Acne & spots

What your doctor can do

Doctors now have some effective treatments to offer, which was not the case a few years ago.

Seeing 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 will prescribe. 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.

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. Tazarotene may be slightly more effective, but can be more irritating..

Antibiotics. Antibiotic creams may contain tetracycline, clindamycin or erythromycin. Some antibiotic creams also contain zinc, benzoyl peroxide or tretinoin, which improves their action. Do not go clubbing with tetracycline cream on your face – it fluoresces under ultraviolet light! 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, but sometimes erythromycin). There are various different types of tetracycline, but they are all equally effective for acne (British Journal of Dermatology 2008;158:208–16). Unfortunately, to be effective, some tetracyclines have to be taken several times a day, 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 (Archives of Dermatology 2003;139:459–464).

Antibiotics have to be taken for at least 6 months; the acne will improve gradually over this period. Benzoyl peroxide should be used at the same time. The treatment may need to continue for 2 years or more until the acne improves of its own accord. Do not stop taking antibiotics suddenly as this may cause a flare–up.

Antibiotics can interfere with the contraceptive pill, so women need to use an additional method of contraception. Also, 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 black skin because it helps to prevent the small dark patches that may follow acne inflammation in black skin (Pulse 2007;3 Oct:49–51).

Hormonal treatment. Women have the option of using hormonal treatment for acne such as Dianette (ethinyloestradiol with cyproterone acetate). This is usually stopped 6 months after the acne has gone. It is a contraceptive pill that blocks the action of the hormone called testosterone (testosterone can encourage the overproduction of sebum). Although it is usually thought of as the ‘lsqumale’ hormone, testosterone also occurs in women’s bodies. Dianette carries a higher risk of thrombosis than ordinary low-dose contraceptive pills, so is usually reserved for severe acne.

Some other contraceotive pills can help to improve acne, such as norgestimate with ethinylestradiol, desogestrel with ethinylestradiol, drospirenone with ethinylestradiol, levonorgestrel with ethinylestradiol (Mims Dermatology 2008;4:34–5). Spironolactone is another hormonal treatment that is sometimes prescribed for older women with acne, but it must not be taken by women who might become pregnant.

Isotretinoin tablets are the best treatment for severe acne, particularly if it is lumpy. For this, your family doctor will need to refer you to a dermatologist. This 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 it are then permanently cured; in the others, acne will reappear over the next 18 months (Clinical Medicine 2005;5:569–72).

Isotretinoin is completely banned if you are pregnant or might become pregnant. It has some side effects, such as reddening and scaling of the skin, lip soreness, and aching muscles and joints. There have been rumours that isotretinoin might cause severe depression, perhaps by interfering with serotonin (the brain’s feel–good chemical). This is possible, but has not been proved (Current Problems in Pharmacovigilance 2006;31:8–9). More research is needed; meanwhile, be aware that depression could be a possible 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, though it is expensive and it is not provided by the National Health Service in the UK. A scientific study (Journal of the American Medical Association 2004;291:2834–9) has concluded that it does not improve acne.

‘Photodynamic therapy’ is claimed to destroy the bacteria that cause, and uses light–sensitising creams to amplify the effect. It also targets the sebaceous (grease) glands. It can provide some initial improvement, but most of the scientific studies of this treatment examined the patients for only the next 3 months, so we do not know whether it is effective long–term and more research is needed (Journal of the European Academy of Dermatology and Venereology 2008;22:267–78).

• Acne & spots – main page
• Why some people get acne
• Common beliefs – true or false
• How you can improve your skin
• Acne and pregnancy
• Scarring
• Useful contacts