A Dermatologist Explains All the Ways to Treat Acne

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Acne affects about 50 million people every year, according to the American Academy of Dermatology (AAD), with treatment costing more than $3 billion annually. And it’s definitely not only a teen thing. The AAD also notes that acne cases have been increasing in women in their 30s and older. While it’s easy to brush off as a vanity issue, the AAD calls the potential negative psychological effects “profound,” which anyone who has experienced acne can likely attest to.

People spend a lot of time trying to figure out how to self-treat their acne, wading through myths versus hard science versus promising treatments. You can see this happening every day in forums like Acne.org and multiple subreddits. It can be overwhelming in all the noise to figure out what really works.

Dr. Rachel Nazarian, a New York City-based dermatologist at the Schweiger Dermatology Group, treats a ton of acne patients in her practice and spoke to Racked about her treatment strategy. There is also information here from the AAD’s evidence-based treatment guidelines, last updated in 2016.

Here are the important bits about the modern approach to acne:

There are really only two types of acne

Hormonal, cystic, stress-induced — forget all the terminology you’ve heard. When dermatologists look at your face, they immediately categorize acne as either inflammatory or non-inflammatory, according to Nazarian. Non-inflammatory acne includes whiteheads and blackheads; inflammatory acne includes those red, painful cysts that are prone to scarring. Some patients have both kinds, but treatment is ultimately based on the type of lesions you have.

Also, it’s important to know that pretty much all acne can be classified as hormonal, since various hormones play a big part in how, why, and where the acne shows up on your face. Gender, pattern, and lesion type all provide clues to help figure out the underlying hormonal cause, making it a little easier to come up with a treatment plan.

At its most basic, acne occurs when your pores get clogged with oil — helped along by hormones that increase oil production in the skin — and dead skin cells. P. acnes, the bacteria most commonly responsible for inflammatory acne, then gets trapped in there, setting in motion a complex immune reaction that results in those familiar red, painful bumps.

There is no one magic bullet to treat acne

Because acne is caused by a cascade of different factors, treating it with one product or medicine usually isn’t enough — you have to attack it from many angles with different types of agents that all work differently. This is by no means an exhaustive list of every potential acne treatment available, but it hits the most commonly used ones.

Topical treatments

Nazarian always starts with topical medications, which include the over-the-counter (OTC) drugstore staples you’re likely familiar with. First, there are keratolytic agents like salicylic acid, which comes in many formulations, and glycolic acid, which is usually in pads or toners. These are exfoliants that work on the skin by chewing up the keratin (a protein found in skin cells) that clogs pores. Then there’s benzoyl peroxide, which breaks up the gunk in clogged pores and inhibits bacteria growth and inflammation. Nazarian recommends a regimen of keratolytics before getting extractions done by a facialist because they help loosen everything, making it easier for a therapist to remove it and potentially preventing skin damage.

For more stubborn acne, topical retinoids, which are vitamin A derivatives, are appropriate. They include tretinoin, adapalene, and tazarotene. All of them are available via prescription only, except for adapalene, which launched lower doses OTC last year under the brand name Differin. Retinoids increase cell turnover and work on acne by decreasing inflammation and unclogging pores. The AAD calls them a “core” of topical therapy. If you’re ever given oral medications for acne, your doctor will likely keep you on retinoids when you’re finished, for maintenance. All these topicals are appropriate for non-inflammatory and mild to moderate inflammatory acne.

Now on to the bigger guns.

Commonly prescribed topical antibiotics (available by prescription only) include clindamycin and erythromycin. They shouldn’t be used alone because there’s a risk for bacterial resistance, so you’ll usually see them formulated with benzoyl peroxide. This makes the antibiotic work better and decreases the chance of resistance. Then there’s Aczone, a newer topical antibiotic for acne treatment that both decreases inflammation and kills bacteria. It also seems to work better in women than it does in men. The downside is that it can be really expensive.

The caveat here is that if you pile all these things onto your face at once, it’s a potential setup for irritation. So test them one by one to see how your skin tolerates it.

