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The treatment of acne

The treatment of acne

Acne is an inflammatory disorder of pilosebaceous units and is prevalent in adolescence. The characteristic lesions are open (black) and closed (white) comedones, inflammatory papules, pustules, nodules, and cysts, which may lead to scarring and pigmentary changes.

Acne is a very common disease among adolescents and young adults but can persist into adulthood. Nearly 85% of teenagers are affected by acne at some point during their teenage years

Acne vulgaris has a substantial impact on a patient’s quality of life, affecting both self-esteem and psychosocial development.

There are 4 grades of severity in acne depending on the clinical manifestations.

Grade 1, is the mild form – open and closed comedones with few inflammatory papules and pustules.

Grade 2, the moderate form – papules and pustules, mainly on the face.

Grade 3, the moderately severe form – numerous papules and pustules, and occasional inflamed nodules, also on chest and back.

Grade 4, the severe form – many large, painful nodules and pustules.


The diagnosis of acne vulgaris is primarily clinical. History and physical examination can help determine if there is an underlying cause of the acne.


Treatment for acne vulgaris should aim to reduce severity and recurrences of skin lesions as well as to improve appearance. The approach depends on the severity of the acne, the treatment preferences and age of the patient, and adherence and response to previous therapy.


Topical therapy is the standard of care for mild to moderate acne. Such treatments are active at application sites, and they can prevent new lesions. The main side effect is local irritation. Gels, pledges (medication-soaked pads), washes, and solutions tend to be drying and are helpful for oily skin. Lotions, creams, and ointments are beneficial for dry, easily irritated skin. Most topical preparations require at least six to eight weeks before an improvement is seen; they may be used for years as needed.

The most common topical prescription medications for acne are:

Retinoids. Drugs that contain retinoic acids or tretinoin are often useful for moderate acne. These come as creams, gels, and lotions.  The main target of acne treatment is the microcomedone. Such therapy decreases the number of comedones and inflammatory lesions. Topical retinoids increase your skin’s sun sensitivity. They can also cause dry skin and redness, especially in people with skin of color.


Antimicrobials. Topical antimicrobials, including benzoyl peroxide, are effective in treating inflammatory diseases. Benzoyl peroxide is a bactericidal agent that prevents the resistance of P. acnes to antibiotic therapy and has moderate comedolytic and anti-inflammatory properties.


Antibiotics. These work by killing excess skin bacteria and reducing redness and inflammation. The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Topical erythromycin and clindamycin are generally well-tolerated and have been shown to reduce inflammatory lesions. Topical antibiotics alone aren’t recommended.


Azelaic acid and salicylic acid. Azelaic acid is a naturally occurring acid. It has antibacterial properties. Prescription azelaic acid is an option during pregnancy and while breastfeeding. It can also be used to manage discoloration that occurs with some types of acne. Side effects include skin redness and minor skin irritation.


Dapsone.  is recommended for inflammatory acne, especially in women with acne. Side effects include redness and dryness.

Evidence is not strong in support of using zinc, sulfur, nicotinamide, resorcinol, sulfacetamide sodium or aluminum chloride in topical treatments for acne.


Patients with mild acne can be treated with topical therapies; however, those with moderate to severe acne will require systemic therapy.


Oral medications

  • Antibiotics. When topical agents are insufficient or not tolerated, or in cases of moderate to severe acne, especially when the chest, back, and shoulders are involved, systemic antibiotics are often considered the next line of treatment to reduce bacteria. Usually, the first choice for treating acne is a tetracycline (minocycline, doxycycline) or a macrolide (erythromycin, azithromycin). These agents also have inherent anti-inflammatory effects. A macrolide might be an option for people who can’t take tetracyclines, including pregnant women and children under 8 years old.

Oral antibiotics should be used for the shortest time possible to prevent antibiotic resistance. These drugs do increase your skin’s sun sensitivity.


  • Combined oral contraceptives. Four combined oral contraceptives are approved for acne therapy in women who also wish to use them for contraception. They are products that combine progestin and estrogen. Common side effects of combined oral contraceptives are weight gain, breast tenderness, and nausea. These drugs are also associated with an increased risk of cardiovascular problems, breast cancer, and cervical cancer.


  • Anti-androgen agents. The drug spironolactone may be considered for women and adolescent girls if oral antibiotics aren’t helping. It works by blocking the effect of androgen hormones on the oil-producing glands. Possible side effects include breast tenderness and painful periods.


  • Isotretinoin. Isotretinoin is a derivative of vitamin A. It may be prescribed for people whose moderate or severe acne hasn’t responded to other treatments. Isotretinoin affects all causative mechanisms of acne — decreases sebum production, decreases P. acnes colonization, and is anti-inflammatory. Indications for isotretinoin include scarring disease, severe nodulocystic acne, and less than 50% improvement with oral antibiotics or hormonal therapies after four months

Potential side effects of oral isotretinoin include inflammatory bowel disease, depression, and severe birth defects.

You can try to avoid or control mild or moderate acne with nonprescription products, good basic skincare and other self-care techniques:

  • Wash problem areas with a gentle cleanser. Twice a day, use your hands to wash your face with mild soap or gentle and warm water. And be gentle if you’re shaving affected skin. Avoid certain products, such as facial scrubs, astringents, and masks. They tend to irritate the skin, which can worsen acne. Too much washing and scrubbing also can irritate the skin.

Avoid irritants. Oily or greasy cosmetics, sunscreens, hairstyling products, or acne concealers can worsen acne. Instead, use products labeled water-based or noncomedogenic, which means they are less likely to cause acne.

  • Protect your skin from the sun. For some people, the sun worsens the discoloration that sometimes lingers after the acne has cleared. And some acne medications make you more susceptible to sunburn. Regularly use a nonoily (noncomedogenic) moisturizer that includes sunscreen.


  • Avoid friction or pressure on your skin. Protect your acne-prone skin from contact with items such as phones, helmets, tight collars or straps, and backpacks.


  • Avoid touching or picking acne-prone areas. Doing so can trigger more acne or lead to infection or scarring.

Shower after strenuous activities. Oil and sweat on your skin can lead to breakouts.




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