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Chapter 7

Stop Acne and Breakouts (No Matter Your Age)

Understanding Acne

Acne is one of the most troublesome and common skincare problems for people around the world and, emotionally, one of the most embarrassing skin disorders. Although most often associated with teenagers and the onset of puberty, the truth is that you can suffer from acne at any age. Even if you never had it when you were younger, acne can still occur.

Most of us are familiar with acne to some degree, even if we don’t know the specifics of what makes it acne and not some other skin problem. Acne’s textbook definition describes it as a skin disorder occurring when hair follicles (every pore on your face is actually part of a follicle) become plugged with dead skin cells and oil that causes skin to become inflamed, erupting as a white fluid-filled sac. [27]

That mixture of oil and dead cells allows the bacteria responsible for acne, Propionibacterium acnes (P. acnes), to flourish inside the follicle instead of remaining on the skin’s surface, where it normally resides without causing too much trouble. [27]

These bacteria feast on the follicle’s contents (gross, huh?), which starts a domino effect that leads to the production of inflammatory chemicals and enzymes. This process then triggers the immune system to send white blood cells to combat the bacteria—a call for help that leads to further inflammation.

Acne is, first and foremost, an inflammatory disorder, so it’s important to remember that when treating it! Anything and everything you can do to reduce inflammation will help acne and the red marks it leaves behind heal faster. The reverse is true as well: Irritation will make inflammation worse and, therefore, cause more breakouts! [3,4]

The last stage in the development of acne is when the wall of the plugged follicle breaks down, spilling everything inside to nearby skin, causing inflammation that leads to the formation of a pimple. [27] Exactly what triggers this process, how fast a pimple develops, and why some pores are affected instead of others remains unknown.

Acne can show up on many areas of the body, including the face, neck, chest, back, shoulders, and arms. When a typical pimple (also called a pustule) forms, it can be one of several types of breakouts, as described below. [53]

Comedones: Comedones are considered non-inflammatory precursors to acne, but these lesions are not acne. In other words, comedones are evidence that conditions are present that could lead to acne breakouts. Comedones come in two forms, whiteheads (sometimes referred to as “closed comedones”) and blackheads (sometimes referred to as “open comedones” because you can see the pore opening).

When too much oil is produced in the pore it can mix with dead skin cells and cellular debris, causing it to get stuck and form a “plug.” This plug pushes to the surface and, if it’s covered by skin, it appears as a slightly raised, whitish, firm bump called a whitehead. These are not pimples.

If these plugs come to the surface and are not covered by skin, they are exposed to the air, which causes the plugs in the pore to oxidize, resulting in a black spot referred to as a blackhead. That dark spot is not dirt showing beneath the surface of the skin!

Papules: These are small, raised bumps that indicate inflammation is occurring in the hair follicles. Papules are unsightly, but typically not painful or sore.

Pustules: Larger than papules, these red, tender bumps have white pus at their tips and are a sign of more advanced, deeper inflammation. They can be painful.

Nodules: One of the most painful forms of acne, these bumps remain below the surface of the skin and are large and solid. They develop when buildup occurs deep within the hair follicles that are severely clogged.

Cysts: These are markedly painful, swollen, pus-filled lumps that form beneath the skin. They present increased risk of scarring due to their depth and collagen-destroying potential. These are also the type of breakout least likely to respond to topical treatments, especially traditional over-the-counter acne products.

Sebaceous filaments: If you look closely at the tip of your nose, you might see tiny dots that resemble blackheads. These marks may be blackheads if they are quite dark, but the dark “dot” you see when you look very closely is also the tip of the columnar structures that fill your pores. They’re known as sebaceous filaments, naturally occurring hair-like formations that channel the flow of oil along the lining of the pore in which they lie. [54] It’s a natural part of skin’s follicle (pore) structure that everyone has, but if your skin is oily or if your pores are large and prone to becoming clogged, you’re more likely to notice it. Removing these filaments manually is possible, but they return shortly, and truth be told, chances are no one besides you and your magnifying mirror notice them anyway. Nevertheless, if sebaceous filaments bother you, regular use of a BHA exfoliant can potentially make them less of a noticeable concern.

Why Does Acne Happen?

You might be wondering: Who gets acne? It’s estimated that 80% of all people between the ages of 11 and 30 will have acne breakouts at some point during this period of their lives, and it’s quite common for many women to have breakouts well into their 40s, 50s, and 60s. [53]

Believe it or not, as long as people have been struggling with acne and even though hundreds of studies have been done, the exact cause remains unknown. Researchers have narrowed it down to a group of several related factors. [27]

 Hormonal activity. Androgens (male hormones) increase in both boys and girls at the onset of puberty, causing the body’s sebaceous (oil) glands to enlarge and produce more oil. Oil production can also increase during pregnancy, or with starting or stopping oral contraceptives. In women, it decreases during menopause. [55]

 Medications. Medicines that contain or stimulate androgens, corticosteroids, and/or lithium can play a role in the development of acne.

