Acne: Do lotions, tablets or light-based treatment help?

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There are many treatment options for acne, including medication that is applied to the skin or swallowed, and over-the-counter or prescription-only products. But which treatment is most suitable for you? And can treatments like phototherapy improve your complexion?

The treatment options for acne will depend on a number of different things. For instance:

  • How severe is your acne?
  • What is your skin type (dry, oily or combination)?
  • How much does your acne bother you?
  • Do you have other health problems?
  • Are you male or female?
  • Are you susceptible to acne scarring?
  • Which treatments have you already tried out and how well did they work?
  • How important are their effects – and their side effects – to you?

Practically all acne treatments require patience to get results. But it can be worth the wait, and is certainly better than constantly switching treatments, which can sometimes make you feel like nothing will help.

Topical medications

There are a variety of creams, lotions and gels that can be applied directly to the skin (topically) with different drugs in them. All of these treatments need to be used for several weeks or months before they start working. To prevent new pimples from forming, they have to be applied to the skin surrounding existing pimples too.

Some medications can irritate the skin, causing things like redness and itching. You can reduce this risk by starting with a low dose and then gradually increasing it. If your skin is already irritated, it may help to use a lower dose. If your skin stays irritated or if the medication hasn't worked after some time, you could try a different medication.

Benzoyl peroxide

In Germany and other countries, benzoyl peroxide can be bought over the counter (without a prescription). It is available in the form of gels, lotions and creams. Benzoyl peroxide is meant to help remove the layer of dead cells on the outer surface of the skin. This makes it easier for oil (sebum) to leave the pore, preventing the sebaceous glands from clogging. It has an antibacterial effect as well. Unlike antibiotics, there is no risk that bacteria will become resistant if you use it a lot.

In mild to moderate acne, benzoyl peroxide can lead to an improvement within a few weeks. But it can also cause problems like redness and itching. If benzoyl peroxide comes into contact with clothes and hair it may bleach them, so it is advisable to be cautious when applying it. The effectiveness of benzoyl peroxide doesn't depend on which form it is used in. It is available in various concentrations: 2.5%, 5% and 10%. Products with higher concentrations don't work better than those with lower concentrations, but side effects are more common when 10% benzoyl peroxide is used.

Antibiotics

In inflammatory forms of acne, the skin is infected with bacteria. Antibiotics that are applied to the skin have an anti-inflammatory effect and can reduce inflammatory forms of acne. It's recommended to only use antibiotics in combination with effective medications like benzoyl peroxide or a retinoid. Antibiotics aren't effective in the treatment of non-inflammatory acne.

Topical antibiotics need to be used for quite some time before they can have an effect. In Germany and other countries, they are only available on prescription. The treatment takes at least three weeks, and many people only see an improvement after three to six months. One problem with antibiotics is that there's always a risk of bacteria becoming resistant. In other words, the bacteria may get used to the drug if it's used too often. As a result, the antibiotics don't work as well the next time you use them, or they may not work at all. So antibiotics aren't suitable for repeated long-term use. Skin irritations and diarrhea are possible, but generally rare. The creams are usually well tolerated.

Retinoids

Retinoids are derivatives of vitamin A. The retinoids used in the topical treatment of acne include adapalene, isotretinoin and tretinoin. In Germany and other countries, these medications are prescription-only and are available as creams, gels or solutions. They can help in both inflammatory and non-inflammatory acne. Treatment with retinoids can lead to a visible improvement within a few weeks.

Side effects such as redness, burning and itching may occur. Retinoids haven't been approved for use in women who are pregnant or breastfeeding.

Other products for topical (external) use

Azelaic acid helps prevent oil glands in the skin from becoming clogged and can improve acne. It has an antibacterial and anti-inflammatory effect. The possible side effects include skin irritations such as itching and burning.

Many acne products, such as cleansing toners and creams, contain salicylic acid. This ingredient is believed to work by removing dead skin cells from blocked pores. It's not clear whether products containing salicylic acid help reduce acne. Salicylic acid can also have side effects such as redness, dryness and peeling.

Fruit acid peels remove the top layer of skin, which is made up of dead skin cells. These peels usually contain glycolic acid. A few studies suggest that they could be effective. They may cause mild skin irritations.

