Acne––What is it?
Acne is a chronic inflammatory skin condition of variable severity. Acne typically appears on your face, forehead, chest, upper back and shoulders. These areas of skin have the most hair follicles that are connected to the sebaceous glands that produce oily sebum. Acne causes one or more of the following:

• Whiteheads – bulging closed hair follicle pores clogged with bacteria, dead skin and sebum
• Blackheads – open hair follicle pores, clogged with bacteria, dead skin and sebum that turns black
• Papules – small red, tender bumps
• Pustules – pimples which are papules with pus at their tips that develop when blocked hair follicles become inflamed or infected with bacteria
• Nodules – large, solid, painful lumps beneath the surface of the skin
• Cystic lesions – painful, pus-filled lumps beneath the surface of the skin

Although acne is a benign condition, it can affect your health in several ways including your appearance, pain and discomfort, permanent scarring, depression, anxiety, and poor self-esteem.

Who gets it?
Acne affects 85% of all adolescents and about 12% of adult women. About 50 million people in the United States have acne at any one time. Risk factors for acne include:

• Age – People of all ages can get acne, but it's most common in teenagers.
• Hormonal changes – As they occur in teenagers, and in the menstrual cycle of girls and women.
• Family history – If both parents had acne, you're more likely to get it too.
• Contact with greasy or oily substances – Acne may develop where your skin comes into contact with oily lotions and creams or with grease in a work area, such as a kitchen with fry vats.
• Friction or pressure on your skin– Contact with items such as telephones, cellphones, helmets, tight collars and backpacks.

What causes acne?
Four main factors cause acne:

• Excess sebum production
• Hair follicles clogged by sebum and dead skin cells
• Bacteria in sebaceous glands (the Proprionibacterium acnes bacterium)
• Activity of androgens, such as testosterone, a type of hormone found in both men and women that increases in adolescence and stimulates sebum production,

These factors can trigger or aggravate acne:

• Hormones – Hormonal changes related to menstruation, pregnancy and the use of oral contraceptives can affect sebum production.
• Certain medications – Examples include drugs containing corticosteroids, testosterone or lithium.
• Diet – Studies indicate that skim milk and carbohydrate-rich foods — such as bread, bagels and chips — and perhaps chocolate may worsen acne, but the evidence is weak and further study of diet is needed.
• Stress – Stress can make acne worse.

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

• Wash problem areas with a gentle cleanser – Gently wash your face twice a day with a mild soap and warm water. If you tend to develop acne around your hairline, shampoo your hair every day.
• Avoid certain products – Avoid products that may irritate the skin, such as facial scrubs, astringents and masks. Excessive washing and scrubbing also can irritate the skin.
• Avoid irritants – Avoid oily or greasy cosmetics, sunscreens, hairstyling products or acne concealers. 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 acne. Regularly use a non-oily (noncomedogenic) moisturizer that includes a sunscreen. And if your doctor has prescribed a tetracycline antibiotic for acne it may cause photosensitivity and you may need to stay out of the sun as much as possible.
• 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 at the problem 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.

Treatments you can undertake yourself
To treat mild to moderate acne or periodic breakouts, many over-the-counter (OTC) acne products are available without a doctor’s prescription. They include cleansing lotions, gels, foams and towelettes, leave-on products, and treatments or kits.

The Food and Drug Administration warns that some popular OTC acne products can cause a serious reaction. This type of reaction is quite rare, it is not  the redness, irritation or itchiness that may occur where you've applied such products. Seek emergency medical help if after using a skin product if you experience difficulty breathing, faintness, throat tightness and swelling of the face, lips or tongue.

Active ingredients in acne products
OTC acne products work in different ways. Some work by killing the bacteria that cause acne inflammation. Others remove excess oil from the skin or speed up the growth of new skin cells and the removal of dead skin cells. Some acne products do a combination of these things.
Here are common active ingredients found in OTC acne products and how they work to treat acne.

• Start with Benzoyl peroxide – This ingredient kills the bacteria that cause acne, helps remove excess oil from the skin and removes dead skin cells, which can clog pores. OTC benzoyl peroxide products are available in strengths from 2.5 to 10 percent. Give it a few days before expecting to see results. Check product labels for the type and amount of its active ingredient. Stronger isn't always better with benzoyl peroxide. In some cases, a 2% or 2.5% product works as well as those with stronger concentrations — and with fewer side effects. Possible side effects include dry skin, scaling, redness, burning and stinging, especially if you have sensitive skin. Be careful when applying benzoyl peroxide, as it can bleach hair and clothing.
• Alpha hydroxy acids – Two types of alpha hydroxy acids that are used in nonprescription acne products are glycolic acid and lactic acid. Alpha hydroxy acids treat acne by helping to remove dead skin cells and reduce inflammation. Alpha hydroxy acids also stimulate the growth of new, smoother skin. This helps improve the appearance of acne scars and gives the impression of smaller pores.

