Treatment of acne depends on its severity – mild, moderate or severe.
General principles of treatment
- Acne can be effectively treated, although response may sometimes be slow.
- Where possible, avoid excessively humid conditions such as a sauna, working in an unventilated kitchen or tropical vacations.
- Follow a low-glycaemic, low-protein and low-dairy diet. Avoid protein or amino acid supplements, particularly if they contain leucine. Eat plenty of fresh fruit and vegetables.
- If you smoke, stop. Nicotine increases sebum retention and increased scale within the follicles, forming comedones (blackheads and whiteheads).
- Minimise the application of oils and cosmetics to the affected skin.
- Abrasive skin treatments can aggravate both comedones and inflammatory lesions.
- Try not to scratch or pick the spots.
- Exposure to sunlight filtered through window glass can help – see information about lasers, lights and acne. To avoid sunburn, protect your skin outdoors using a sunscreen and protective clothing.
Management of mild acne
Most patients with mild acne can be treated with topical treatment (gels, solutions and lotions) that can be obtained over-the-counter in New Zealand without prescription. Most people just use topical agents for facial skin as they can be difficult to apply to one's back. Extra vitamins and minerals have not been proved to help.
- Wash affected areas twice daily with a mild cleanser and water or an antiseptic wash.
- Acne products should be applied to all areas affected by acne, rather than just put on individual spots.
- A thin smear should only be applied to dry clean skin at nighttime.
- Acne products may work better if applied in the morning as well.
- They often cause dryness particularly in the first 2–4 weeks of use. This is partly how they work. The skin usually adjusts to this.
- Apply an oil-free moisturiser only if the affected skin is obviously peeling.
- Avoid applying oily cosmetics such as foundation or sunscreen.
- It may take several weeks or even months to see convincing improvement.
- Discontinue using product if severe irritation results. See your doctor for advice.
Suitable topical agents for mild acne that can be obtained without prescription include:
- Antiseptic washes with triclosan or benoyl peroxide (Acnederm wash™, Benzac™ AC Wash, Dalacin™ T Prewash, Oxy™ Daily Skin Wash)
- Mild salicylic acid preparations to exfoliate and unplug the follicles (Neutrogena® Oil-free Acne Wash and many others)
- Benzoyl peroxide cream/lotion/gel (PanOxyl™ Acne Gel, Brevoxyl™ Cream, Oxy-10™, Clearasil™ Ultra Acne Cream, Benzac AC Gel)
- Azelaic acid (Skinoren™ cream, Acnederm™ medicated lotion, Azclear™ Action Lotion)
- Hydrogen peroxide in stabilised cream (Crystacide®, Crystaderm™)
- Tea tree oil products
Topical agents for mild acne which require prescription include:
- Antibiotics, such as clindamycin solution (Topicil™, ClindaTech™) or erythromycin solution (Stiemycin™) and gel (Eryacne™), which are best used with benzoyl peroxide or azelaic acid to reduce the chance of antibiotic resistance
- Retinoids i.e. tretinoin (ReTrieve™, Retin-A™), isotretinoin (Isotrex™), adapalene (Differin™)
Combination prescription topicals include clindamycin / benzoyl peroxide (Duac™) and adapalene/benzoyl peroxide gel (Epiduo™).
Management of moderately severe acne
Treatment for moderately severe acne usually includes the topical agents described above. In addition, oral medication may be prescribed, usually for at least 6 months.
Suitable oral medications include:
- Antibiotics such as tetracycline, minocycline, doxycycline or erythromycin
- In females, oestrogens and antiandrogens such as Diane 35™/Estelle 35™ and/or spironolactone are helpful, particularly if there are signs of hyperandrogenism
- Some patients are helped by nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen but these may not be suitable long-term because of potential adverse effects on stomach and heart
- For resistant or persistent acne, oral isotretinoin may be more suitable
Management of severe acne
Treatment for severe acne requires oral treatment. Patients should be under the care of a dermatologist.
Many patients will be treated with oral isotretinoin.
The following may also be prescribed:
- High dose oral antibiotics for six months or longer
- In females, especially those with polycystic ovary syndrome, oral antiandrogens such as oestrogen/cyproterone or spironolactone may be suitable long-term
- Systemic corticosteroids are sometimes used
Physical treatments for acne
- Sunlight is anti-inflammatory and can help briefly. However, exposure to ultraviolet radiation results in ageing skin and can eventually lead to skin cancer
- Lasers and other light systems using visible light wavengths, appear safe and helpful for acne. Treatment is often delivered twice weekly for four weeks. The effect may be enhanced by use of a photosensitising agent (photodynamic therapy)
- Cryotherapy (freezing treatment) may be useful to control new nodules
- Intralesional steroid injections can be used to shrink older nodules and pseudocysts
- Comedones can be expressed or removed by cautery or diathermy (electrosurgery)
- Microdermabrasion can help mild acne
- Note: X-ray treatment is no longer recommended for acne, as it may cause skin cancer