Treating acne

Nobody in this day and age should end up with permanent post-acne scarring.

If your acne has progressed to the deeper, nodulocystic type, you should contact your general practitioner or dermatologist to seek a treatment like isotretinoin (Roaccutane).

As a general principle, consult your doctor as soon as possible to prevent permanent scarring.

If you feel you might be experiencing side effects of the medication that your doctor has prescribed (especially when taking oral antibiotics or oral isotretinoin), you should consult your doctor as soon as you can.

To treat and prevent acne, and to reduce the damage it may cause, your doctor is likely to prescribe one or more of the following:

Topical treatments 

a. Cleansers, moisturisers and sunscreens

Most people with acne have oily skin, so it’s best to cleanse the skin with a mild, foaming cleanser. 

However, some people (with a background history of eczema) may have more sensitive skin. If this is the case, it would be best to use a cream-based cleanser. It’s fine to use a mild toner such as a Micellar water to remove make-up. Note, however, that harsh, abrasive scrubs tend to irritate the skin and aggravate acne.

All moisturisers and sunscreens should be of a light-weight formulation, oil-free and non-comedogenic (doesn’t block pores). Look for "dry touch" sunscreens.

b. Topical retinoids

These are chemicals derived from the vitamin A molecule and include tretinoin, adapelene and retinol. They’re best used in the early stages of acne and are the best topical treatments for blackheads and whiteheads.

The “original” retinoids (e.g. tretinoin) are very effective, but they tend to be more irritating to the skin and therefore can’t be used by everyone. Adapelene and retinol tend to be less irritating.

These products are best used at night and should be introduced to the skin slowly to build up a tolerance. A good idea is to use them at night on a Monday, Wednesday and Friday for at least two weeks. Then, assuming that they’re well tolerated, you can start using them every night.

Tretinoin and adapelene require a prescription from a doctor, whereas topical retinols don’t. It’s generally recommended that these products aren’t used during pregnancy or breastfeeding, as no adequate, well-controlled human studies have proven that they’re safe.

It’s essential to use a high-factor, broad-spectrum sunscreen on a daily basis while using topical retinoids, as they may make your skin more sensitive to the sun.

c. Benzoyl peroxide

This is a very useful agent that kills off the Propiobacterium acnes bacteria that cause the red bumps and pustules typical of acne.

The great advantage of benzoyl peroxide is that it tends to prevent bacterial resistance to antibiotics. It may be used on its own or in combination with topical retinoids or topical antibiotics such as clindamycin.

It’s available in various concentrations, but a popular choice is a 5% benzoyl peroxide gel (Benzac AC 5 Gel), used in the morning as a spot treatment and applied to red bumps and pustules.

The only side effect is that it can bleach clothing and linen. For this reason, it’s important to wash it off your fingers after use. If you use it on your body at night, it’s best to wear an old T-shirt to prevent bleaching your sleepwear or linen.

Most dermatologists consider benzoyl peroxide safe for use during pregnancy and lactation.

d. Azelaic acid

Azelaic acid (Skinoren) helps to unblock pores, and has anti-bacterial as well as anti-inflammatory effects. It’s available in a cream as well as a gel, and is generally well tolerated.

People with acne and darker skin often develop dark spots at the site of the previous pimple – a condition called post-inflammatory hyperpigmentation (PIH). It’s been shown that azelaic acid can lighten this pigmentation.

Azelaic acid is safe to use during pregnancy and lactation.

e. Topical antibiotics

Topical antibiotics help to reduce an overgrowth of bacteria. Unfortunately, there’s increasing bacterial resistance to antibiotics, especially topical erythromycin. This is often why the antibiotic is combined with benzoyl peroxide. A useful combination is clindamycin with benzoyl peroxide (Clindoxyl Gel).

The topical antibiotics are generally deemed to be safe in pregnancy and lactation, especially if used as a spot treatment.

f. Salicylic acid

Salicylic acid is available in many anti-acne products and helps to unblock pores. It’s available in various concentrations and is generally well tolerated.

If salicylic acid is used in a lower concentration (2%), and as a spot treatment only, it’s safe to use during pregnancy.

Systemic treatments

The next step in the treatment of acne (i.e. when acne becomes more inflamed with multiple red bumps and pustules) is systemic treatment (oral medication).

a. Antibiotics

The most commonly prescribed antibiotics are the tetracycline group.

One of the safest and best tetracycline antibiotics is lymecycline (Tetralysal). It’s very effective and has few side-effects. Doxycycline (Cyclidox) is another commonly prescribed antibiotic, but it can cause sensitivity to the sun and upset the gastrointestinal tract.