These are found in over-the-counter acne treatments but are not well proven to be effective:

• Salicylic acid – This ingredient helps prevent pores from becoming plugged. OTC salicylic acid products are available in strengths from 0.5 to 5 percent. Possible side effects include mild stinging and skin irritation.
• Sulfur – Sulfur removes dead skin cells that clog pores and helps remove excess oil. It's often combined with other ingredients, such as salicylic acid, benzoyl peroxide or resorcinol. Products containing sulfur may cause dry skin. And some products have an unpleasant odor.

Of the various topical agents, the American Academy of Dermatology (AAD) considers that there is little or no evidence that these products marketed by prescription or over the counter are effective as a therapy for acne: azelaic acid, dapsone, salicylic acid, sulfur, nicotinamide, resorcinol, sodium sulfacetamide, aluminum chloride, and zinc.

Choosing an effective acne product
Acne products are just one part of a good skin care routine. When using acne products:

• Wash problem areas twice daily – Use a gentle non-soap cleanser and don't overdo it. Excessive washing and scrubbing can worsen acne.
• Try cleansing cloths or towelettes – These are gentle alternatives to cleansers and washes. Cloths with an open weave are good for dry, sensitive skin. Cloths with a tighter weave are better at removing dead skin cells.
• Consider pore-clearing adhesive pads – These products (Biore Deep Cleansing Pore Strips, others) are intended to remove dirt, oil and plugs from pores. You apply the strip to wet skin, let it dry and then peel it off. Further study is needed to prove their use in treating and preventing acne. Don't use them more than once every three days.
• Don't use too much – Apply just enough acne product to cover the problem areas and apply it just after cleansing the skin. Some cloths and towelettes come with benzoyl peroxide and other active ingredients in them, so you don't need to apply more product with these active ingredients after cleansing.
• Use an oil-free, water-based moisturizer – This helps alleviate dry, peeling skin.
• Avoid oily cosmetics, sunscreens and hair products – Use products labeled water-based or noncomedogenic.
• Don't pick or squeeze blemishes – Infection or scarring may result.
• Watch what touches your face – Keep your hair clean and off your face. Also avoid resting your hand or phone against the side of your face
• Don’t be too rough with your skin – Scrubbing too hard or using harsh products such as astringents and masks can worsen acne.
• Touching your face – Keep your hands, phone and hair away from your face. Too much contact can cause flare-ups.

When to see a doctor for acne care
If self-care remedies don't clear your acne, after two or three months of home treatment see your primary care doctor. He or she can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from dermatologist, a doctor who specializes in the care of skin. A dermatologist can help you:

• Control your acne
• Avoid scarring or other damage to your skin
• Make scars less noticeable

Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection or reducing inflammation — which helps prevent scarring. With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely.Talk with your doctor about the risks and benefits of medications and other treatments you are considering.

Topical medications
The most common topical prescription medications for acne are as follows:

• Retinoids and retinoid-like drugs – These come as creams, gels and lotions. Retinoid drugs are derived from vitamin A and include tretinoin (Avita, Retin-A, others), adapalene (Differin) and tazarotene (Tazorac, Avage). You apply this medication in the evening, beginning with three times a week, then daily as your skin becomes used to it. It works by preventing plugging of the hair follicles.
• Antibiotics – These work by killing excess skin bacteria and reducing redness. For the first few months of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the morning and the retinoid in the evening. The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with benzoyl peroxide (Benzaclin, Duac, Acanya) and erythromycin with benzoyl peroxide (Benzamycin). Topical antibiotics alone aren't recommended.
• Dapsone – Dapsone (Aczone) 5 percent gel twice daily is recommended for inflammatory acne, especially in adult females with acne. Side effects include redness and dryness.
• Azelaic acid – Azelaic acid is a naturally occurring acid found in whole-grain cereals and animal products. It has antibacterial properties. A 20% azelaic acid cream seems to be as effective as many conventional acne treatments when used twice a day for at least four weeks. It's even more effective when used in combination with erythromycin. Prescription azelaic acid (Azelex, Finacea) is an option during pregnancy and while breast-feeding. Side effects include skin discoloration and minor skin irritation.
• Salicylic acid – Salicylic acid may help prevent plugged hair follicles and is available as both wash-off and leave-on products. Studies showing its effectiveness are limited.

Evidence is not strong in support of using zinc, sulfur, nicotinamide, resorcinol, sulfacetamide sodium or aluminum chloride in topical treatments for acne.  Of these topical agents the American Academy of Dermatology (ADA) considers that there is evidence that dapsone 5% gel is moderately effective, azelaic acid 20% cream is mildly effective.

Oral medications
For moderate to severe acne, you may need oral antibiotics to reduce bacteria and fight inflammation. Usually the first choice for treating acne is tetracycline — such as minocycline or doxycycline — or a macrolide. Oral antibiotics should be used for the shortest time possible to prevent antibiotic resistance.

Oral antibiotics are best used with topical retinoids and benzoyl peroxide. Studies have found that using topical benzoyl peroxide along with oral antibiotics may reduce the risk of developing antibiotic resistance.

