topical treatments.
Basically, oral antibiotics kill the bad bacteria that contribute to acne, but they also kill much of the good bacteria that your body relies on. That means that prolonged, continued use can lead to chronic vaginal yeast infections and stomach issues.
There is also the risk that the acne-causing bacteria will become immune or resistant to the antibiotics. If you use an oral antibiotic for more than 6 months, which you’re almost certain to do, it will slowly lose its effectiveness, but the negative side effects will continue.
However, the immediate benefits for severe acne with scarring that may be apparent on a visit with a healthcare provider could warrant the use of oral antibiotics like doxycycline.
It is important to keep in mind that in extremely low doses of doxycycline, the profile of the antibiotic changes. In low doses, the “antibiotic” has less antibacterial power and more “anti-inflammatory” power, essentially keeping it at a “sub-microbial” profile so that it can be used long term without adding to the conundrum of antibiotic resistance.
The medication itself is unique and intriguing: in low doses (like 50-150mg daily) doxycycline can reduce inflammation, while in high doses (like 100mg twice daily) it can treat pneumonia (a severe bacterial lung infection).
Minocycline is also used as an oral antibiotic/anti-inflammatory to treat acne with typically more tolerable gastric side effects than doxycycline.
Oral contraceptives
Certain types of birth control (oral contraceptive) pills have been shown to be effective at reducing acne blemishes and overall oil production. However, there is no guarantee of acne reduction with this approach. In fact, it’s possible that instead of improving acne, oral contraceptive pills will actually worsen acne.
Birth control pills are generally a combination of a variety of synthetic female hormones, some of which block the male hormones that promote oil production in the skin. Therefore, only birth control pills that block male hormones have been approved by the FDA for acne treatment, including brand names like Ortho Tri-Cyclen, YAZ, and Estrostep.
Hormonal birth control may cause the following side effects:
- Nausea
- Headaches
- Weight gain
- Mood swings
- Decreased libido
- Breast tenderness
- Intermenstrual spotting
- Missed periods
- Vaginal discharge
Cortisone Shots
Cortisone, a corticosteroid, is a chemical that is naturally produced inside your body to help fight off inflammation. Ideal for treating large acne cysts and nodules, the chemical, usually a drug called triamcinolone, is injected directly into the acne lesion to reduce swelling.
How It Works
Generally considered a last resort for most patients, triamcinolone (brand name “Kenalog”) is injected directly into the cyst or nodule. The extreme anti-inflammatory properties of the chemical begin working on the pimple immediately, reducing redness and swelling. The results are so fast and complete that most cysts and nodules disappear within 24 hours.
Risks & Side Effects
Since cortisone is a naturally occurring chemical found in your body, the side effects are few, mild, and short lived. The most common is atrophy of the fatty tissues around the injection, leading to a dimple. This is temporary, but it can take a few months to return to normal.
Other side effects include mild, temporary pain and lightening of the skin at the injection site in darker skinned patients. Lightening of the skin is also temporary and resolves within days to months (longer duration of lightening is associated with joint injections of steroids, for example osteoarthritis of the knee or bursitis of the hip).
What It Costs
If this seems like a viable solution to your acne problem, call your healthcare provider or dermatologist to set up an appointment. With health insurance, steroid injections are typically covered, but co-insurance or deductibles may play a role in a possible out of pocket cost after your visit.
If you are uninsured, the costs of injections can vary from $50-200+. A responsible healthcare provider will likely recommend maintenance therapies that work with you and your specific needs during your visit, and not just offer a solitary visit with a steroid injection.
Light Therapy
Intense Pulsed Light (IPL) — also known as photofacials — can be used to treat a wide variety of skin conditions, including both acne and acne scarring. Photofacial rejuvenation treatments are usually painless and significantly improve the appearance of your skin.
How It Works
IPL photofacials that are specifically designed to target acne use short pulses of yellow, green, and red light. This broad-spectrum light penetrates through several layers of skin to reach the acne blemishes. The yellow and green lights kill the P. acnes bacteria, and the red light targets the overactive sebaceous glands that are producing too much oil, shrinking them. The light also has the added benefit of stimulating collagen production in the area, which reduces scarring.
An effective treatment for all types of acne — especially cysts — the procedure is short and painless, with greatest success and fewer side effects occurring in patients with lighter skin.
The entire procedure lasts about 15 to 20 minutes. Usually 3 to 5 treatments are required, spaced out over a few weeks. In the time after your session, your skin will slowly rebuild itself and you’ll notice a gradual improvement.
Risks & Side Effects
Most risks associated with photofacials are short and temporary, including very minor swelling, redness, and visible capillaries. These usually fade within hours. In rare cases blistering, bleeding, and scarring have also been reported, along with both darkening and lightening of the skin.
What It Costs
Used by general medical practitioners, cosmetic surgeons, dermatologists, and aesthetic laser technicians, photofacial treatments are fairly common. However, despite their widespread availability, they remain more expensive than some other options, with an average price tag of about $500 to $600 per session.
Medical grade home versions of this treatment also exist, like the Quasar Baby Blue, which costs about $350, and the Project E Beauty LED 3 Colors Photo-rejuvenation Kit, which costs about $50-$60.
Photodynamic Therapy
Designed to fight resistant, hard to treat, active acne, photodynamic therapy (PDT) is another light-based treatment. It’s a fast and effective way to clear the skin, stop future breakouts, reduce existing scars, and prevent future scars from forming.
How It Works
A special light-activated solution, usually either a 20% solution of Levulan (5-aminolevulinic acid, or ALA) or a 20% solution of methyl aminolevulinate (MAL), is applied to the target area under a dressing for up to 3 hours. This allows it to be absorbed into the skin and the sebaceous oil glands.
