Medication

Personalised Advice

Leaving acne to clear up by itself isn’t a good idea, since it can persist for many years and lead to scarring. Acne presents at 12-14 years old, and resolves at around 23-27 years if not treated (1).

With acne medication, significant improvement should be noted after 12 weeks. Aggravation is often experienced in the first couple of weeks, especially with topical retinoids.

After acne has cleared, it is essential to continue using a product which addresses hyperkeratinisation (azelaic acid, benzoyl peroxide, or topical retinoids). This will prevent acne from returning (2) by resolving microcomedones and preventing new microcomedones from forming. Failing to continue treatment after clearing up is the main reason for acne relapse!

The most up-to-date guidelines for acne management, published in 2003, state that as many areas of acne pathogenesis should be targeted as possible by using a combination therapy (2).The targetable factors in acne are (i) overactive sebaceous glands, resulting in sebum overproduction, (ii) change in sebum composition, (iii) hyperkeratinisation, (iv) P. acnes overgrowth in the anaerobic micro-environment created by the keratin plug, and (v)  follicular and perifollicular inflammation.

It is essential to use the treatment each day. Remember, poor compliance is the main cause of treatment failure (1, 2). A large-scale study found adherence with acne therapy was just 50% (3). Poor adherence was associated with side effects, lack of improvement, previous therapy, and lack of knowledge about acne treatment. Educating patient on acne improves adherence (3), which is why I have included extensive information on this website for free. The recommended treatment should not interfere with the patient’s lifestyle (i.e. avoiding sun exposure), else compliance will be low (1).  

When using retinoids, sunscreen must be used to reduce side effects. With all treatments, moisturiser should be applied twice daily. Side effects should be minimised since poor compliance is related to tolerability. Also, combinations should be used as single product to increase convenience. Acne treatments are abandoned prematurely due to slow onset of action, irritation, or inconvenience in use. Instead of multiple topical, they should be in the form of a combination (2, 4, 5).

When applying medication to face, corners of eyes, under eye area, and mouth should be avoided since they are easily irritated. Use a moisturiser to minimise side-effects.

  1. Katsambas AD. Why and when the treatment of acne fails. What to do. Dermatology. 1998;196(1):158-61.
  2. Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003 Jul;49(1 Suppl):S1-37.
  3. Dreno B, Thiboutot D, Gollnick H, Finlay AY, Layton A, Leyden JJ, et al. Large-scale worldwide observational study of adherence with acne therapy. Int J Dermatol. 2010 Apr;49(4):448-56.
  4. Zaghloul SS, Cunliffe WJ, Goodfield MJ. Objective assessment of compliance with treatments in acne. Br J Dermatol. 2005 May;152(5):1015-21.
  5. Katsambas A, Dessinioti C. New and emerging treatments in dermatology: acne. Dermatol Ther. 2008 Mar-Apr;21(2):86-95.

Topical Retinoids

Retinoids bind to retinoic acid receptors (RARs) and retinoic X receptors (RXRs) (1-3), with RARγ being most abundant in keratinocytes (4, 5). Additionally, topical retinoids upregulate nuclear FoxO1 (6).

Retinoids are effective against inflammatory and non-inflammatory acne (7), since they target hyperkeratinisation and inflammation

Indications

Monotherapy with topical retinoids is recommended for mild acne. For moderate-to-severe acne, they should be combined. Since retinoids decrease stratum corneum integrity, penetration of other agents into follicular canals is increased.

Hyperkeratinisation

Retinoids suppress microcomedone formation and resolve existing microcomedones by correcting abnormal desquamation seen in acne (4, 8, 9).

They resolve microcomedones by relaxing the cohesiveness of the stratum corneum of the infrainfundibulum by disintegrating desmosomes, promoting desquamation (10), eliminating the horny plug (5). This converts the pilosebaceous unit into an aerobic environment which is non-optimal for P. acnes growth.

They prevent microcomedone formation by decreasing keratinocyte differentiation and proliferation (11) so horny plug does not form.

Inflammation

Retinoids are also anti-inflammatory (12, 13). Retinoids downregulate AP-1 (2), which is partly responsible for the anti-inflammatory activity (4).

