Acne: Topical Therapies

Posted by Audrey Kunin, MD There have been 0 comments

Acne Topical TherapiesKnowing how and why acne forms and the role that so many effective oral medications play is indispensible in really understanding acne. That leaves topical therapy, appropriate skin care, the latest Sci-Fi treatments and exciting new developments for us to discuss.

Topical Therapies

A hot topic in acne therapy is how to best handle breakouts with topicals. Some don't want to take pills, and others have extenuating circumstances and can't take pills. Most simply want to get clear fast and understandably want to incorporate whatever measures they can to maximize treatment. Topicals are as varied in their actions as systemic therapy. They are an invaluable means for treating minor outbreaks and rounding out therapy.

Synthetic Retinoids

These derivatives of Vitamin A are indispensable in acne therapy. Similar to the actions of Accutane, they help normalize the keratinization process (formation of those aberrant cells lining the sebaceous gland). Topically they help eliminate blackheads, dry up excess oils and squelch papular and pustular acne. Those in the prescription category are more potent but if this is not an option, retinols like Poetry In Lotion intensive 1% retinol can be beneficial.

  • Tazarotene (Tazorac)
  • Tretinoin (Retin A, Avita)
  • Adapalene (Differin)

Retinoids are a source of complaint when overused or too potent for a patient. Make sure to follow these steps:

  • Begin use just every other night.
  • Wait 30 minutes after washing before application.
  • Apply a PEA sized amount of cream to your finger.
  • Dab the cream/gel around the area to be treated and rub it in well.
  • Avoid getting in the eyes and wash hands well.
  • Do not layer with any other skin treatment or moisturizer.
  • Reduce frequency of use if skin becomes irritated.

Vitamin A topicals whether OTC or prescription should not be used while pregnant or nursing and may increase sun sensitivity. Wear an SPF 30 daily when using.

Topical Antibiotics

As previously mentioned, bacteria drives acne formation. A myriad topicals exist that possess bacteria-killing abilities. These products are typically applied twice a day when treating whiteheads and small inflammatory acne lesions.

  • Clindamycin (Cleocin T)
  • Erythromycin (Erycette, Emgel)
  • Metronidazole (MetroGel/Lotion/Cream & Noritate)
  • Plexion Lotion & Cleanser (Sulfa based)

This is an abbreviated list of brand options.

Benzoyl Peroxide

Benzoyl peroxide is a tried and true acne treatment. Strengths range from 2 1/2% all the way through 10%. Gels, creams, lotions, soaps, masques and even shaving creams provide formulations for every need. Its benefits are also based upon its bacteria thwarting abilities, although it's not technically classified with the antibiotics. Benzoyl peroxide can be found in both over-the-counter and prescription treatments, often at the same levels! Recent variations have married benzoyl peroxide with other ingredients vs. mono-therapy.

This is an abbreviated list of brand options.

Benzoyl peroxide can cause dryness, redness and irritation if overused. There are even an unfortunate few who are allergic to benzoyl peroxide. Pay attention to what your skin is telling you and reduce your use should these symptoms develop.

Azelaic Acid

Azelaic Acid is a naturally occurring dicarboxylic acid found in grains like wheat, rye and barley. Azelaic acid has been shown in lab studies to possess antibacterial activity against common skin bacteria Proprionobacterium acnes (P. acnes) and Staphylococcus epidermidis (S. epidermidis). It may also play a role in normalizing the keratinization process within the gland, bestowing it with anti-acne/anti-comedogenic talent. Look for it in prescription acne medications Azelex 20% Cream, Finacea (15% for rosacea) and nonprescription Ain't Misbehavin' medicated acne control serum.


If only one could prevent DHT from revving up the sebaceous glands; thus reducing acne flare-ups and oily skin. We know birth control pills and Spironolactone can, but is there any topical hope?

