What to do when OTC treatments don’t improve your acne

Remember the treatment options that dermatologists have for improving acne fall into eight main groups:

• Skin care products--which we discussed in the post: How to Choose Acne Treatment Skin Care Products and Ingredients
• Surface antibiotics
• Surface retinoids
• Oral antibiotics
• Oral retinoids
• Oral hormones
• Chemical peels or Microdermabrasion/Acne Surgery
• Light-based dermatology office treatments

So let’s discuss the medical treatment of acne with prescription oral and surface antibiotics and surface retinoids, when and how they are used, and the possible side effects of medications used to treat acne.

Before we start, my lawyer has dropped by and wants me to remind you:

Electronic message exchanges to, from, or with Dr. Cook do not constitute medical advice, an evaluation, or consultation and must not be considered a replacement or substitute for a formal evaluation in the office. Information and correspondence in this blog does not form and will not result in a doctor-patient relationship. If you desire an evaluation or consultation, contact our office for an appointment. Recommended changes to your present treatment plan or therapy must be approved by your physician. Explanation and/or discussion of off-label services and/or products, if mentioned, do not reflect endorsement or promotion by Dr. Cook and must not be construed as such.

Alternatively, as I would say—I am not your doctor, unless I really am your doctor.

Onward. When dermatologists develop a treatment plan, we go through an algorithm in our mind. We divide acne vulgaris into three main types—mild, moderate and severe. Within those groups we then subdivide based on whether it is non-inflammatory or inflammatory, and whether it is scarring or non-scarring. Non-inflammatory acne lesions include blackheads and whiteheads, which are not pus-filled but solid plugged pores. Inflammatory acne lesions are red bumps, pustules (small pus filled bumps), nodules (hard solid bumps under the skin) and cysts (red or skin color, pus-filled lesions larger than a very small pea). By definition, scarring puts you in the moderate or severe category. For females there are two more subdivisions based on whether there is evidence of a strong hormonal component or not, and whether the patient is pregnant or at risk of pregnancy. Finally, there are more unusual presentations of acne vulgaris that require a different approach and are beyond the scope of this post. Therefore, our acne prescription treatment plan starts with classifying your acne properly.

Acne Treatment Classification

• Mild acne—non-inflammatory
• Mild acne—inflammatory
• Moderate acne—non-inflammatory, non-scarring
• Moderate acne—non-inflammatory, scarring
• Moderate acne—inflammatory, non-scarring
• Moderate acne—inflammatory, scarring
• Severe or resistant acne—non-inflammatory, non-scarring
• Severe or resistant acne—non-inflammatory, scarring
• Severe or resistant acne—inflammatory, non-scarring
• Severe or resistant acne—inflammatory, scarring

In females, this is further subdivided:

• Probable hormonal abnormality contributing to acne
• Patient is at risk of pregnancy—is sexually active and not using consistent, reliable birth control
• Pregnant or possibly pregnant

As usual, females are more complicated. We add these subcategories because:

• Many times if a woman has a significant hormonal component to her acne, unless we address it, we aren’t going to get anywhere. See my previous post Open Pandora’s Box—Hormones, Women and Acne. We will talk about hormonal treatment of acne in women in another post because it really is a Pandora’s Box of hormones.
• In pregnancy, we are significantly restricted in the medications we can safely use.
• News flash—if you are sexually active and not using consistent, reliable birth control you are likely to get pregnant, and we have to assume you will.

Medications Used in Acne Treatment

The medications used for acne treatment are either topical (used on the surface of the skin), or oral.

Surface acne medications are in two groups or a combination of the two:

• Retinoids—Vitamin A derivatives used to unplug pores and keep new plugs from forming. They include tretinoin (Retin-A or generic tretinoin), adapalene (Differin or generic adapalene), and tazarotene (Tazorac). They are drying but most patients are able to use them. They come in various cream, lotion and gel forms for use depending on the patient’s skin type. Most patients who are not on isotretinoin should be on a retinoid as they treat the root cause of acne—plugging of the oil glands. They are used alone for mild non-inflammatory acne.
• Surface antibiotics—clindamycin (Cleocin, Clindagel, Evoclin and generics in solutions, lotions, gels, pads, foam), erythromycin (Akne-mycin ointment and generic solutions and gels), dapsone (Aczone gel) and benzoyl peroxide (Benzac, Brevoxyl, Triaz, Desquam-X and generics in creams, pads, gels and washes) decrease bacteria and inflammation. They are used if inflammatory lesions are present.
• Combinations—clindamycin + benzoyl peroxide (Acanya, Duac, Epiduo, and generics) and clindamycin + tretinoin (Ziana).

Oral acne medications are added to the above when there is moderate or severe acne with or without scarring, in resistant acne, and usually if scarring is observed in mild acne. The major group that is used are the tetracycline group—tetracycline, minocycline, and doxycycline. Tetracycline was the first in the group, is the cheapest. However, the other two usually work better, and tetracycline must be taken on an empty stomach or it is not absorbed. This means no food or milk 2 hours before and 2 hours after a dose taken twice a day. Hard to do. Minocycline (Minocin, Dynacyn, Solodyn and generics) and doxycycline (Adoxa, Avidoxy, Doryx, Monodox, Oracea, Vibramycin and generics) are used most often. Other oral antibiotics may be used for acne in patients allergic to the tetracycline group or if acne doesn’t respond. These include erythromycin (Ery-Tab, PCE and generics), azithromycin (Zithromax and generics), and trimethoprim/sulfamethoxazole (Bactrim, Septra and generics).

Side effects of oral antibiotics for acne

Any oral medication may cause an allergic reaction. Any oral antibiotic can cause vaginal yeast infection, gastrointestinal upset, and may interfere with effectiveness of birth control pills, increasing the risk of pregnancy. The tetracycline group rarely causes severe headaches from increased intracranial pressure, and is not used during pregnancy to prevent staining of fetal bones and teeth. Minocycline may cause vertigo/dizziness, or sun sensitivity. Rarely an allergic reaction with rash, fever, hepatitis or respiratory distress occurs. Rarely over a long period of time, patches of bluish color on the lower legs, gums, teeth, or in scars occur. If Minocycline is discontinued when pigmentation appears, the color usually fades. Doxycycline may cause significant sun sensitivity, nausea or diarrhea. The second line oral acne medications have risks of side effects as well. This is not a complete list of side effects, and as with all medical care, you should discuss these with your physician.

Surface acne medications that are considered safe to use during pregnancy include erythromycin, clindamycin, and glycolic acid and azelaic acid. Oral acne medications that are considered safe to use during pregnancy include erythromycin, azithromycin, cephalosporins and penicillins.

Next we will talk about how to use these medications successfully and how to deal with the side effects.