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Prescription and Non-Prescription Products for Acne

Question
There are many prescription and non prescription products for treating acne, including combination products. What do you recommend?

Answer
I use a treatment method that emphasizes good basic skin care and a stepwise approach to prescribing medications for the treatment of acne. When seeing new patients with acne, I usually start by reviewing the over-the-counter (OTC) products that they use, and making these skin care suggestions:

• Use a gentle cleanser with an alpha- or beta-hydroxy acid to soften and dissolve the clogged pore. Neutrogena Oil-Free Acne Wash , which contains 2% salicylic acid, is effective; several other excellent brands are available, including Clean & Clear Continuous Control Acne Wash , Oil Free and pHisoderm Anti-Blemish Body Wash . I am frequently asked about the Proactiv Acne System and similar products, such as Klear Action Acne Treatment System and Neutrogena Advanced Solutions Complete Acne Therapy System . These products are similar but expensive, and I believe that the same basic skin care can be achieved with less costly products.
  
  
• Wash the face gently, only twice a day. Acne isn't caused by dirt or oil on the surface of the skin, but by clogged oil glands.
  
  
• Throw out astringents (which are mostly alcohol), exfoliants, microdermabrasion devices, or any product that says "scrub" on the label. These products only aggravate the oil glands.
  
  
• After washing, apply a benzoyl peroxide aqueous gel (no creams or lotions). Benzoyl peroxide kills Propionibacterium acnes , the microorganisms that multiply in clogged follicles.

It is best to get to the root of the acne early in the course of treatment. Acne can be viewed as a consequence of irritated oil glands. The source of this irritation is testosterone, a hormone produced by both sexes. This hormone causes an enlargement of the oil glands and clogging of the pores. Redness, inflammation, open or closed comedones, and cysts are then caused by this mechanical blockage of the pilosebaceous units and by secondary infection with P acnes . One of the best treatments to calm these irritated oil glands is a retinoid. Topical retinoids, in order of weakest to strongest, include adapalene ( Differin ), tretinoin (either Avita or Retin-A ), or tazarotene ( Tazorac ). The patient should apply the topical retinoid to a dry face at bedtime, waiting at least 30 minutes after washing in order to minimize irritation. Retinoid products should be used every night at bedtime, but I recommend starting with an every-other-night regimen for the first 2 weeks to allow the skin to get used to the medication.

The combination of a cleanser and a prescription topical retinoid will treat most of the mild-to-moderate cases of acne. If there are signs of secondary infection, such as pustules, I recommend replacing the benzoyl peroxide gel with clindamycin or erythromycin topical gels or solutions. If signs of deep infections (cysts or nodules) are present, I prescribe an oral tetracycline (doxycycline 100 mg twice daily, or minocycline 100 mg twice daily) or erythromycin 500 mg twice daily if the patient can't tolerate tetracyclines. I have had some success with sulfamethoxazole/trimethoprim in patients who cannot tolerate routine antimicrobials.

Each time you start a new medication, you must have patience to wait 4-6 weeks to see a result. Female patients should also know that if they become pregnant or are attempting pregnancy, they should discontinue all tetracyclines and retinoids.

If you are agreeable to using birth control medications, a female patient with acne may wish to consider the use of an oral contraceptive to suppress androgen production. This adjunct therapy works well for some women who experience flare-ups of acne associated with their menstrual cycles. The best oral contraceptives to prescribe for acne are those with low-androgen activity. A drospirenone-containing pill ( Yasmin or Yaz ) actively blocks testosterone-binding sites in a matter that is similar to spironolactone.

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