Treatments for acne vulgaris

How is acne vulgaris treated?

The choice depends on the types of spots, their severity, previous treatment and the risks of each medicine. A few spots can often be managed with pharmacy treatments. Moderate or severe acne can need a topical medicine combined with tablets. Tell the prescriber what you have already tried, how long you used it and whether it caused side effects. Prescription treatment is not reserved for the most severe cases: acne that is not improving also deserves review.124

What topical treatments help acne vulgaris?

Topical medicines can be enough for mild acne or remain part of treatment when tablets are added. Do not automatically combine several acne products: benzoyl peroxide should be used with other acne treatments only when a doctor or pharmacist has approved the combination. Products that also cause dryness or peeling can add irritation.15

How to start benzoyl peroxide

1. 1Check that the product is suitable for the area you are treating. Some products are for the face only.
2. 2Start with the lowest strength and follow the packet. Benzoyl peroxide is usually used once or twice daily.
3. 3For a leave on gel, wash your hands, gently clean and dry the skin, then apply a thin layer to the affected area.
4. 4For a wash, wet the area, wash with a small amount for 1 to 2 minutes, then rinse and pat dry.
5. 5Wash your hands afterwards.

How long does treatment take?

Most acne treatments take at least 4 to 6 weeks to make a noticeable difference. Oral treatments are commonly taken daily for at least 3 to 6 months. A short trial can therefore end before the medicine has had enough time to help. For benzoyl peroxide, seek advice if acne worsens or has not improved after 12 weeks. Using extra benzoyl peroxide does not make it work faster.15

When are tablets useful?

Oral antibiotics such as doxycycline reduce bacteria and inflammation in moderate to severe acne. They should be combined with benzoyl peroxide or a topical retinoid rather than a topical antibiotic to help limit antibiotic resistance. Hormonal treatment is another option for women, particularly when contraception is also wanted. The combined contraceptive pill can reduce the hormonal drive behind oil production; spironolactone also blocks androgen effects. Its possible side effects include breast pain and menstrual irregularities.14

Isotretinoin reduces oil production and is a very effective option for severe acne, acne causing scars or acne that has not responded to other treatment. Significant effects on social life, work or psychological wellbeing also matter when considering treatment. Dry lips, skin, nose and eyes are common problems, and blood tests can be needed. Isotretinoin must not be taken with tetracycline antibiotics because the combination can raise pressure inside the skull.14

Who should be careful?

Discuss pregnancy or plans to become pregnant before choosing treatment. Isotretinoin causes major birth defects and must not be used during pregnancy or for at least one month before becoming pregnant. Tetracycline antibiotics are also avoided during pregnancy. Benzoyl peroxide can usually be used during pregnancy, but check first. During breastfeeding, check its suitability and do not apply it to the breasts.45

Benzoyl peroxide can cause dry, peeling, itchy or painful skin; using it less often can help. Get advice for persistent or troublesome symptoms. Avoid broken or infected skin and the eyes and mouth. Use sunscreen and avoid prolonged sun exposure. Keep the medicine off hair and fabrics because it can bleach them. Stop using it and get emergency help for difficulty breathing or swelling of the throat or tongue.5

What should the rest of the routine look like?

Wash twice daily with a gentle cleanser and choose skincare and makeup labelled noncomedogenic, meaning designed not to clog pores. Avoid scrubbing, excessive exfoliation and squeezing spots, which can worsen irritation or cause scars. Loose, breathable clothing helps with body acne during sweating or exercise. Evidence that reducing dairy or sugar improves acne is weak, and chocolate or greasy food should not automatically take the blame.123

When should you see a doctor?

Arrange an appointment if self treatment is not helping, you have many spots, deep painful lumps or scarring, or acne affects your mental health. Hot, swollen, red skin can signal infection and also needs assessment; redness can be harder to see on brown or black skin. Severe acne warrants consideration of a dermatologist referral.12

What if acne has already left scars?

Control active acne before starting scar treatment, so new breakouts do not keep creating new scars. Sunken and raised scars need different approaches, and treatment can involve more than one procedure. Options include peels, fillers, lasers, microneedling and scar surgery. Talk through the results you want and your budget before scar treatment, because 'better skin' is not a very detailed brief. Tell the dermatologist about acne medicines used within the past two years, because some affect procedure safety.6

After scar treatment, follow the procedure's specific washing and makeup instructions. Apply a broad spectrum, water resistant sunscreen with SPF 30 or higher every day to treated skin. Scar improvement takes time, and several treatment sessions can be needed. Continue acne treatment as advised to prevent new breakouts and new scars.7