Side effects

Prolonged sun exposure should be avoided to minimise side effects, since retinoids increase photosensitivity.

The side-effects of retinoids includes red skin, dryness, itching, stinging. This occurs during the first month (14) but decrease over time. Initial acne breakout is also common, since treatment releases follicular inflammatory factors (15).

  1. References
    1. Kang S. The mechanism of action of topical retinoids. Cutis. 2005 Feb;75(2 Suppl):10,3; discussion 13.
    2. Krautheim A, Gollnick HP. Acne: topical treatment. Clin Dermatol. 2004 Sep-Oct;22(5):398-407.
    3. Shalita AR, Chalker DK, Griffith RF, Herbert AA, Hickman JG, Maloney JM, et al. Tazarotene gel is safe and effective in the treatment of acne vulgaris: a multicenter, double-blind, vehicle-controlled study. Cutis. 1999 Jun;63(6):349-54.
    4. Bikowski JB. Mechanisms of the comedolytic and anti-inflammatory properties of topical retinoids. J Drugs Dermatol. 2005 Jan-Feb;4(1):41-7.
    5. Chivot M. Retinoid therapy for acne. A comparative review. Am J Clin Dermatol. 2005;6(1):13-9.
    6. Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009 Oct;18(10):833-41.
    7. Leyden JJ, Shalita A, Thiboutot D, Washenik K, Webster G. Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment. Clin Ther. 2005 Feb;27(2):216-24.
    8. Thielitz A, Sidou F, Gollnick H. Control of microcomedone formation throughout a maintenance treatment with adapalene gel, 0.1%. J Eur Acad Dermatol Venereol. 2007 Jul;21(6):747-53.
    9. Lavker RM, Leyden JJ, Thorne EG. An ultrastructural study of the effects of topical tretinoin on microcomedones. Clin Ther. 1992 Nov-Dec;14(6):773-80.
    10. Hatakeyama S, Hayashi S, Yoshida Y, Otsubo A, Yoshimoto K, Oikawa Y, et al. Retinoic acid disintegrated desmosomes and hemidesmosomes in stratified oral keratinocytes. J Oral Pathol Med. 2004 Nov;33(10):622-8.
    11. Marcelo CL, Madison KC. Regulation of the expression of epidermal keratinocyte proliferation and differentiation by vitamin A analogs. Arch Dermatol Res. 1984;276(6):381-9.
    12. Jones DA. The potential immunomodulatory effects of topical retinoids. Dermatol Online J. 2005 Mar 1;11(1):3.
    13. Wolf JE,Jr. Potential anti-inflammatory effects of topical retinoids and retinoid analogues. Adv Ther. 2002 May-Jun;19(3):109-18.
    14. Akhavan A, Bershad S. Topical acne drugs: review of clinical properties, systemic exposure, and safety. Am J Clin Dermatol. 2003;4(7):473-92.
    15. Spellman MC, Pincus SH. Efficacy and safety of azelaic acid and glycolic acid combination therapy compared with tretinoin therapy for acne. Clin Ther. 1998 Jul-Aug;20(4):711-21.

Adapalene

  • Hyperkeratinisation
  • Sebum oxidation
  • Bacteria
  • Inflammation
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Adapalene
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Tretinoin

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Tretinoin
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Isotretinoin

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Isotretinoin

You may be surprised to find out that it’s the skin, which you might not think of as an organ. It has a total area of 22 square feet in adults, weighing approximately 5 kilograms! 

So why do we require all this skin? Aside from keeping our bones, muscles and organs nicely tucked away, it plays a number of vital functions which we simply could not survive without. It protects us against UV light, dehydration and invasion by micro-organisms, allows us to have a sense of touch, is involved in regulating our core body temperature, acts as a water-barrier and is essential for the production of vitamin D.