Oral medications

Next come the oral medications, all of which need to be prescribed. Antibiotics like doxycycline and minocycline are the gold standard, but you should always be using a topical medication too. Antibiotic resistance is a huge issue, so dermatologists will generally try to avoid long-term antibiotics. The “good” gut bacteria, which antibiotics can kill along with acne bacteria, is also an issue.

“Overall for acne, antibiotic use is starting to go down because it messes with your bacterial colonization. We know that the natural pH inside the body and outside the body is very important, and the good bacteria keep that in check. So as much as we love using our antibiotics, we’re always looking for a way not to,” says Nazarian.

Then there’s treatment to try to address the hormonal issues. Spironolactone is a decades-old drug that was used as a diuretic for people with blood pressure and heart problems. But to treat acne, it decreases circulating testosterone, which is the hormone responsible for that monthly acne that pops up, usually on the jawline, right before a woman gets her period. It’s also one of the cheapest acne treatments out there. (It should be used cautiously in men as an acne treatment since it messes with testosterone.) There are also four types of oral contraceptives that the Food and Drug Administration has approved for acne treatment, but birth control pills come with a host of potential side effects.

Finally, there’s Accutane, now prescribed in its generic version, isotretinoin. “It’s a fantastic medication, and it always works,” says Nazarian. But it also has a host of potential side effects that need to be monitored. Most crucially, women cannot get pregnant while on it because it has a high risk of birth defects. Every patient has to enroll in the iPledge program before they can start a regimen. It also requires regular blood testing.

High-tech options

There are in-office procedures available that insurance sometimes covers. Chemical peels “shrink down oil glands and help clean the pores,” says Nazarian. She also uses a treatment called Isolaz. “It’s a little vacuum, and during the suction mode, it also zaps the skin with heat and red light, then blue light, which help kill bacteria and decrease inflammation,” she explains. One treatment costs between $125 and $350, depending on where in the country you live. Patients usually require a treatment every two weeks for four total sessions.

But do at-home light treatments for acne work as well as the office version? Nazarian says no, but there can still be benefits if you use them regularly. They cost anywhere from $19.99 for Neutrogena’s version to $169 for Tria’s; the technology is slightly different on all the at-home versions, so it’s difficult to compare them. The AAD notes that there is still a lack of large, multi-center studies about the effects and efficacy of light and laser treatments.

Myth versus reality

Online chatter and old wives’ tales often become hopelessly entangled as people hunt for an acne fix. Here are some concepts that people often ask about, and the evidence we know about them:

Purging: Often when people start a new skin care routine, they try to analyze if new breakouts are a reaction to the products or a phenomenon called purging. Nazarian says purging is an actual thing. It happens when a bunch of new lesions pop to the surface of your skin when you start a new regimen. She explains that acne lesions are at all different stages underneath the surface, and no one treatment will just kill them all instantaneously. But treatments like retinoids or antibiotics can loosen up what’s in your pores and speed skin cell turnover, bringing it all to the surface more quickly, where it presents as a pimple. Then theoretically you’re left with pores that are no longer a setup for infections and inflammation. But in the beginning, it can feel like a minefield. (This is a great explanation, with pictures.)

Diet: This is a tricky one to directly correlate with acne since we eat so many different things. But there is mounting evidence that both dairy and high glycemic foods that spike your blood sugar quickly (starchy things like white bread and potatoes, for example) can potentially exacerbate acne. So doing an elimination trial of milk or potato chips for a few weeks can’t hurt.

Probiotics: Probiotics are an exciting area of study in acne. Taking them orally (or eating yogurt or kombucha) can potentially have a few benefits. First of all, they’re helpful for replacement if you’re on oral antibiotics, which can kill the so-called good bacteria in your gut. Second, they may have some anti-inflammatory benefit to the skin directly, though large, well-designed studies haven’t yet been done to support their use. But more dermatologists are definitely recommending them to patients as evidence mounts. (Just be aware that they are marketed as dietary supplements and aren’t regulated by the FDA.)

Niacinamide: Niacinamide, a B vitamin, is a darling of topical skin care formulations lately, with good reason. It can decrease inflammation caused by acne and improve skin texture. Nazarian has also prescribed oral niacinamide in a prescription supplement preparation called Nicadan. It’s not usually covered by insurance, and she cautions that it’s by no means a home-run treatment, but some patients do respond.