Oral medications

Oral (swallowed) medications are usually considered in people with moderate to severe acne, or if topical treatment hasn't led to a big enough improvement.

Antibiotics

Antibiotic tablets can help improve inflammatory acne when taken for several weeks or months.

Oral antibiotics can have side effects, including dizziness, digestive problems and allergic reactions such as rashes. The antibiotics called tetracycline and minocycline aren't suitable for anyone who is pregnant or breastfeeding. People who take minocycline for longer than three weeks should have a blood test before starting the treatment, as well as regular blood tests during the treatment. This is done in order to detect any problems with the liver, kidney or the formation of blood as soon as possible.

As with topical antibiotics, there is a risk that the bacteria may become resistant and that oral antibiotics will then stop working if they are used too often.

Hormones

One of the main causes of acne is higher levels of, or an increased sensitivity to, the hormone androgen. Certain hormone products can reduce the production and effect of androgen, leading to better skin.

Some hormone products can be prescribed especially for the treatment of acne. These medicines also have a contraceptive effect. Three combinations have been approved for the treatment of acne in girls and women in Germany:

  • Ethinyl estradiol / cyproterone acetate
  • Ethinyl estradiol / chlormadinone acetate
  • Ethinyl estradiol / dienogest

In women with moderate to severe acne, these hormone products are often used together with a topical treatment in order to improve the overall effect. The combination of ethinyl estradiol / dienogest is considered to be "second line" treatment. This means that they should only be taken by women or girls who would like to use birth control pills as contraception anyway and whose creams and tablets aren't effective enough.

Hormone products such as birth control pills, on the other hand, are intended for contraceptive use and are usually not approved for the treatment of acne. But if girls and women who have acne use the contraceptive pill as a form of contraception anyway, it may also have a positive effect on their acne. This is only true, though, if they take a pill that has the hormones estrogen and progestin in it.

Hormone products can also cause side effects, such as headaches and nausea. Some birth control pills increase the risk of deep vein thrombosis, too.

Retinoids

Retinoid tablets are one of the most effective treatments for acne, but they also have the most side effects. Because of this, they are generally only used if other medications haven't worked. Retinoid tablets can lead to a noticeable improvement, or might even make acne clear up completely. The acne sometimes comes back again after a while, though.

Because retinoids lower the production of oil in the skin, people who take them might have dry lips and skin or dry eyes. Other possible side effects include headaches, achy joints and backache. The higher the dose of retinoids you take, the more likely you are to experience side effects. Serious side effects are rare, though, if they occur at all. Pregnant women and women who are breastfeeding aren't allowed to use retinoids because they can harm the child.

Retinoids will only be considered as a treatment option for sexually active women if they use at least one contraceptive method, or preferably two at the same time. For example, if they take the pill and use condoms as well, to be on the safe side. Contraception must be continued for at least four weeks after the treatment ends. This is because retinoids can cause birth defects in unborn babies.

It is thought that there might be a link between using isotretinoin and a higher risk of suicide, but this has not been confirmed in studies. Still, it is important to look out for any unusual changes in mood if you are taking retinoids, and to inform the doctor if you notice any. In any case, it always makes sense to seek medical and/or psychological help if acne is a major problem for someone or if it causes mental health problems.

Research summaries

Light-based treatment

Besides topical and oral medications, different types of light-based approaches can be used to treat acne. These treatments are usually only a good idea when used in combination with medication because they probably aren't as effective as the medication.

In phototherapy, the skin is treated with (usually blue) light under the supervision of a doctor. Studies suggest that this can improve acne over the short term. But the studies have considerable flaws, so their results are very unreliable. Phototherapy may lead to side effects such as skin redness.

In UV phototherapy, the skin is treated with UV light. Due to the risks for the skin, though, it is not recommended for acne treatment. Phototherapy is not the same as using a tanning bed.

Research suggests that laser treatments can also improve inflammatory acne over the short term. But there's a lack of good-quality research on the long-term effects of this approach, so it's not clear how effective they actually are.

Other treatments

People with acne sometimes also use complementary or alternative medicine approaches to try to improve their skin. These include things like herbal and homeopathic products, tea tree oil and purified bee venom. Acupuncture, cupping and special massages are offered for the treatment of acne too. But none of these products or approaches have been clearly proven to work yet.