Introduction
If you're struggling with acne, you're not alone. In fact, acne affects an estimated 85% of people around the world at some point in their lives. I used to have acne too, and if you're one of those 15% who have never experienced acne, what are you doing here? You are lucky, get your clear skin out of here.
But the good news is, if you have acne, you've clicked on one of the best post you could possibly find. I'm going to take you through everything you can do to treat acne, from lifestyle and over-the-counter options, all the way through to prescription creams and even tablets.
Seriously, I think this post is the most comprehensive guide to acne treatment that exists on the internet. So make sure to stick around all the way to the end, where I give you my specific recommendations on what you should use.
To understand acne treatments, you have to have at least a basic understanding of what acne is. But this post isn't a detailed explainer about acne, so I'm going to keep this part super brief.
What Causes Acne
Your skin has oil glands in it, and the highest concentration of these are on the face, the chest, the shoulders, and the back. These sebaceous glands, as they're known, secrete oil onto the base of hair shafts, and this then travels all the way to the surface of the skin. The purpose of this is so that your skin remains nice and hydrated, and so that that barrier remains intact.
But acne occurs when there is a blockage of that hair shaft, and then there is a buildup of oil and fatty acids underneath the surface of the skin. Now, if the top of that blockage is closed, then you get what is known as a closed comedone, or a whitehead. But if the blockage is open to the air, then those oily secretions become oxidized in a reaction with the air, and then they turn dark, giving you blackheads.
Now, once you have this blockage underneath the surface of the skin, a specific bacteria known as Propionibacterium acnes gets involved and causes a lot of inflammation. If that inflammation is severe and it is at a deep level, then you can also get nodular and cystic acne, not just those whiteheads and blackheads. And if these cysts rupture, then you can get long-term scarring.
So in summary, the pathway is oil glands secrete an oily secretion, you get a blockage at the hair shaft, bacteria gets involved and multiplies, and you have inflammation.
I'm going to keep referring back to this pathway throughout this post so that you know exactly where each treatment has its effect.
How to Treat Acne with Lifestyle Changes
So let's start with lifestyle, and I'm intentionally focusing on this first because I think too often medical doctors jump straight to prescriptions rather than talking about lifestyle interventions that can help. So which of these interventions have real evidence that they can help with acne?
1. Dietary Modification
Let's start with diet, there are certain foods that have a clear connection with causing acne flares. These include whey protein, skim milk, and concentrated sugars. And beyond this, even if there's not clear scientific proof of certain foods causing acne flares, you probably know for a fact there are certain types of foods that even if you just take small amount of them, you get an acne breakout. And for me, that's ground.
2. Reduce your Stress
Stress worsens every kind of skincare condition, whether that's eczema, psoriasis, or in this case acne. This is why you tend to have acne flares around exam time, when you're traveling internationally, or when you have a wedding day coming up and a gigantic spot appears in a late play to become your maid of honor.
3. Quit Smoking
Now we don't actually know why smoking increases acne severity, but it does seem to. The best theory at the moment is that it has an impact on the type of oil that your skin produces, making it slightly more sticky.
4. Increase your Sleep Hygiene
Increasingly we're starting to become aware of the fact that having bad sleep increases the amount of stress hormones in your body, and that then worsens your acne.
So with all of that being said, the lifestyle interventions that you can implement to improve your acne is to make sure that you avoid those foods we talked about, is to not smoke, make sure you're getting a good night's sleep, and also to reduce your stress levels.
OTC Medications for Acne
Now let's talk about over-the-counter treatments, and there are truly tens if not hundreds of thousands of different creams available over-the-counter targeting acne. But rather than focus on specific brands because there's so much variation throughout the world, I'm going to talk about ingredients. And there's really only a handful that have compelling evidence of being helpful.
1. Salicylic acid
So let's start with salicylic acid, and this is truly one of the OGs of acne treatment. Who amongst us went through teenage years without at some point trying that orange Neutrogena face wash?
But salicylic acid is also in a ton of other cleansers and creams, and it belongs to an overall category of ingredients known as BHAs, or beta hydroxy acids. It works by softening keratin, which is the main protein in skin cells, and it can also dissolve sebum, which is an oily secretion on the skin.
So you can imagine the block pores on our skin kind of like block drains, and think of salicylic acid as a drain buster that goes down there and slowly dissolves all of that gunk to make sure that we don't get the inflammation.
2. Benzoyl peroxide
Next up, let's talk about benzoyl peroxide, and this works in three main ways. The first of these is that it directly kills Propionibacterium acnes, the acne-causing bacteria.
