Acne: What really works

The Pediatric Insider

© 2013 Roy Benaroch, MD

Mark wrote in about acne: “What products are proven to work? And is it wise to start slathering on the benzoyl peroxide at the first sign of acne in order to *prevent* it from getting worse, or should you just wait until it gets bad before doing anything?”

There are plenty of products that work. The trick often isn’t in choosing which acne treatment—it’s in using whatever’s chosen correctly. We’ll get to that later. But first, the Insider Acne Treatment Roundup:

Topical Benzoyl Peroxide: The grand old man of acne therapy, benzoyl has been around a while, and it’s really the foundation of almost any acne plan. The OTC versions are as good as the prescriptions. For mild acne, Benzoyl works fine alone; for more severe acne, benzoyl is added to other things. Watch out, I’ll bleach your sheets.

Topical antibiotics: These work well for mild-to-moderate acne, and topicals are unlikely to lead to much resistance. Older versions are inexpensive. There seem to always be a few new ones out there, in crazy sorts of variations or vehicles (foam!) that supposedly justify brand-name prices. Don’t fall for that.

Topical retinoids: These are the first-line therapy recommended by dermatologists for all but the most mild acne. They do work, but they can take weeks or longer to make much difference. And many are irritating and drying. There are basically three retinoids out there: adapelene (Differin or generic)—the mildest and least effective; tretinoid (Retin-A and many generics); and tazarotene (Tazorac), the harshest and most effective.

Combo topicals: pick two of any of the above, and someone’s probably put together a combo in one tube. Some of these are really, really expensive—far more expensive than the two separately. Older combos often have affordable generics. Combos probably save a little time, and might help people actually use both products correctly.

Oral antibiotics: they work, but there are more potential side effects and concerns of encouraging antibiotic resistance. The dermatologists officially recommend using them only for the short-term, but then turn around and leave people on them for two years. Go figure.

Oral isotretinoin (Accutane used to be the brand name, a name that’s still used despite the withdrawl of the original product from the market.): Hoo boy this stuff can work, even on the worst scarring acne. But there are many, many potential side effects. Patients have to get repeated blood tests and women & girls have to take contraceptives to avoid the almost-certain occurrence of birth defects if pregnancy occurs on Accutane.

All sorts of washes/scrubs and other OTCs are sold, some under very well known brand names. They do very little to fight acne, and end up irritating the skin. Just wash with a nice mild soap.

And forget about diet. Acne isn’t caused by chocolate or oily food. It has nothing to do with what anyone eats. Or impure thoughts, or sex, or masturbation, or not cleaning your skin. Those are all myths.

Back to using medicines correctly. The crucial step is to use whatever you’re using every single day. Teenagers (and the rest of us, too, honestly) stop using their acne meds as soon as their skin clears up. It’s much more effective to stay on it, every day, to keep acne under control than to start and stop these meds.

And: acne topicals do not have to be used in bulk. Slathering is not encouraged. The best application method is to squeeze out a little pea-sized blob, then use that blob to make little dots on the affected areas of the face. Then spread it around with both hands.

Mark also wanted to know: should acne therapy start when acne is first noticed? That’s a matter of patient preference. Acne that bothers the patient should be treated; any acne that’s scarring or even near-scarring should be treated aggressively. Early treatment can get acne under control, but if your child really isn’t bothered by mild acne, I’m not sure it’s worth pestering her into taking care of it (she won’t use the medicine anyway.)

Effective acne therapy means coming up with a medicine or combination that will work, and convincing the patient to stick with the plan. It may take weeks to reach maximum effect. Sometimes the first regimen doesn’t work, and you have to try something else—there’s no one magic regimen that’s perfect for everyone. But a good pediatrician, family doc, or dermatologist should be able to teach you and your kiddo how to use these meds to keep those zits under control.

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7 Comments on “Acne: What really works”

  1. oldmdgirl Says:

    Is there a reason you didn’t mention combination oral contraceptives.

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  2. Dr. Roy Says:

    I didn’t think of including them, but they can certainly help young women with acne. A few brands are specifically FDA-approved for the treatment of acne, though my understanding is that any of them can help.

    Thanks for the reminder!

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  3. Mark Says:

    This is great info. A few follow-up questions:
    1. Benzoyl peroxide comes in several concentrations. Are the lower concentrations useful, or should one go straight to the more potent stuff?
    2. Other than benzoyl peroxide, it seems the other active ingredient in over-the-counter products is salicylic acid, but I don’t see that mentioned on your list. Is that ingredient effective?
    3. Is there any evidence that acne products can create a lifelong dependence on those products to keep away acne?
    4. It sounds like some of the prescription products (like the topical antibiotics you mentioned) are pretty benign. Does it make sense to go ahead and ask the pediatrician early on for such products, or should one try as long as possible to get by with over-the-counter products?

    Thanks!

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  4. Dr. Roy Says:

    Great questions!

    1. Benzoyl as you go up in concentration becomes modestly more effective, but much more irritating. I like 5% as a “sweet spot” for most kids, to get good benefit without much drying or irritation. People with thicker or oily skin could probably tolerate higher concentrations. Another consideration: high concentrations of benzoyl can bleach skin with prolonged use, which is especially problematic for African-American children.

    2. Salicylates, I don’t like much for acne. Lots of irritation and drying, minimal effectiveness.

    3. Acne products don’t cause dependence in any way that I am aware of.

    4. Personal preference. You do need to keep a “buy-in” from teenagers– if the first product doesn’t work or doesn’t work fairly quickly, they’ll quit and it may be hard to get them to try something else.

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  5. Mindy Says:

    I have a couple of questions/comments. First, can you recommend brands that have 5% benzoyl peroxide? When I went looking for something with low amounts, I think i found one Neutrogina that was 2.5% and everything else it 10%. Second, I disagree that over the counter is the same as prescription. I personally didn’t start having acne issues until I became an adult and I find OTC 10% products to be VERY irritating. However, my prescription 10% Benzac (generic) is much less drying and seems much higher quality. (though it is too strong for my daughter and irritated her skin, thus the quest for lower percentages OTC)

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  6. Dr. Roy Says:

    Mindy, Jan Marini has a big line of products at lots of strengths and styles that I’ve heard good things about. I think you can get those from Amazon or a beauty place like Ulta (probably not at Walgreens.)

    Whether a product is sold OTC or by Rx is entirely a marketing decision– it has nothing whatsoever to do with gentleness or anything objective. The generic Benzac you’ve found will have the same active ingredient as any other 10% benzoyl, but the vehicle may be different– in fact, next time you fill that, you might get a different generic, with yet another different vehicle. If you really like a specific generic, be sure to ask the pharmacist to use the same generic manufacterer next time if possible (tho the chains will buy whichever is cheapest, and may not carry more than 1 generic at a time.) One advantage of buying OTC directly is that you’ll have at least some control over which product you end up with.

    Also: Gels are more drying than creams, which are more drying than lotions, which are more drying than ointments. And: mild acne does well with just a benzoyl peroxide wash.

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