  1. References
    1. Kang S. The mechanism of action of topical retinoids. Cutis. 2005 Feb;75(2 Suppl):10,3; discussion 13.
    2. Krautheim A, Gollnick HP. Acne: topical treatment. Clin Dermatol. 2004 Sep-Oct;22(5):398-407.
    3. Shalita AR, Chalker DK, Griffith RF, Herbert AA, Hickman JG, Maloney JM, et al. Tazarotene gel is safe and effective in the treatment of acne vulgaris: a multicenter, double-blind, vehicle-controlled study. Cutis. 1999 Jun;63(6):349-54.
    4. Bikowski JB. Mechanisms of the comedolytic and anti-inflammatory properties of topical retinoids. J Drugs Dermatol. 2005 Jan-Feb;4(1):41-7.
    5. Chivot M. Retinoid therapy for acne. A comparative review. Am J Clin Dermatol. 2005;6(1):13-9.
    6. Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009 Oct;18(10):833-41.
    7. Leyden JJ, Shalita A, Thiboutot D, Washenik K, Webster G. Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment. Clin Ther. 2005 Feb;27(2):216-24.
    8. Thielitz A, Sidou F, Gollnick H. Control of microcomedone formation throughout a maintenance treatment with adapalene gel, 0.1%. J Eur Acad Dermatol Venereol. 2007 Jul;21(6):747-53.
    9. Lavker RM, Leyden JJ, Thorne EG. An ultrastructural study of the effects of topical tretinoin on microcomedones. Clin Ther. 1992 Nov-Dec;14(6):773-80.
    10. Hatakeyama S, Hayashi S, Yoshida Y, Otsubo A, Yoshimoto K, Oikawa Y, et al. Retinoic acid disintegrated desmosomes and hemidesmosomes in stratified oral keratinocytes. J Oral Pathol Med. 2004 Nov;33(10):622-8.
    11. Marcelo CL, Madison KC. Regulation of the expression of epidermal keratinocyte proliferation and differentiation by vitamin A analogs. Arch Dermatol Res. 1984;276(6):381-9.
    12. Jones DA. The potential immunomodulatory effects of topical retinoids. Dermatol Online J. 2005 Mar 1;11(1):3.
    13. Wolf JE,Jr. Potential anti-inflammatory effects of topical retinoids and retinoid analogues. Adv Ther. 2002 May-Jun;19(3):109-18.
    14. Akhavan A, Bershad S. Topical acne drugs: review of clinical properties, systemic exposure, and safety. Am J Clin Dermatol. 2003;4(7):473-92.
    15. Spellman MC, Pincus SH. Efficacy and safety of azelaic acid and glycolic acid combination therapy compared with tretinoin therapy for acne. Clin Ther. 1998 Jul-Aug;20(4):711-21.

Isotretinoin (Oral)

  • Hyperkeratinisation
  • Sebum oxidation
  • Bacteria
  • Inflammation
Side effects
Clindamycin
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Topical Antibiotics

You may be surprised to find out that it’s the skin, which you might not think of as an organ. It has a total area of 22 square feet in adults, weighing approximately 5 kilograms! 

So why do we require all this skin? Aside from keeping our bones, muscles and organs nicely tucked away, it plays a number of vital functions which we simply could not survive without. It protects us against UV light, dehydration and invasion by micro-organisms, allows us to have a sense of touch, is involved in regulating our core body temperature, acts as a water-barrier and is essential for the production of vitamin D.