If you reduce the amount of P. acnes on the skin, that means that there's less of it around to cause inflammation and bad acne flares. Benzoyl peroxide also has exfoliating qualities similar to salicylic acid, which we just spoke about. And finally, it can directly reduce inflammation.
This is why benzoyl peroxide is also really popular as a spot treatment, because it can turn down the volume on those angry red bumps. But be warned, this ingredient can feel very harsh on the skin. Over-the-counter options of benzoyl peroxide come in 2.5%, 5%, and 10%, but I personally would never go near 10% when it comes to the face.
That's really designed for use on the body for things like bacne. The only time you might want to use 10% benzoyl peroxide on your face is if you're going to a Halloween party the next day, and you're planning to dress as a thing.
3. Retinoids
Now, anyone who's been following my blog for a while knows that I'm absolutely obsessed about retinoids, and I will find every opportunity to bring them up. Retinoids are a family of vitamin A-related chemicals, and they are the single best ingredient in the entire world of skincare. They have a bunch of different benefits, including anti-pigmentation, anti-aging, even anti-cancer, but for the sake of this post, we're going to focus on their anti-acne effects.
Within the family of retinoids, there are over-the-counter and prescription options. The over-the-counter options contain retinol esters, retinol, retinaldehyde, or adapalene. Now, just because they're not prescription-strength doesn't mean these ingredients don't work, and I actually always tell people, if you've never used a retinoid before, you should always start with an over-the-counter option, because you're going to risk side effects if you go straight to prescription-strength tretinoin.
Retinoids work across the entire acne pathway that we spoke about earlier. They reduce the size of your oil glands, they also make sure the oily secretions are less thick and sticky, they exfoliate to make sure there's no blocked pores, they kill P. acnes, the bacteria that causes acne, and they are directly anti-inflammatory. But the main issue with topical retinoids is that they can feel harsh on your skin, especially when you first start using them.
I'll do a whole post in future specifically talking about the best way to start using a retinoid product.
4. AHA Containing Products
So let's wrap up with some quick fire ingredients, AHAs or alpha hydroxy acids are things like glycolic acid, lactic acid, and mandelic acid, and these are gentle exfoliants that help to unblock pores.
Azelaic acid is another ingredient that kills bacteria, is anti-inflammatory, and also exfoliates.
5. Niacinamide
Finally, niacinamide reduces the amount of oil secretion from sebaceous glands and is anti-inflammatory. So let's move on to the prescription category.
Topical Prescription Drugs for Acne Treatment
Sometimes, no matter how perfect your over-the-counter skincare routine or your lifestyle interventions, your acne is going to be too severe and you are going to need prescription treatments. Why is that? Well, it's your parents' fault. Don't blame me, blame them.
Jokes aside, genetics are a major determinant of not just how many oil glands we have, but their activity and the specific type and stickiness of the oil you secrete. So there's no shame in needing to go see a doctor for your acne. It doesn't mean you're doing anything wrong, and it is way better to go there early. So what prescription options do we have to help acne?
1. Clindamycin
Let's start with clindamycin, and this is slightly more heavy duty of an antibiotic that targets P. acnes and can be used alongside benzoyl peroxide.
2. Prescription Retinoids
We also have prescription retinoids, and these are things like tretinoin of various concentrations, as well as tazaratine. All of the same benefits we talked about with over-the-counter retinoids are applicable here, except the concentration is even higher.
That means that the anti-acne effect is stronger, but also that those potential side effects of flaking and inflammation can also be worse. So make sure you're using a tiny amount and maybe use it every other night for a few weeks until ultimately you want to aim for every night.
3. Azelaic acid
Moving on to the next option, we have azelaic acid, but available in 15 and 20% concentrations, whereas over-the-counter you can only get 10%.
Prescription creams can also sometimes combine multiple of these ingredients together. So a great example is Epiduo, which combines adapalene and benzoyl peroxide, making it easier to use both in your regular routines.
4. Benzaclin
There's also Benzaclin, which is actually a combination between benzoyl peroxide and clindamycin.
Oral Prescription Drugs for Acne Treatment
So that is all of the prescription creams and we're almost at the end of this post, but we have to talk about prescription oral tablets. There are three main options for these,
1. Oral antibiotics
Starting with number one, which is oral antibiotics. Doxycycline is by far the most popular option for this. And the way I want you to think about it is that if clindamycin and benzoyl peroxide target bacteria on the surface, kind of like shooting bows and arrows at it, then taking doxycycline as a tablet is a little bit like blowing up dynamite under the surface.
It is far more effective at reducing the amount and the activity of P. acnes and therefore it does a great job of reducing acne severity. Doxycycline is also independently anti-inflammatory aside from its antibacterial effect, and so it can give amazing results when you're taking it.
