Wednesday, December 1, 2021

Topicals, Oral Medications, and More

  • Prescription acne medication is usually prescribed for severe acne and when moderate-to-severe acne doesn’t respond to over-the-counter treatments
  • Combination therapy in the form of topical and oral prescription medications offer best results, but either may be used as monotherapy depending on the situation
  • Topical options include alpha and beta hydroxy acids, and benzoyl peroxide
  • Oral medications include antibiotics, retinoids and birth control pills
  • Side effects of prescription acne medications range from mild to severe

Acne is a chronic skin disorder that affects nearly 50 million people a year in the United States alone. Fortunately, there are a wide range of treatments available that work to prevent and treat mild-to-severe acne symptoms. Prescription acne medication is an important consideration in acne treatment; for greater efficacy two or more medications may be prescribed simultaneously. 

Prescription acne treatments are available in a wide range of preparations including topical creams, ointments and gels; and systemic treatments such as oral antibiotics and contraceptives.

Who Should Use Prescription Acne Medication? 

Prescription medication is an appropriate choice for moderate–severe acne or for acne that fails to respond to over-the-counter (OTC) treatments. Treatment selection will be determined by a number of factors including severity, patient preference and tolerability.

Acne presents as either noninflammatory, which is characterized by blackheads and whiteheads, a mild form of comedonal acne that plugs pores; or inflammatory which manifests as cysts, pustules, papules and nodules. These raised lesions are red, pus-filled and painful. 

Nodulocystic acne is a more severe inflammatory acne that develops in the deeper layers of the skin as hard, tender lumps. It sometimes requires alternative treatments due to its complex and difficult-to-treat nature. 

Although they are united by the same primary cause–hair follicles become blocked with excess oil, debris and dead skin cells—acne types are targeted with different treatments.

Comedonal acne is characterized by hard plugs of debris and is not associated with inflammation. However, inflammatory acne does exhibit inflammation and increased acne severity as a result of the proliferation of Cutibacterium acnes (formerly Propionibacterium acnes) bacteria.

In sum, moderate–severe comedonal acne requires a prescribed treatment designed to clear pores; inflammatory acne additionally requires a specific medication to kill C. acnes, calm inflammation and shrink raised lesions.

Who should avoid them? 

Women who are breastfeeding, pregnant, or trying to become pregnant should avoid certain oral and topical acne medications, particularly isotretinoin and tazarotene, as these drugs are known to cause birth defects. Spironolactone has been shown to feminize the male fetus.

Drug-drug interactions can also result; it is important to tell your care provider about all the medications you take—even natural remedies—in order to reduce the risk of adverse effects.

Anyone allergic to a medication should avoid taking it. As well, some health issues such as Crohn’s disease or intestinal disease prohibits use of some prescribed medications. 

How Does It Treat Acne?

A prescription-strength acne regimen is effective in a number of ways and typically involves combination therapy to target acne through topical application as well as through systemic agents.

In this way, combination treatments can take advantage of their individual mechanisms of action; this strategy has been shown to be more effective at treating acne. 

These medications help break down the debris that plug cells, maintain clear pores, regulate oil production and encourage skin cell turnover, Some are prized for their ability to kill acne-causing bacteria, and ease redness, pain and inflammation. 

Topical Medications

Some topical medications kill acne-causing bacteria and play a significant role in preventing acne formation by preventing buildup within follicles and promoting skin cell turnover.

Topical formulations are available in a wide range of formulations including ointments, creams, lotions, gels, foams and sprays. Your care provider will decide which is appropriate based on several factors including your skin type, medication history and tolerance level. 

Antibiotics 

Topical antibiotics can effectively kill C. acnes, and alleviate inflammation and redness. These include: 

While effective on their own, antibiotics are typically paired with another medication such as benzoyl peroxide or retinoids for greater results. Benzoyl peroxide in particular, plays an important role in preventing antibiotic resistance when combined with antibiotics, and when used after a course of antibiotics. 

Length of treatment will depend on the severity of the acne but is typically as follows: for short term, from 2–4 weeks; medium term, from 4–8 weeks; long term, more than 8 weeks.

Azelaic acid

Antioxidant-rich azelaic acid is commonly prescribed for acne, as it has a number of compelling healing properties: it is anti-inflammatory, antibacterial and antikeratinizing. While powerful, it is gentle to the skin and exfoliates, smooths and evens skin tone. It also works to decrease swelling and redness.

Creams containing 15% to 20% azelaic acid are prescribed for twice-daily use for 4 weeks or more. When used in combination with erythromycin, a significant reduction in acne lesions has been demonstrated, in addition to fewer side effects.

Azelaic acid is also prescribed as maintenance therapy after a course of antibiotics.

Benzoyl peroxide

Benzoyl peroxide has long been the cornerstone of acne treatment due to its efficacy and its role in antibiotic-resistance therapy. It works best for inflammatory acne due to its strong antibacterial quality; it also works as a peeling agent by sloughing off accumulated debris, skin cells from pores. 

Benzoyl peroxide is prescribed in strengths of 2.5%, 5% or 10%. Of interest is that all three concentrations have been found to be equally effective in improving inflammatory acne, however higher strengths are associated with increased adverse effects. 

Retinoids

Retinoids are derived from vitamin A and are highly effective in treating both mild–moderate inflammatory and noninflammatory acne. They are considered a mainstay of acne therapy and are typically considered in combination therapy alongside an antimicrobial; they reach deep within pores to clear comedonal lesions and exfoliate dead skin cells while the latter targets acne bacteria.