Next, red and/or blue light is directed towards the skin in a session lasting about 15-20 minutes. This light “turns on” the solution, which kills the acne-causing bacteria, and shrinks the oil glands. This is usually done 3 to 5 times, at 2 to 4 week intervals.
Unlike photofacial treatments, photodynamic therapy can be quite painful, causing the skin to be extremely sensitive to light. You’ll need to stay indoors, completely out of sunlight and even bright indoor light for two days. For this reason, this treatment is used on moderate to severe acne cases.
That said, most patients see a 75% reduction in inflammatory acne after 3 treatments, and results are semi-permanent. Because the procedure is fairly new, it’s hard to know how long the results last, but some doctors have reported 1 to 2 years of reduced symptoms.
Risks & Side Effects
The potential long term side effects of PDT are not yet fully understood. Some of the short-term side effects that have been observed include:
- Pain
- Swelling
- Redness
- Itching
- Peeling and/or crusting for a week or so
- Occasional skin darkening lasting for about a month
- Extreme skin photosensitivity
- Short-term, transient acne breakouts
What It Costs
If you’re interested in photodynamic therapy to treat your acne, contact your dermatologist. Generally, this therapy is not covered by insurance, and can cost upwards of $400 per treatment.
Laser Treatments
Working on a similar premise as light-based acne therapies, laser treatments kill the acne causing bacteria found within the follicles. This treatment is most effective against papules and pustules, as well as acne scars, but doesn’t seem to work nearly as well for whiteheads, blackheads, and the more severe cysts and nodules. Like other light options, you’ll likely need 3 or more treatments, spaced about a month apart.
How They Work
Similarly to light-assisted techniques, the intense beam of the “fractional laser skin treatment,” commonly known by the name brand “Fraxel”, penetrates the layers of skin to reach the acne-causing bacteria where it lives. The focused energy of the laser not only kills the bacteria, it also helps to smooth out the skin, helping to repair old scars, while preventing new ones from forming.
The biggest difference between light therapy and laser therapy is their method of action: light therapy uses multiple wavelengths of light, whereas lasers use a single wavelength of light. For example, depending on the Fraxel laser type used, it can use a wavelength of 1550nm (nm = nanometers) with the Fraxel Re:Store erbium laser, or a 10,600nm wavelength with the Fraxel Re:Pair carbon dioxide laser.
There’s some debate on the usefulness of this technique, however. Studies looking into its effectiveness suffer from small sample sizes, use different devices, don’t follow up with patients, and don’t use any controls.
The general consensus is that the results should be short term because bacteria tends to grow back quickly. Furthermore, the overall effectiveness of the treatment is fairly unpredictable, clearing anywhere from only 36% to as much as 83% of acne lesions.
It should also be noted that laser treatments are more commonly used to reduce the appearance of fine lines, wrinkles and sun spots.
Risks & Side Effects
Pain or discomfort is fairly common during the procedure, but side effects are usually mild and temporary. Depending on the particular laser used they can include:
- Inflammation
- Skin peeling
- Occasional blistering and/or crusting
What It Costs
Laser therapy is usually performed by cosmetic surgeons, dermatologists, and aesthetic laser technicians, and costs around $200-$500 per session.
Chemical Peels
Containing a special acid (or acids), and applied to the skin every two to four weeks, chemical peels can be administered by healthcare providers and medical aestheticians in strengths of up to 70%, and work best for people with superficial acne or acne scars.
Although the exact mechanism is still up for debate, what we do know is that they work to chemically exfoliate your skin, speeding up skin cell turnover, and preventing your pores from getting clogged.
How They Work
Chemical peels work by exfoliating the outer layers of skin. This exfoliating action causes the skin cells to reproduce more quickly, while helping to remove the extra dead cells that lead to clogged pores, shrink those pores, and aid in reducing red/dark marks from previous acne breakouts.
Most patients show about 45-50% reduction in their acne blemishes after a series of 4 to 6 peels, reporting “fair” to “good” results. However, these results are temporary, lasting only about a month or two before acne symptoms reappear.
Risks & Side Effects
The most common side effect is a sunburned appearance, with various degrees of peeling after the treatment. The intensity of the peeling usually improves after each session, assuming that the strength of the peel remains unchanged. Your provider may decide to adjust or increase the concentration of the peel’s strength at each subsequent visit.
Chemical peels can also remove the outermost protective layer of your skin leaving you much more sensitive to sunlight and UV rays.
Depending on the depth of the peel (superficial, medium, or deep), the risks of post-procedural discomfort, side effects, and the “amount” of peeling vary tremendously. Temporary skin darkening has been reported, which is more common in people with darker skin and those who are prone to keloid scarring. Darkening of the skin and increased sun sensitivity can be prevented or protected through the use of proper sunscreen.
What It Costs
Most doctors and dermatologists offer this treatment, as well as spas, and costs usually run about $100 to $500 per peel, depending on the type, strength, and where it is administered.
Like some other treatments, “at-home” options are available, like Vichy’s Double Glow Peel Mask (about $35), and REN’s Glycol Lactic Radiance Renewal Mask (about $70). However, it’s important to keep in mind that any over-the-counter peels will be much more mild than something you can get from a healthcare provider’s office.
Finding a Doctor
The first step in acne treatment are over-the-counter remedies, however, this is rarely sufficient for those who suffer from severe acne.
If, after a few weeks of over-the-counter treatment, you see little to no improvement, speak with a certified dermatologist who specializes in acne. Treating acne early is the best way to regain control of your skin and avoid scarring.