Antibiotics may cause side effects, such as an upset stomach and dizziness. Tetracyclines also increase your skin's sun sensitivity (photosensitivity). Severe adverse reactions to systemic antibiotics used for treating acne are rare. Doxycycline may cause photosensitivity and gastrointestinal disturbances, while minocycline may cause tinnitus, dizziness, and pigment deposit in the skin, mucous membranes, and teeth.

Combined oral contraceptives
Four combined oral contraceptives are approved by the FDA for acne therapy in women who also wish to use them for contraception. They are products that combine estrogen and progestin (Ortho Tri-Cyclen, Yaz, others). You may not see the benefit of this treatment for a few months, so using other acne medications with it the first few weeks may help.

In addition to improving acne, oral contraceptives can lessen menorrhagia (heavy menstrual bleeding) and dysmenorrhea (pain) and reduce the formation of benign ovarian tumors. Estrogen-containing contraceptives are associated with a small increase in blood clots and may have effects on cancer risk, both positive and negative (protective effect against ovarian, colorectal, and endometrial cancers and possible increased risk of breast and cervical cancers).

The most common side effects of oral contraceptives are weight gain, breast tenderness and nausea. A serious potential complication is a slightly increased risk of blood clots.

Don't take birth control pills for acne if you:

• Are pregnant or trying to get pregnant
• Haven't reached puberty
• Are over age 35 and smoke
• Have a history of migraines, especially those with an aura
• Have high blood pressure and vascular disease
• Have a history of heart disease
• Have a history of breast cancer, undiagnosed abnormal uterine bleeding or liver disease
• Have a history of blood clots

Isotretinoin
Isotretinoin (Amnesteem, Claravis, Sotret) is a powerful drug for people whose severe acne doesn't respond to other treatments. It is very effective. But because of its potential side effects, doctors need to closely monitor anyone they treat with this drug. Isotretinoin use is associated with mucocutaneous and ophthalmic dryness and occasional musculoskeletal pain. Elevations of serum cholesterol, triglycerides, and transaminases are occasionally observed; thus, monitoring at baseline and during therapy is recommended.

Despite concerns, a causative relationship between isotretinoin use and inflammatory bowel disease or psychiatric disease (depression, anxiety, mood changes, or suicidal ideation) has not been shown. Potential side effects include ulcerative colitis, an increased risk of depression and suicide, and severe birth defects. Isotretinoin carries such serious risk of side effects that all people receiving isotretinoin must participate in a Food and Drug Administration-approved risk management program called iPLEDGE, to prevent isotretinoin exposure during pregnancy. The iPLEDGE requires a pregnancy test prior to use and use of effective contraception while taking isotretinoin.

Other Therapies
These therapies may be suggested in select cases, either alone or in combination with medications. The American Academy of Dermatology does not consider these other therapies such as chemical peels, light therapy, and laser therapy to have been shown to be effective. And the AAD does not recommend  specific dietary changes for acne management.

• Lasers and photodynamic therapy – A variety of light-based therapies have been tried with some success. But further study is needed to determine the ideal method, light source and dose.
• Chemical peel – This procedure uses repeated applications of a chemical solution, such as salicylic acid, glycolic acid or retinoic acid. This procedure has traditionally been used to lessen the appearance of fine lines, sun damage and minor facial scars. Any improvement in acne is not long lasting, so repeat treatments are usually needed.
• Extraction of whiteheads and blackheads – Your doctor may use special tools to gently remove whiteheads and blackheads (comedos) that haven't cleared up with topical medications. This technique may cause scarring.
• Steroid injection – Nodular and cystic lesions can be treated by injecting a steroid drug directly into them. This therapy has resulted in rapid improvement and decreased pain. Side effects may include thinning in the treated area.
• Anti-androgen agents – The AAD notes that evidence does not support the use of anti-androgens for the treatment of acne. However, the drugs spironolactone (Aldactone) or flutamide may be prescribed for women and adolescent girls if oral antibiotics aren't helping.

Summing up

The benefits of treating acne include reducing discomfort, psychological morbidity, and scarring. The response to therapy usually occurs within 8 to 12 weeks. Topical antibiotics, retinoids and topical acne treatments can result in skin irritation, redness and dryness that may be minimized by decreasing the application frequency from daily to every other or every third day.

Topical therapy must be used continuously to maintain a satisfactory clinical response. Numerous topical vehicles are available. For acne resistant to topical management alone, combined oral contraceptives, isotretinoin, and systemic antibiotics should be considered.
Systemic antibiotics should be used for the shortest duration needed to achieve control of acne. Adherence to complicated or time-intensive regimens can be challenging, but effective acne treatment can improve associated depression, anxiety and poor self-image.

References

Patient Care & Health Information, Acne. The Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/acne/symptoms-causes/syc-20368047
https://www.mayoclinic.org/diseases-conditions/acne/diagnosis-treatment/drc-20368048

Roman CJ, Cifu AS, Stein SL. Management of Acne Vulgaris. Journal of the American Medical Association. 2016;316(13):1402–1403. doi:10.1001/jama.2016.11842

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