  1. References
    1. Kang S. The mechanism of action of topical retinoids. Cutis. 2005 Feb;75(2 Suppl):10,3; discussion 13.
    2. Krautheim A, Gollnick HP. Acne: topical treatment. Clin Dermatol. 2004 Sep-Oct;22(5):398-407.
    3. Shalita AR, Chalker DK, Griffith RF, Herbert AA, Hickman JG, Maloney JM, et al. Tazarotene gel is safe and effective in the treatment of acne vulgaris: a multicenter, double-blind, vehicle-controlled study. Cutis. 1999 Jun;63(6):349-54.
    4. Bikowski JB. Mechanisms of the comedolytic and anti-inflammatory properties of topical retinoids. J Drugs Dermatol. 2005 Jan-Feb;4(1):41-7.
    5. Chivot M. Retinoid therapy for acne. A comparative review. Am J Clin Dermatol. 2005;6(1):13-9.
    6. Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009 Oct;18(10):833-41.
    7. Leyden JJ, Shalita A, Thiboutot D, Washenik K, Webster G. Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment. Clin Ther. 2005 Feb;27(2):216-24.
    8. Thielitz A, Sidou F, Gollnick H. Control of microcomedone formation throughout a maintenance treatment with adapalene gel, 0.1%. J Eur Acad Dermatol Venereol. 2007 Jul;21(6):747-53.
    9. Lavker RM, Leyden JJ, Thorne EG. An ultrastructural study of the effects of topical tretinoin on microcomedones. Clin Ther. 1992 Nov-Dec;14(6):773-80.
    10. Hatakeyama S, Hayashi S, Yoshida Y, Otsubo A, Yoshimoto K, Oikawa Y, et al. Retinoic acid disintegrated desmosomes and hemidesmosomes in stratified oral keratinocytes. J Oral Pathol Med. 2004 Nov;33(10):622-8.
    11. Marcelo CL, Madison KC. Regulation of the expression of epidermal keratinocyte proliferation and differentiation by vitamin A analogs. Arch Dermatol Res. 1984;276(6):381-9.
    12. Jones DA. The potential immunomodulatory effects of topical retinoids. Dermatol Online J. 2005 Mar 1;11(1):3.
    13. Wolf JE,Jr. Potential anti-inflammatory effects of topical retinoids and retinoid analogues. Adv Ther. 2002 May-Jun;19(3):109-18.
    14. Akhavan A, Bershad S. Topical acne drugs: review of clinical properties, systemic exposure, and safety. Am J Clin Dermatol. 2003;4(7):473-92.
    15. Spellman MC, Pincus SH. Efficacy and safety of azelaic acid and glycolic acid combination therapy compared with tretinoin therapy for acne. Clin Ther. 1998 Jul-Aug;20(4):711-21.

Clindamycin

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  • Sebum oxidation
  • Bacteria
  • Inflammation
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Erythromycin

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Anti-Androgenic Contraceptives

Anti-androgenic contraceptives is not used as monotherapy. It is used for female patients with moderate or severe acne.

  1. References
    1. Kang S. The mechanism of action of topical retinoids. Cutis. 2005 Feb;75(2 Suppl):10,3; discussion 13.
    2. Krautheim A, Gollnick HP. Acne: topical treatment. Clin Dermatol. 2004 Sep-Oct;22(5):398-407.
    3. Shalita AR, Chalker DK, Griffith RF, Herbert AA, Hickman JG, Maloney JM, et al. Tazarotene gel is safe and effective in the treatment of acne vulgaris: a multicenter, double-blind, vehicle-controlled study. Cutis. 1999 Jun;63(6):349-54.
    4. Bikowski JB. Mechanisms of the comedolytic and anti-inflammatory properties of topical retinoids. J Drugs Dermatol. 2005 Jan-Feb;4(1):41-7.
    5. Chivot M. Retinoid therapy for acne. A comparative review. Am J Clin Dermatol. 2005;6(1):13-9.
    6. Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009 Oct;18(10):833-41.
    7. Leyden JJ, Shalita A, Thiboutot D, Washenik K, Webster G. Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment. Clin Ther. 2005 Feb;27(2):216-24.
    8. Thielitz A, Sidou F, Gollnick H. Control of microcomedone formation throughout a maintenance treatment with adapalene gel, 0.1%. J Eur Acad Dermatol Venereol. 2007 Jul;21(6):747-53.
    9. Lavker RM, Leyden JJ, Thorne EG. An ultrastructural study of the effects of topical tretinoin on microcomedones. Clin Ther. 1992 Nov-Dec;14(6):773-80.
    10. Hatakeyama S, Hayashi S, Yoshida Y, Otsubo A, Yoshimoto K, Oikawa Y, et al. Retinoic acid disintegrated desmosomes and hemidesmosomes in stratified oral keratinocytes. J Oral Pathol Med. 2004 Nov;33(10):622-8.
    11. Marcelo CL, Madison KC. Regulation of the expression of epidermal keratinocyte proliferation and differentiation by vitamin A analogs. Arch Dermatol Res. 1984;276(6):381-9.
    12. Jones DA. The potential immunomodulatory effects of topical retinoids. Dermatol Online J. 2005 Mar 1;11(1):3.
    13. Wolf JE,Jr. Potential anti-inflammatory effects of topical retinoids and retinoid analogues. Adv Ther. 2002 May-Jun;19(3):109-18.
    14. Akhavan A, Bershad S. Topical acne drugs: review of clinical properties, systemic exposure, and safety. Am J Clin Dermatol. 2003;4(7):473-92.
    15. Spellman MC, Pincus SH. Efficacy and safety of azelaic acid and glycolic acid combination therapy compared with tretinoin therapy for acne. Clin Ther. 1998 Jul-Aug;20(4):711-21.