However, because of the side effects of taking long-term oral antibiotics, including on your gut bacteria, you can only really take doxycycline for around three months. Although it's very effective while you're taking it, there's actually no long-term benefit when it comes to acne reduction once you stop.
2. Oral contraceptives
Moving on to tablet option number two, which is hormonal targeting treatments. These include oral contraceptive pills, which reduce the amount of hormone surges in your body, and something called spironolactone, which blocks the hormone receptor on your sebaceous glands. What that means is that no matter what's happening with the hormone levels in your body, it's not communicating through to your skin. Androgen hormones, like testosterone, normally attach to specific receptors on sebaceous glands and tell them to produce more oil and to produce thicker, stickier oil.
As you can imagine, this dramatically increases your chances that you're going to get a blockage in your pores and therefore, you're going to get really severe acne. This is why classically acne is at its worst during puberty, because that's a time where you're having surges of these androgens.
Now both of these hormonal targeting medications are only really an option for biological females, otherwise it causes a lot of unwanted side effects in biological males.
And this is a great time to disclaim that you should always discuss all treatment options with your own doctor. This is not medical advice, this is education, all of that stuff, don't sue me.
3. Accutane
This is the big kahuna, the nuclear weapon in the fight against acne, the treatment to end all acne treatments. And this is also the treatment that has the worst reputation of all when it comes to social media users. Accutane, also called isotretinoin, is, as the name suggests, part of that retinoid family I talked about earlier.
But rather than being a cream which is specifically applied to the skin, oral isotretinoin is taken as a tablet and because of that it's absorbed throughout the body. Now the plus side of that is that isotretinoin is by far, by a million miles, the strongest and most effective treatment when it comes to reducing acne severity. It reduces the size and activity of oil glands permanently, meaning that once you complete your roughly five-month course where you take the tablet each day, your acne will be improved for life.
The majority of people who take isotretinoin will never need more than one course in their entire lives. But the downsides of it being absorbed as a tablet is that it can have side effects on things like your cholesterol, your liver, and other parts of your body. I'll do a full separate post about Accutane in the future focusing on all of its benefits and its side effects when we look at the clinical trial data.
But for now just know that it is the end game of acne treatment, offering potentially incredible results but with the risk of side effects and therefore requiring a lot of blood work. Because of its potential danger when it comes to developing babies, especially for biological females, you need to come in every month and get a pregnancy test done and so the whole process can be a bit of a logistical nightmare for those five months that you're taking the medication.
Newer Prescription Drugs for Acne Treatment
Finally, we have some newer prescription creams such as Axone, which is topical dapsone, something which is anti-inflammatory and has an antibacterial effect. And even more recently than that, we have something called Winlevy, which specifically targets the hormone receptors on your oil glands and so is a great option for people with hormonal acne.
Closing Thought
Well, I did it. You basically just sat there and read everything. But that is every acne treatment in the world that is worth knowing.
So here's specifically what you should do depending on the severity of your acne. If you have whiteheads, blackheads, and slightly oily skin, you should use a salicylic acid based cleanser in the morning and you should use an over-the-counter retinoid product at night. It's also a good idea to keep a benzoyl peroxide spot treatment around in case you get the odd angry bump.
After one or two months of this regimen for this type of acne, you're usually really well controlled. If your acne persists even though you're doing this, or if you have deep acne from the beginning which causes pigmentation or scarring, then you should really go see a dermatologist and discuss prescription options. They'll likely give you a prescription antibiotic cream in the morning and a prescription retinoid at bedtime.
And if you have severe cystic or scarring acne, then go to your dermatologist and they will likely give you oral medications. Whether that is a short-term oral antibiotic course, whether it's a hormonal targeting treatment, or whether it's accutane right from the beginning depending on your severity. And my last most important piece of advice is that if you have severe acne, I'm begging you, don't try 50 different over-the-counter creams.
They're not going to fix severe hormonal or cystic acne despite what these skincare companies say because honestly, they're liars. I've seen it firsthand. They will advertise these ridiculous before and after photos where someone goes from severe hormonal acne to clear in just one month using a night cream.
For some people, even the world's best over-the-counter cream, which mine will be, will still not be enough and so you need to go see your dermatologist and get a prescription strength option. Don't blame yourself for not changing your pillow enough or think that just one more juice cleanse is going to take you from severe cystic acne to clear skin. It's not.
And every month you wait, you're increasing your chances of pigmentation and scarring, which is so much harder to get rid of than it is to stop in the first place. Thank you so much for sticking with me to the end and I will see you in the next one.
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