 Heredity. Researchers believe that good old genetics could have a hand in whether or not a person gets acne. [56] Thus, if your parents suffered from breakouts, you’re at greater risk of suffering from them, too.

In addition to the actual causes of acne, there are other factors that can make acne worse if you’re already prone to breakouts, such as those below. [27]

 Hormonal changes that occur in girls or women two to seven days before the beginning of their menstrual cycle. It’s no surprise to women around the world that breakouts are quite typical during your period.

 Breakouts and oily skin can also plague women going through perimenopause (the beginning phase of menopause that normally begins after a woman turns 40) and during menopause. What happens is that estrogen levels (estrogen is the “female” hormone) drop, but the androgen levels (the male hormone that women also have) remain constant. [55] Androgens are a primary trigger of acne and when you have more of them in your body without the estrogen to balance it, your skin can start acting like you have a teenager’s skin, and not in a good way. The extra androgens cause the oil glands to produce more oil, and a stickier oil to boot, that can clog pores. There’s also the issue of older women having excess skin cells due to accumulated sun damage which can also lead to clogged pores.

 Sensitizing reactions to makeup, irritating skincare ingredients, specific foods (rarely), allergies, or medicines. Sometimes such reactions aren’t true acne, but rather what’s known as “irritant contact dermatitis.” The red bumps seen with this type of reaction can resemble acne and tend to happen quickly, while true acne develops over a longer period of time. [27,57]

 Inflammation caused by conditions inside the pore or by outside influences, such as using products that contain irritating ingredients, trying to “dry” up a pimple, or over-scrubbing. Squeezing pimples doesn’t increase the incidence of acne, but when done incorrectly, it can further inflame the breakout, potentially push the contents deeper into the pore lining, and generally keep it around longer. [27]

 Allergic reactions to foods such as milk and milk products, gluten, nuts, or fish can cause acne in some people, but there’s research showing that this may not be true. Nonetheless, if you want to see if certain foods are acne triggers for you, it’s easy enough to experiment to see how your skin reacts if you eliminate one or more of these from your diet for several weeks. [27]

We touched on this above but to elaborate a bit before moving on to the next section: Acne and its typical partners-in-crime whiteheads and blackheads aren’t the result of dirty skin. The black dots that comprise the tip of blackheads aren’t dirt; dead skin cells and oxidized oil make these plugs appear dark. You cannot wash or scrub acne, whiteheads, or blackheads away, so please ignore all products making such claims. In truth, finally getting your acne under control is far more involved than that.

Getting Acne Under Control Is the Same for Everyone

Although there really isn’t a cure for acne, there’s a lot you can do to greatly reduce the problem and get it under control. No matter what else you do, the most important thing to remember about acne is that it’s an inflammatory disorder, which means anything you can do to reduce or avoid inflammation is going to help keep breakouts, the swelling, and the telltale redness at bay.

We describe below key steps you can take to make sure acne doesn’t stick around for long.

Keep skin clean, but don’t overdo it. Clean skin is a good thing because washing removes the excess oil and dead skin cells that contribute to clogged pores and create conditions ripe for acne to occur. However, washing too often, especially if you use harsh cleansers or scrubs, will lead to irritation and chronic inflammation. (Remember, anything that causes inflammation will increase acne conditions in your skin.) The best way to go is to wash your skin twice a day (once in the morning, once at night) with a gentle, water-soluble cleanser. We can’t stress the “gentle” part enough!

Also stay away from bar soaps and bar cleansers—they can leave a film or residue on your skin, which in turn can clog pores and reduce the effectiveness of any anti-acne products you apply after cleansing. [58]

Avoid skincare and makeup products that can cause irritation. Irritation = inflammation, and that’s bad news! Unfortunately, many skincare and makeup products, including many claiming to treat acne, contain irritating, drying ingredients. Don’t use products that contain SD or denatured alcohol because it dries out skin and actually can lead to increased oil production. [3,4,53]

Also on the “do not use” list are mint (including menthol and peppermint), witch hazel, eucalyptus, or citrus ingredients, as they will wreak havoc on your skin—yet these ingredients show up in a shocking number of products claiming to help acne.

Be sure to remove all your makeup before going to bed. Sleeping with makeup on will prevent skin from exfoliating and also block pores, which increases the conditions that promote acne. If you wear heavy makeup or just want to feel extra clean (without causing inflammation), it can help to use a Clarisonic brush or a washcloth with your gentle water-soluble cleanser. After you’ve rinsed your face, follow with a gentle toner that contains anti-inflammatory ingredients or a gentle makeup remover to be sure every last trace of makeup is gone before your head hits the pillow.

Avoid overly emollient or thick moisturizers. These types of products not only make oily skin feel more oily and greasy, but also can block pores and even absorb into pores, adding to the clog that’s already there or creating a new one. No matter how you look at it, these types of products are usually a problem for someone struggling with breakouts and oily skin.

Exceptions to this are the small percentage of the population who have acne, clog-prone skin and dry skin with little to just-visible pores. This confusing skin type is not easy to treat. More emollient moisturizers may be necessary to deal with the dryness, but they can also clog pores. The best way to deal with this is to follow our skincare routine suggestions and then experiment to find the lightest lotion moisturizer that will take care of your dry skin and not trigger more breakouts. Layering two or three thin-textured hydrating products (for example, a water-based serum layered with a lotion moisturizer) may be necessary.