Contraceptives

  • Hyperkeratinisation
  • Sebum oxidation
  • Bacteria
  • Inflammation
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Antimicrobials

Topical antimicrobial monotherapy is not recommended for acne. Instead, antimicrobials should be combined with topical retinoids, benzoyl peroxide or azelaic acid for mild to moderate acne.

In women with moderate acne, topical antimicrobials should be used alongside hormonal anti-androgens (in mild acne antiandrogen contraceptives are not prescribed).

Topical antimicrobial is applied twice a day and treatment should last 12 weeks.

  1. References
    1. Kang S. The mechanism of action of topical retinoids. Cutis. 2005 Feb;75(2 Suppl):10,3; discussion 13.
    2. Krautheim A, Gollnick HP. Acne: topical treatment. Clin Dermatol. 2004 Sep-Oct;22(5):398-407.
    3. Shalita AR, Chalker DK, Griffith RF, Herbert AA, Hickman JG, Maloney JM, et al. Tazarotene gel is safe and effective in the treatment of acne vulgaris: a multicenter, double-blind, vehicle-controlled study. Cutis. 1999 Jun;63(6):349-54.
    4. Bikowski JB. Mechanisms of the comedolytic and anti-inflammatory properties of topical retinoids. J Drugs Dermatol. 2005 Jan-Feb;4(1):41-7.
    5. Chivot M. Retinoid therapy for acne. A comparative review. Am J Clin Dermatol. 2005;6(1):13-9.
    6. Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009 Oct;18(10):833-41.
    7. Leyden JJ, Shalita A, Thiboutot D, Washenik K, Webster G. Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment. Clin Ther. 2005 Feb;27(2):216-24.
    8. Thielitz A, Sidou F, Gollnick H. Control of microcomedone formation throughout a maintenance treatment with adapalene gel, 0.1%. J Eur Acad Dermatol Venereol. 2007 Jul;21(6):747-53.
    9. Lavker RM, Leyden JJ, Thorne EG. An ultrastructural study of the effects of topical tretinoin on microcomedones. Clin Ther. 1992 Nov-Dec;14(6):773-80.
    10. Hatakeyama S, Hayashi S, Yoshida Y, Otsubo A, Yoshimoto K, Oikawa Y, et al. Retinoic acid disintegrated desmosomes and hemidesmosomes in stratified oral keratinocytes. J Oral Pathol Med. 2004 Nov;33(10):622-8.
    11. Marcelo CL, Madison KC. Regulation of the expression of epidermal keratinocyte proliferation and differentiation by vitamin A analogs. Arch Dermatol Res. 1984;276(6):381-9.
    12. Jones DA. The potential immunomodulatory effects of topical retinoids. Dermatol Online J. 2005 Mar 1;11(1):3.
    13. Wolf JE,Jr. Potential anti-inflammatory effects of topical retinoids and retinoid analogues. Adv Ther. 2002 May-Jun;19(3):109-18.
    14. Akhavan A, Bershad S. Topical acne drugs: review of clinical properties, systemic exposure, and safety. Am J Clin Dermatol. 2003;4(7):473-92.
    15. Spellman MC, Pincus SH. Efficacy and safety of azelaic acid and glycolic acid combination therapy compared with tretinoin therapy for acne. Clin Ther. 1998 Jul-Aug;20(4):711-21.

Benzoyl Peroxide

  • Hyperkeratinisation
  • Sebum oxidation
  • Bacteria
  • Inflammation
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Azelaic Acid
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Azelaic Acid

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Salicylic Acid

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Glycolytic Acid

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Glycolic Acid
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Sulphur

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Sulphur
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Tea Tree Oil

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