A Comprehensive Guide to Acne Treatment

Alright, so acne is one of my favorite subjects, so I’m pretty excited to sit down and write about it. It’s a good thing too because I will spend half my life talking about it and thinking about it, and that’s only during working hours. It’s also really important. People hate acne and whether they admit it or not, it bothers everyone who has it and for some of them it can be dramatic and cause significant scarring.

However, please keep this in mind, it's very treatable and should not be ignored. So, If you’re in a hurry Google “acne dermatologist near me” to learn more about acne – let me explain to you about it and please make sure to take advantage of our very effective and often treatments.

Identifying Acne Subtypes at First Glance

I have a specific algorithm for my approach to acne. When I first look at a patient, even before I ask any questions, I’m already assessing the subtype of acne.

Subtypes of acne:

• Commedonal
• Inflammatory
• Hormonal
• Trunk
• Systemic inflammatory

Commedonal Acne

The most common and simplest is comedonal acne. This is how acne starts. Patients present with small “black head” and “white head” subtle bumps often on the forehead and nose. This is the basic structure of acne which is the blockage of the pilosebaceous unit. For this type of acne facial, scaring is not a concern, so my thought process shifts to a long-term solution, and not worried about immediate results but thinking of long-term sustained clearance.

So, the most effective acne spot treatment for comedonal acne is a retinoid topical medication, a derivative of vitamin A. This highly useful and impressive class of medications is the most effective at preventing the blockage of the pilosebaceous unit making the comedones disappear and facilitating very smooth and healthy-looking skin.

Choosing the Right Retinoid for Comedonal Acne

After determining that a patient has comedonal acne and would benefit from a topical retinoid as the effective treatment, I ask myself which one of the retinoids should be used. They are all very effective medications but each has subtle differences that need to be considered.

Retinoid medications (vitamin A derivatives):

1. Tretinoin (Retin-A)
2. Adapalene (Differin)
3. Tazarotene (Tazorac, Arazlo)
4. Trifarotene (Aklief)

Tretinoin, is the original retinoid, first generation. It works well but excessive or improper use can negatively affect existing acne from dry skin. It is also deactivated by the sun so it must be used at night or with sunscreen on top. It's also unstable when combined with other acne medications such as benzoyl peroxide.

It comes as a generic and is usually very inexpensive so I may even have my DappleDoc patients purchase it without using insurance and it makes it cheaper, don’t get me started on how insurance companies drive up prices. Anyways, for simple early-stage acne, tretinoin is a good choice. Tretinoin comes in three basic concentrations, 0.025%, 0.05%, and 0.1%. It also comes as a cream, lotion, and gel.

Why Direct Retinoic Acid Is More Effective For Itchy Acne?

Another common topic of conversation that is often included in my discussion with acne patients is the use of retinol. Many over-the-counter products contain retinol that advertised as useful for acne. However, this is misleading given that the utility of retinol is very minimal. The reason for this can be explained by understanding the retinoic acid pathway:

Retinol → Retinal → Retinoic acid (tretinoin)

It takes several steps to convert topically applied retinol until it becomes a useful molecule of retinoic acid. As such, retinol that is sitting on your skin is unable to achieve physiologically useful concentrations inside the body to affect your acne. Thus, directly using retinoic acid such as tretinoin or adapalene on your skin will have enough potency to make important physiological changes to your skin quality and resolve your acne.

Important Considerations When Using Retinoids

1. Drying of the skin – the most significant side effect of this medication is dryness

It is the most common reason that people don’t continue to use it. Before using a retinoid, it's hard to comprehend the extent of dryness this can cause. People are very motivated to use it and clear their acne so they start every day very aggressively. Or inexperienced providers, especially PAs that pose as dermatologists but are not, will prescribe it without giving instruction and lack the knowledge to explain that it must be a titrated dosage.

I vehemently express to my patients that this medication can cause dryness. I always have them start every other night and make sure to use a good face moisturizer twice a day. I recommend Cerave AM and PM. If it is still too dry, drop down to twice a week.

2. Results take time

This process is slow. The mechanism of this pathway is to change skin cells lining the pilosebaceous unit so that it decreases in size and prevents occlusion. I describe that this medication is to be used in the long term, it's not a quick fix.

3. Mechanism - retinoids are for comedonal acne

It’s not an effective treatment for inflammatory or hormonal acne.

Inflammatory Acne

Now this is where I start getting concerned. Inflammatory acne is more than just unsightly and painful, it risks permanent scarring. These are the red firm and painful bumps on the skin. I urge everyone to get this treated and not wait for it to resolve. This type is called “teen acne facial” and is typical for teenagers and highly influenced by elevated circulating testosterone and hormone levels. For this type of acne, my algorithm shifts to urgent/immediate acne treatment for sensitive skin and a long-term solution to prevent recurrence and maintain clear skin.

The most effective short-term fix for inflammatory acne is an oral antibiotic – either doxycycline or minocycline. Now it’s often mistaken that the mechanism of action for antibiotics is the killing of bacteria in the skin but these two medications, known as tetracyclines, are highly effective skin-directed anti-inflammatory medications.

For whatever reason, doxycycline and minocycline subside inflammation of the skin. I use this for several other skin conditions because of its tropism to the skin. It's much more effective than any other oral antibiotic medication. So, I usually provide 1-3 months of oral antibiotics to calm down the inflamed skin while at the same time starting the patient on benzoyl peroxide topical, usually combined with clindamycin. This combination of topical meds provides a direct anti-inflammatory effect with a sustained anti-microbial effect.

Harnessing Doxycycline and Minocycline As A Potent Anti-Inflammatory Approach

The combination of the benzoyl peroxide with the clindamycin has proven to be an effective duo to prevent bacterial resistance with long-term use. This is important because topical meds are given for long-term use. I always advise my patients that after their skin clears, keep using the topical combo meds to prevent the inflammatory acne from coming back. The quicker the acne clears, the less likely for permanent scarring.

Important factors for scarring:

1. Subside the acne as quickly as possible
2. May take 6 months to 1 year for the skin changes to resolve. Meaning, I always advise patients to wait 6 months before considering acne laser treatment to address the scarring, because some of the scars will resolve on their own, and laser treatment can be expensive.

Other acne meds (that don’t work well):

1. Dapsone (aczone)
2. Topical minocylcine (amzeeq)
3. Sulfur cream
4. Clascoterone (winlevi)

How Effectively Treat Persistent Acne

Lastly, when all else fails, and acne just won’t go away or won’t stay away without oral meds, accutane (isotretinoin) will work. This is an oral medication with many listed side effects. However, in truth, my advice to patients is that this medication works and has two definitive side effects that will happen while taking it:

1. Dry lips – this is a requirement of taking it.

2. Birth defects if a woman gets pregnant while taking it.

So, dry lips will happen, not such a big deal but will be present the entire 6-8 months of using this medication. For birth defects, it's real, but it's only if someone gets pregnant while on this medication. So don’t get pregnant, is it that hard? After stopping, this medication is out of your system after one month and the risk of birth defects is basically resolved and after 6 months, you’re back to being a normal person.

So please, treat your acne and use DappleDoc for your acne spot treatment. It's easy and will save you time and probably money.