These topicals include adapalene, tretinoin and tazarotene, and are available in gel, cream and lotion formulas that are prescribed at the lowest dose and gradually increased depending on response and tolerance.

Retinoid therapy is safe for long-term use and can take up to 12 weeks to produce noticeable results. 

Salicylic acid

Salicylic acid is an excellent choice for noninflammatory comedonal acne. As an oil-soluble beta-hydroxy acid, it can reach deep into pores to dissolve oil and debris buildup that results in whiteheads and blackheads. 

It’s available in a number of formulas including gels, lotions, ointments pads and cleansers in strengths of 0.5% to 6%.  

This acid is also used as a peeling agent in concentrations of 30% and higher depending on the formulation and desired outcome.

Oral Medications 

Oral medications are prescribed when topical medications are not effective, or for severe or difficult-to-treat acne. Oral medications may be prescribed as a sole treatment or used alongside another medication, usually a topical. 

Antibiotics

Antibiotics are a staple in acne treatment and management, and are very effective in treating moderate-to-severe inflammatory acne by killing P. acnes. However, they are significant contributors to antibiotic resistance. With this in mind, antibiotics are used for the shortest time possible and combined with other effective nonantibiotic topical treatments. 

In addition to killing bacteria, these antibiotics reduce swelling, redness and itchiness – symptoms that often accompany inflammatory acne:

Isotretinoin

Isotretinoin is a powerful retinoid drug that shrinks oil glands to effectively reduce oil production – a primary contributor to acne formation. 

While isotretinoin has been proven effective against acne, it is associated with a number of adverse effects, some severe. It can cause birth defects and has been linked to increased depression, psychosis and liver disease. 

This medication is therefore reserved for severe acne or for acne that fails to respond to other medications. Patients will be closely monitored for side effects while taking this medication.

Oral contraceptives

Hormonal fluctuations can cause an imbalance in oil production and cause acne breakouts in women. For women in this category, and who require birth control, oral contraceptives can be an effective choice to counteract this imbalance and calm symptoms.

Combination birth control contains estrogen and progestin (a synthetic progesterone) which balance hormone levels by decreasing levels of androgen. This reduces oil production and clears acne; results should be seen at 2–3 months.

Best Prescription Medications for Adult Acne

There is no one best prescription for adult acne. Everyone responds differently to medications and multiple factors are at play including skin type, acne severity, treatment history, genetics and environment.

With that being said, prescription-strength benzoyl peroxide is a safe, established, effective treatment. Depending on the severity of your acne, your care provider may also pair it with another medication for greater results; they will determine what is best for your acne. 

How long does it take to see results?

Acne is known to be difficult to treat, and each person will respond differently; it can take 4 to 8 weeks to begin seeing the results of prescription acne treatments.

Acne therapy typically involves adjusting the medication type and dose, and close monitoring to achieve best results. It is also important to follow your care provider’s instructions fully to gain the most from your medication.

Are There Side Effects? 

All medications carry a risk of side effects, and prescription acne medications are no different. The most common side effects are mild and include dry skin, burning, itching and redness.

It is important to tell your care provider about all the medications you are taking, both oral and topical, as some drugs are contraindicated for acne medications and can cause adverse effects.

Some medications, such as isotretinoin have a range of possible mild to severe side effects and must be taken with care. 

Prescription Acne Medication (Topical)Potential Side EffectsPrescription Acne Medication (Oral)Potential Side Effects
AntibioticsAbdominal painBurningDry or oily skinPeelingRedness and stingingUpset stomachAntibiotics DizzinessUpset stomachSensitivity to sunlight
Azelaic acidDry skinChanges in skin colorIrritation, itching and peelingTinglingWarm sensationBirth controlFatigueHeadacheHeightened risk of blood clotsHigh blood pressureNauseaTender, painful breastsWeight gain
Retinoids (Tretinoin)Blistering and crustingBurning and stingingChanges in skin colorDry skinIrritation, itching and peelingPainRednessSensitivity to sunlightSore throatSwellingWarm sensationIsotretinoinBirth defectsChanges in liver functionChanges in triglyceridesDepressionDry skin eyes, lips, nose, mouthMuscle achesNosebleedsSensitivity to sunlightWorsened night vision
Salicylic acidDry skinIrritation and peelingSpironolactoneMenstrual discomfort or painTender, painful breasts

Over-the-Counter Alternatives

If you have mild-to-moderate acne you can purchase OTC lower-strength versions of prescription medications such as:

  • Benzoyl peroxide
  • Salicylic acid
  • Retinoids

If you don’t see any improvement in your symptoms after using an OTC treatment for several weeks, it is important to see your dermatologist to discuss other options and begin a treatment regimen to control your acne.  

Takeaway

There are many established prescription acne medications that are effective in treating and controlling acne. They are typically reserved for moderate-to-severe acne and for treatment-resistant acne.  

While some prescriptions are used as monotherapy, combination therapy offers greater results when several medications are used in tandem to target acne using different mechanisms of action. 

Topical prescription acne medications such as azelaic acid and benzoyl peroxide have antibacterial, anti-inflammatory and antikeratinizing agents. Alternatively, oral medications such as retinoids, antibiotics and oral contraceptives work systemically to kill bacteria and regulate oil production. 

Side effects of prescription acne medications range from mild to severe. It is important to discuss any side effects with your care provider in order to balance safety with results.

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