What your doctor can do about acne and spots
See your doctor about acne
Do not feel shy about seeing your doctor. Most doctors are now sympathetic and helpful to people with acne, and recognize how much psychological distress even acne that is not very severe can cause. Tell your doctor how much your spots are upsetting you.
Getting prompt and effective treatment will lessen the chances of being left with scars. This is really important – acne is usually a temporary problem, but the scars can be permanent.
Do not expect an immediate miracle from the treatment your doctor prescribes. Expect a 20% improvement in 2 months, 40% in 4 months and 80% in 8 months.
Acne treatments usually control rather than cure the condition. This means that if you stop the treatment the acne often reappears, so you may have to continue the treatment for several years to maintain improvement.
Doctors now have some effective treatments to offer, which was not the case a few years ago.
Tretinoin cream/lotion/gel is an effective treatment if blackheads and whiteheads are the main problem, because it unblocks the pores by removing the build-up of dead skin cells. Apply it thinly at bedtime, because it is partly inactivated by light. There is usually a 60% improvement after 3 months’ treatment. In some people, the acne worsens during the first few weeks of treatment, but then improves.
Some peeling and irritation of the skin may occur. If this happens, use a smaller amount or use it less often (for example every other day), or apply it for an hour and then wash it off. Tretinoin can also make your skin sensitive to sunlight, so you should always use an oil-free sunscreen (at least SPF 15) during the day and avoid strong sunlight. Do not apply skin toners, astringents or aftershave to the area. Tretinoin should not be used by women who are pregnant or may become pregnant.
Adapalene and tazarotene are cream or gel treatments that are similar to tretinoin. Like tretinoin, they work for mild-to-moderate acne in which there are blackheads, whiteheads and inflamed spots. The effectiveness of adalpene is similar to tretinoin (60% improvement after 3 months), but it needs to be applied only once a day before bed, and is less irritating than tretinoin.
Antibiotics. Antibiotic creams may contain clindamycin or erythromycin. Some antibiotic creams also contain adapalene, zinc, benzoyl peroxide or tretinoin, which improves their action. Unfortunately, acne bacteria are starting to become resistant to these antibiotics (especially erythromycin).
For moderately severe acne, and especially if the spots are inflamed and angry-looking, the usual treatment is antibiotic tablets (usually tetracyclines). There are various different types of tetracycline tablets. Unfortunately, to be effective, some tetracyclines have to be taken several times a day, before food and not with milk, which can be inconvenient. If you think this will be problematic, ask your doctor if a once-daily tetracycline (such as lymecycline, doxycycline or minocycline) would be suitable for you. If you are taking doxycycline, avoid sunlight or you may get a skin rash. A low dose of doxycycline (20 mg twice a day) is effective.
Oral antibiotics are usually given for 6 weeks in the first instance. At review, as long as they are working, they may be continued for a further 6 weeks. Because of problems with increasing antimicrobial resistance, i.e. more bacgteria developing resistance to antibiotics, there are now treatment guidelines aimed at reducing the duration of antibiotic use in acne. Benzoyl peroxide should be applied to the skin at the same time as using antibiotics as this reduces the chance of the acne bacteria developing resistance to the antibiotic.
Tetracyclines must not be taken during pregnancy, while breastfeeding or by children under 12. Some women develop thrush while taking antibiotics.
Azelaic acid cream is another possibility for mild acne. It discourages bacteria, and has some anti-inflammation and anti-blackhead effects. It is a good treatment for acne in skin of colour because it helps to prevent the small patches of pigment that may follow acne inflammation in skin of colour.
Hormonal treatment. Women have the option of using hormonal treatment for acne such as Dianette (ethinyloestradiol with cyproterone acetate). Dianette is usually stopped once the acne has settled. Dianette blocks the action of the androgen hormones that cause overproduction of sebum. Dianette carries a higher risk of thrombosis than ordinary low-dose contraceptive pills, so only has a licence as a contraceptive in the UK.
Some other contraceotive pills can help to improve acne, such as norgestimate with ethinylestradiol, desogestrel with ethinylestradiol, drospirenone with ethinylestradiol, and levonorgestrel with ethinylestradiol. Spironolactone is a water tablet (diuretic) that is sometimes prescribed for women with acne as it reduces androgen hormones. Spironolactone should be avoided by women who might become pregnant.
Isotretinoin capsules are very effective for severe acne. Your family doctor will usually need to refer you to a dermatologist for consideration and prescribing of isotretinoin. Isotretinoin is usually very effective as it reduces sebum production, clears the build-up of the dead cells that block the pores and reduces inflammation. It is usually given for 4–6 months. Around two-thirds of people who use isotretinoin will have long-term remission; in the others, acne will reappear over the next 18 months.
Isotretinoin must not be used by pregnant women or women who might become pregnant as it can result in serious damage to the unborn fetus. It commonly causes drying effects on the skin, lips and eyes, and can occasionally cause aching muscles and joints. There effects tend to be caused by the dose prescribed, so lowering the dose may relieve some of the side effects. There are concerns that isotretinoin might cause depression, perhaps by interfering with serotonin (the brain's feel-good chemical). More research is needed to understand this potential side effect, as study results are contradictory. Meanwhile, be aware that mood change and depression could be a possible rare effect of isotretinoin.
Freezing/steroid injection. Lumpy cysts can sometimes be treated by freezing with liquid nitrogen or injecting triamcinolone steroid.
Laser treatment with a ‘pulsed-dye’ laser (N-Lite) is being used by some dermatologists, although it is expensive and not provided by the National Health Service in the UK.
Photodynamic therapy (PDT). There are a number of studies examining this novel treatment, which uses a cream or gel to make the skin more sensitive to red and/or blue light, which destroy the bacteria that cause acne. PDT also targets the sebaceous (grease) glands. It can provide some initial improvement, but most studies of this treatment only examined the patients for 3 months, so we do not know whether it is effective in the long term. More research is also needed to compare PDT with other treatments.
Fast Facts medical handbooks are written for doctors, read by patients too.
The new edition of Fast Facts: Acne
by Drs Layton, Thiboutot and Bettoli is out now.
Acne is one of the ten most common diseases worldwide, and the inflammatory skin disease seen most often by family physicians and dermatologists. Fast Facts: Acne provides an overview of all available treatments, including their potential side effects, and advises on the best treatment for all different types of acne.
Written by: Dr Alison Layton
Edited by: Dr Alison Layton
Friday, October 21st 2016
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