Nordihydroguiaretic acid (NDGA) is a natural, plant derived lipooxygenase inhibitor, meaning its function is to reduce inflammation. What's interesting about NDGA is that journal articles such as The Journal of Biochemistry and Pharmacology (March 2002) suggest NDGA possesses the ability to reduce 5-alpha reductase function, the enzyme responsible for changing testosterone into DHT. Both Calm Cool & Corrected anti-redness tranquility cream and Ain't Misbehavin' medicated acne control serum contain NDGA and can help make your acne regimen, (whether it's acne rosacea or traditional acne), more tolerable and effective by reducing the amount of sebum available to nourish bacteria or able to plug pores and help clear blemishes already visible.


Sulfur helps inhibit the growth of P. acnes and unclog pores. Used solo one can find it in either OTC or Rx options. In combination with Sulfa, it's approved for use in acne rosacea and seborrheic dermatitis.

This is an abbreviated list of brand options.

General Skin Care For Acne Patients

How to keep skin fresh, healthy, glowing and blemish free? Acne is not due to a lack of cleansing. But, removing pore-plugging oils and surface cellular debris goes a long way to minimizing breakouts.

Glycolic and salicylic acids help dissolve grease and grime, lifting away cells plugging the pores. Glycolic acid tends to be most versatile, found in cleansers (think Ain't Misbehavin' medicated AHA/BHA acne cleanser), treatments and toners. BHA often assists glycolic acid in AHA/BHA products.

Reducing oiliness eliminates a main source of nourishment for acne-causing bacteria. Picture Porefect can help absorb excess skin oils without causing parching; mattifying skin all day long.

Here's what dermatologists recommend their acne patients use in routine skin care:


Dermatologists may include procedures in their approach to acne. Most commonly, "acne surgery" is performed. This essentially refers to the use of a comedone extractor much like Tweezerman Skin Care Tool being firmly applied around a blackhead and pushed out of the skin.

Other possiblities include chemical peels, microdermabrasion and the old-time application of liquid nitrogen to an acne cyst. I have personally found these rather limited in my approach to acne therapy and turn to them on a limited basis.

PIH The Great Fake Out

I lost count long ago of the number of acne patients concerned about newly formed acne scars when there wasn't a scar in site. What they were really noticing was skin discoloration where the pimple existed. This post inflammatory hyperpigmentation (PIH) is not an acne scar. It's a normal remnant of the skin's inflammatory process.

For those with pale skin tones, this aftermath color is usually pink, red or purple in color. Patients with darker skin tones may notice brown or black spots where acne once was.

Mederma can be helpful for treating newly healed wounds and resolving acne, helping hasten the resolution of reddened spots. Although a light gel formulation unlikely to flare acne, it is important not to apply it too generously, as acne prone skin may not tolerate any product smothering the skin. It's senseless to trigger acne in an attempt to fade discoloration.

PIH can fade unassisted. Unfortunately, the darker the PIH, the longer it may take to resolve. And while it is not a true scar, when it lasts a year, it certainly seems that way. This form of PIH may require some intervention in order to hasten the process. Ask your doctor about prescription bleaches like Glyquin or Lustra. Don't overlook the importance of wearing sunscreen when trying to fade PIH.

Sci-Fi Treatments

The future is truly here. Light is being used as never before in medicine in an effort to conquer acne.

Acne Blues?

Those who make their way to a dermatologist often credit summer's natural sunlight as helpful reduce acne severity. Studies indeed support the benefits of sunlight in acne therapy. But with concerns of UV induced skin cancer (not to mention wrinkles), indiscriminate use of medical ultraviolet phototherapy is not the treatment de jour. Leave it to medical science to find a way to get that summertime-like improvement.

P. acnes bacteria produce a natural byproduct of metabolism called porphyrins. Porphyrins are light sensitive and exquisitely vulnerable to narrow band visible blue light. When porphyrins are exposed to this light (or to a lesser extent, natural sunlight which contains less concentrated blue light), a chemical reaction toxic to P. acnes takes place. Kill the P. acnes, improve the acne. P. acnes literally self-destruct as a result of their metabolic process.

