—Jonathan F., fifth-year student, University of Waterloo, Canada
Acne is extremely common in adolescents and young adults. As an adolescent, I tried to persuade myself that I was growing freckles, but, alas, I was not. Let’s take a brief look at how acne forms, and then explore some potential treatment options depending on the severity of acne you’re dealing with.
Acne typically develops in hair follicles on the face, back, and shoulders. It usually starts when glands in the skin become plugged by dead cells and other substances, causing what is known as a closed comedone. Eventually, this material becomes harder and oxidized, and turns black, forming an open comedone (or “blackhead”). Fatty substances and other material allow bacteria to grow, and the whole thing becomes inflamed and makes a red dot, or papule. Eventually pus becomes evident, forming a pustule (or “whitehead”). Sometimes large lesions called nodules will form and, if they get worse, become cysts. When the more advanced lesions heal, they tend to form scars. In some people, the inflammatory process will lead to darker patches due to hyperpigmentation.
Acne is more common in those assigned male at birth than those assigned female at birth, but if an individual assigned female at birth takes testosterone to transition to male, this person is more likely to develop acne. So, we know testosterone also plays a role in acne formation.
The treatment of acne depends on the stage of the lesions and the type of skin a person has: dry or oily. I would recommend first and foremost speaking with your health care provider or dermatologist to determine which of the following methods would be best for you.
The basis of most acne treatments are topical agents (i.e., products applied to the skin’s surface). These can include derivatives of Vitamin A (retinoids), benzoyl peroxide, or acids such as salicylic and azelaic, and other products such as adapalene and tazarotene. Topical agents act to prevent the plugging up of pores and are also anti-inflammatory, decreasing the redness that often accompanies acne. These products are effective as long as you use them, but note that it can take a few weeks to months for them to become fully effective. They also need to be used on the entire area where a person gets acne; they are not meant to be used as spot therapy.
The main side effect of these products is drying and irritation of the skin. I usually suggest starting with a less potent form of an agent and using the product every other evening at first, then increasing the frequency as the skin adapts. The goal is that your skin feels dry and slightly tight without being red and peeling. If that happens, you can step back to a weaker product or use it less frequently.
The second level of treatment involves topical antimicrobials, which include the benzoyl peroxide previously mentioned as well as various antibiotics. These work on the bacterium that leads to the papules and pustules. Unfortunately, the bacterium may become resistant to the antibiotics, so antibiotics are best used in conjunction with the peroxide, as this seems to decrease the likelihood of resistance.
The next step is to combine one topical agent with a topical antimicrobial. If this is not working or if a person has those juicy whiteheads, then a combination of a topical agent with an oral antibiotic may be used. The problem with oral antibiotics is that resistance is more likely to occur, so they tend to be used for just three to four months. Oral antibiotics are also more likely to cause side effects.
This combination works faster than the other methods listed because the antibiotics act on existing lesions. However, after a couple of weeks the acne returns, as the development of whiteheads takes a while—so even though visible pustules are treated, others are developing under the skin and appear later. Also note that antibiotics are not fully effective for a few weeks. Therefore, what happens is a relatively quick clearing of the skin, followed by a second wave, then a third wave, resulting in a slower but more consistent clearing of the skin. The skin then remains lesion free for as long as the person is taking the antibiotics. Once an antibiotic regimen is stopped, the acne may return.
The final treatment option is oral isotretinoin, better known by its commercial name Accutane. Because of the serious side effects related to this medication, it is usually used for a maximum of 20 weeks. However, the effects of this medication can last for several months and sometimes years after the treatment is finished. Note that one of the most dangerous side effects of Accutane is severe birth defects, so people who can get pregnant need to take extra precaution when using this medication.
There is a new medication being studied, which is a topical testosterone blocker. It appears to be very effective, although more research is needed to see how effective it will actually be. Another option is spironolactone, an oral medication that works as a testosterone blocker. This may lead to potassium problems, so blood tests are required periodically to check on potassium levels. Various forms of light therapy are also being studied, but the jury on those is still out. For individuals assigned female at birth, the use of various combined oral contraceptive pills may also be a very useful option, serving both as an acne medication and to prevent pregnancy.
In summary, there appears to be only one product that has a lasting effect when stopped, making it effective for controlling acne in the long term, and that is oral isotretinoin. All the other options are effective only while they are being used.