These antibiotics have an anti-bacterial as well as an anti-inflammatory action on the acne. They should, however, not be used for longer than four months.

Tetracyclines should also not be used during pregnancy or while breastfeeding.

b. Hormonal treatment

All acne is hormonally linked. For this reason, hormonal treatment is especially useful in women who want contraception and also suffer from acne.

Most ordinary, combination-type oral contraceptives are effective in the treatment of milder forms of acne. In slightly more severe forms, it’s useful to combine an oestrogen with an anti-androgen, i.e. a medication that blocks the action of the male hormone testosterone on the skin (Diane 35). Unfortunately, a small percentage of women may put on weight with this hormonal pill.

Women with darker skin should avoid excessive sun exposure and use a high-factor, broad-spectrum sunscreen on a regular basis to prevent the formation of pigmentation or melasma while on this hormonal treatment.

This type of hormonal treatment is just as safe and effective as any other normal combination oral contraceptive pill. It’s also very useful in women with a hormonal imbalance such as polycystic ovarian syndrome (PCOS). These hormonal pills usually regulate the menstrual cycle, improve acne, reduce excessive hair growth on the face, and reduce thinning of the hair on the scalp.

c. Systemic isotretinoin

There’s essentially only one drug that can put acne into remission: isotretinoin (Roaccutane), taken orally.

Isotretinoin is derived from vitamin A and works by means of three mechanisms:

• It reduces sebum production.
• It makes the top layer of the skin, the stratum corneum, less sticky (thus helping to control blackheads).
• It has as an anti-inflammatory action. Nobody in this day and age should end up with permanent scarring from acne. Oral isotretinoin is the best treatment, especially for the more severe forms of acne. It’s also indicated where other treatments have failed.

Isotretinoin is however a powerful drug that needs to be given under supervision, preferably by a healthcare practitioner who is experienced in prescribing the medication. The treatment generally lasts six to eight months. As it makes you more sensitive to the sun, it’s often best to take it during the winter months in South Africa.

Isotretinoin may affect the liver and raise blood cholesterol (although this is rare). For this reason, your doctor will do blood tests before prescribing the medication. It’s essential to either abstain from alcohol or to keep intake to an absolute minimum while on isotretinoin.

It’s also incredibly important not to fall pregnant while taking the medication, as there have been reports of abnormalities in the foetuses of women who took the drug. A pregnancy test should be performed before commencing isotretinoin treatment, and a fertile, sexually active woman must use very effective contraception while on the medication.

Adjunctive treatments

• Oral as well as topical vitamin A products help for open comedones (i.e. blackheads), but will not help for closed comedones or whiteheads.
• Every blackhead and whitehead will eventually become a pimple, so a deep cleanse with comedone extraction by a trained skin therapist is very useful to remove the whiteheads.
• Chemical peels containing glycolic acid or salicylic acid are also useful for the more comedonal acne.
• Various lasers, especially Intense Pulsed Light (IPL), can be useful for treating inflamed acne. The intense, pulsed light acts on the overgrowth of the bacteria in the hair follicle, so it has an anti-inflammatory as well as an anti-bacterial action. This is especially useful in persons reluctant to take antibiotics, those who are allergic to the tetracycline-type antibiotics, or in people who prefer not to take isotretinoin.
• A fairly unique treatment for acne is the Acleara Acne Clearing System (Theraclear). This dual-action treatment combines IPL with a special vacuum action that deep cleanses the pores by extracting blackheads and whiteheads. The IPL is a broadband light that targets porphyrins (a metabolite produced by the P. acne bacteria). In this way, it helps destroy the bacteria, while reducing sebum production. It’s also very effective at reducing erythema (redness). This is a useful treatment in pregnant women who can’t take systemic antibiotics or isotretinoin. The treatment is available at various dermatological practices in South Africa.
• If a person has a few larger, deeper acne cysts, a very useful technique is to inject cortisone into the cysts. This will cause immediate shrinking of the cysts, but has to be done by an experienced doctor, preferably a dermatologist, as you don’t want to inject too much cortisone into the cyst. 

Treatment of post-acne scarring

The more severe types of acne can essentially produce two types of scarring:

1. Raised hypertrophic or keloid scars

These tend to occur along the jawline or upper trunk in men as well as women. They’re usually a complication of the more severe forms of acne and often occur in people who tend to fiddle or pick the acne lesions. In the early stages, a topical silicone gel (Kelocote Gel) may be helpful. But for the more raised keloid scars, a combination of laser with cortisone injections into the keloid scars is best. This will require a number of treatments. But with proper treatment, you should be able to flatten the scar.