A process called Acne PhotoClearing (marketed under the name ClearLight) employs a high intensity, enhanced narrow band beam of visible blue light to destroy P. acnes and clear acne.

ClearLight is FDA approved for the treatment of mild to moderate inflammatory acne, i.e., small red inflammatory papules and pustules (whiteheads). ClearLight is unlikely to resolve blackheads or cysts, minimize pore visibility, or reduce oiliness.

Not all cases of acne are triggered by, so the procedure is not for everybody.

Remission with ClearLight usually lasts between 4-8 months. Repeat series of ClearLight may be required for maintaining a clear complexion.


This laser takes aim at the root of the problem-the root of the sebaceous gland, so to speak. After a series of treatments Smoothbeam is able to alter the structure and function of the sebaceous glands. Heat in and around the sebaceous gland creates a thermal injury.

Eventual results are fairly impressive. Improvement can be seen as early as 3 weeks and rapidly reaches 98% after 4 treatments. In one study, at a 24-week follow up, 100% clearance was seen in just one of the original 27 patients.

Therapy Down The Pike

Two candidates in the acne pipeline include topical versions of oral medications already used to treat severe caess of cystic acne. Isotrex is essentially Accutane mixed in a protective sunscreen base and is available in Canada and Europe. I have had some patients present who have been given "homemade" forms of this product which consisted of their pharmacist poking holes in the Accutane capsule and applying the liquidy gel straight to the skin. So far they have reported all this method did was locally irritate and dry the skin without helping clear the acne lesions. I have read mixed reviews out of Canada and Europe from dermatologists. It will be interesting to see if this medication makes its way through the FDA and onto the U.S. market and how it will truly perform.

Dapsone is occasionally prescribed for severe cystic acne when Accutane cannot be used or has not been effective. Dapsone is typically used in the treatment of certain forms of blistering disorders and systemic infections like . It has both antibiotic and antiinflammatory actions. Known as Atrisone, it is still in the clinical trials phase. It sounds interesting in initial reports. Should it be passed by the FDA it would offer an entirely new category of acne therapy.

Tips About Acne Treatment

  • Blackheads frequently need some form of topical vitamin A-containing ingredient for best results.
  • Cysts respond best to pill therapy.
  • A corollary: If you're under 13, nursing or pregnant, tetracycline based medications are off limits as they can permanently discolor the tooth enamel. If you really need oral medication, usually it's limited to Erythromycin.
  • Consistency of treatment results in a better outcome.
  • Don't pick, it can lead to scar formation.
  • Allow at least 6-8 weeks for any new therapy to take effect before giving up on it.
  • Don't scrub the face or have facials if you're acne prone. These actions may traumatize sebaceous glands and lead to further flare-ups.
  • Keep bangs off the forehead and hands off the face. Bad habits like these deposit pore-plugging oils on the skin.
  • Avoid the use of heavy skin care products like cocoa butter, they will smother the skin and flare your acne.
  • Don't apply your acne creams/lotions, etc. heavily like a masque (unless it is one). There is no reason that your product needs to be seen in order to work.
  • Remove your make-up when you're at home. Let your skin breathe!

Too many acne sufferers go untreated far too long. No one need suffer with acne; today there are more effective therapy options than ever. If you have acne that doesn't respond to over-the-counter treatment, please check with a board certified dermatologist.

Audrey Kunin, M.D.

This content is sponsored by DERMAdoctor. The author receives compensation for its creation. All content is the legal copyright of DERMAdoctor, Inc, and it may not be used, reprinted, or published without written consent.

The information provided is for entertainment purposes only and is not intended to provide medical, legal or other professional advice.

This post was posted in Articles, Acne and was tagged with benzoyl peroxide, sulfur, retinoids, topical, acne

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