2. Depressed or atrophic scar

These sometimes have the appearance of sharp depressions, which dermatologists call “ice pick” scars. These scars are more difficult to treat. Their appearance can be improved, but they may not be completely cleared. Useful treatments include medical micro-needling such as Dermapen, as well as fractional lasers.

Treatment of pigmentation

In people with darker skins and more severe forms of acne, it’s very important to use a lightweight, dry-touch, non-comedogenic, broad-spectrum sunscreen to prevent the formation of brown marks at the site of the acne. This is called post-inflammatory hyperpigmentation (PIH).

Although they’re not scars as such, these brown marks can be very distressing. There are various treatment options available to people with PIH, including topical retinol, kojic acid, arbutin, azelaic acid and, in more severe forms, topical hydroquinone.

Complementary/alternative treatments

There are various naturally derived products that have been proven to help for acne: 

• Topical tea tree oil has been shown to have anti-bacterial and anti-inflammatory effects. It has a fairly slow onset of action, and a small percentage of people develop an allergic reaction to the tea tree oil.
• Gluconolactone is a polyhydroxy acid derived from a naturally occurring yeast. This has been shown to help for acne, thanks to its anti-inflammatory effects.
• A 2% lotion of green tea, applied topically, has also been shown to be useful in mild acne. Green tea has anti-bacterial and anti-inflammatory properties.

Many of the above naturally occurring products are found in various concentrations in cosmeceuticals. These are available over the counter without a prescription.

Acne treatments in pregnancy

Acne often improves during the first trimester, but may worsen during the third trimester of pregnancy – a result of an increase in maternal male hormone concentrations.

Dermatologists recommend cleansing the skin with a gentle cleanser, and to avoid harsh scrubs. Cleansers containing low concentrations of salicylic acid (2.0%) and glycolic acid are considered safe during pregnancy. 

Topical products that can be used safely as a spot treatment, according to the American Academy of Dermatology, include topical erythromycin, topical clindamycin, azelaic acid, 2% salicylic acid, and 5% benzoyl peroxide.

Even though the package inserts in many of these anti-acne products state that their safety during pregnancy hasn’t been established, they are deemed safe to use by authorities like the American Academy of Dermatology and the Food and Drug Administration (FDA).

The following products should not be used in pregnancy or while breastfeeding:

• Topical retinoids, i.e. tretinoin, retinol, adapelene
• Topical isotretinoin (Isotrex Gel)
• Oral tetracyclines
•  Oral hormonal treatments
• Oral isotretinoin (Roaccutane)

Gentle chemical peels containing a low concentration of glycolic acid are generally considered safe in pregnancy. Glycolic acid is an FDA Pregnancy Category N drug, i.e. it hasn’t been rated by the American Food and Drug Administration.

An excellent treatment for acne in pregnancy and during breastfeeding is dual-action Acleara Acne Clearing System (Theraclear). Read more about this treatment under the “Adjunctive treatments” section above.

If you have a darker skin type, or if you tend to pick at your acne lesions, you’ll be more prone to post-inflammatory hyperpigmentation (PIH) in pregnancy. It’s therefore very important to be meticulous about using a high-factor, broad-spectrum sunscreen that doesn’t clog pores. Go for non-comedogenic, dry-touch formulations.

Practical steps for managing acne

• Use a mild, foaming cleanser that has been formulated for oily, acne-prone skin.
• Don’t over-cleanse and don’t use harsh scrubs or exfoliators.
• Avoid heavy make-up and don’t use rich, greasy skin products.
• Choose moisturisers, sunscreens and make-up that display the words “oil-free” or “non-comedogenic” on their labels.
• Use “dry-touch” sunscreens for a matt finish that controls oil and shine.
• A tinted, dry-touch sunscreen will help to reduce the visibility of any imperfections on the skin.
• If you’re a woman, and you experience any symptoms or signs of a hormonal imbalance, you should consult your GP or gynaecologist as soon as possible.
• If you have a strong family history of severe acne, your acne might start at a younger age and go on for longer. Consult your GP or dermatologist as soon as possible.
• Check whether the medication you’re currently using could be making your acne worse.
• Acne is treatable. If in doubt, consult your healthcare practitioner.

Read more: Preventing acne

Reviewed by specialist dermatologist, Dr Ian Webster, MBChB (UCT) FF DERM (SA), February 2018

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