Does wearing makeup cause acne? Not for most people. Foundations are designed to stay on the top of skin; they don’t absorb into the pore and cause problems like thick, emollient moisturizers can. But what can cause acne is not getting all of your makeup off at night. So don’t blame your breakouts on the makeup you’re wearing, blame it on being a bit too tired at night to follow your skincare routine.

Use lighter hair-care products. If your hairstyle is such that your hair touches your forehead or the sides of your face, traces of the products you use to style your hair will also end up on your skin. Therefore, if you have acne-prone skin, you should avoid thick, waxy hairstyling products along the hairline because they can clog pores and lead to breakouts. Conditioners can also trigger acne breakouts, so avoid getting these on your face. If you have neck or back acne, try rinsing the conditioner in a way that prevents those areas from coming into contact with it.

Protect yourself from the sun. You might have heard that a good dose of sunlight can “clear up” acne breakouts, but there’s no research indicating that sun exposure clears up acne. Sun damage is yet another form of inflammation, and inflammation is necessary to avoid. [4,27] If you’re concerned that the emollient texture of your sun-protection products might cause breakouts, look for lightweight options. See the end of Chapter 9, Managing Oily Skin, for a list of some of our favorite lightweight, matte-finish sunscreens.

We realize that this is a lot of information to digest all at once, but preventing (or at least reducing) acne once you know what to use and what not to use can be surprisingly simple. We hope the information in this book will make your decision process far easier.

Acne Myths: A Reality Check

Regarding acne, there’s no shortage of advice and there are all sorts of theories as to what works and why. Among them are the following myths that turn up all the time, no matter how many times they’ve been debunked.

MYTH: You can dry up blemishes. Water is the only thing you can “dry up,” and a pimple has nothing to do with skin being wet. Drying up the water and other moisture-binding substances in skin actually hurts its ability to heal and fight inflammation, which encourages bacterial proliferation. [3,4,53] Absorbing oil that’s on the skin’s surface or in the pore is radically different from “drying up” skin with harsh ingredients such as SD or denatured alcohol, sulfur, camphor, and witch hazel.

MYTH: Acne is caused by not cleaning your skin well enough. This mistaken belief often leads to over-cleaning or scrubbing of the face with soaps and strong detergent cleansers, which only increases the risk of irritation, inflammation, and dryness, while doing nothing to prevent pimples. [53]

MYTH: You can spot-treat acne. Although you can greatly reduce the redness and swelling of a breakout with a salicylic acid (BHA)–based product or with a benzoyl peroxide disinfectant (both explained below), that doesn’t help prevent other breakouts from popping up on other parts of your face. Dealing with only the pimples and pustules you see means you’re ignoring those that are in the process of forming. [27,34]

As you may have guessed, spot-treating leads to a never-ending cycle of chasing acne around your face. Spot-treating tends to be most useful for those whose breakouts are consistently infrequent and localized (for example, always on the chin, nowhere else), rather than for those who experience them more frequently and/or randomly all over the face.

MYTH: If it tingles or feels cooling, it must be working. Ingredients that make your skin tingle, such as menthol, peppermint, eucalyptus, and lemon, show up in countless anti-acne products, yet there’s no research showing they have any benefit for acne or oily skin.

In fact, these ingredients irritate and inflame skin, only making matters worse! Irritating skin triggers stress-sensing nerve endings at the base of the pore, which in turn stimulate oil production. [4] That cooling sensation, however nice, has no ability to reduce acne.

MTYH: Eating chocolate or greasy food causes acne. Although it’s absolutely true that eating healthy food and an overall anti-inflammatory diet is good for your skin and your overall well-being, specifically eating chocolate or greasy food isn’t going to give you acne. [53] If that were true, then everyone who ate either of these things would have acne, and that’s simply not the case! On the other hand, diets high in sugar, dairy products, gluten, nuts, and fish may worsen acne for some people. [59,60,61,62,63]

MYTH: You can scrub acne, whiteheads, and blackheads away. It can help to use a gentle scrub as an extra cleansing step, but it won’t change acne conditions in skin. None of these problems are about skin being dirty or needing a “deep” cleansing.

In terms of blackheads, gentle scrubbing can remove only the top portion of the problem, kind of like mowing over a weed rather than pulling it out of the soil, roots and all. That’s why, within a day, if not within hours, of scrubbing blackheads, the dark dots are again lining your nose and cheeks. [64] The same concept applies to blackhead-removing pore strips, and the adhesives on these strips can be quite irritating. Depending on the scrub and how you use it, you most likely will be inflaming your skin, making matters worse!

MYTH: “Non-comedogenic” products won’t cause breakouts. You’ve no doubt seen the term “non-comedogenic” dozens of times—you may even look for it when shopping for makeup, in the belief that a product with this claim won’t clog pores or cause acne. Unfortunately, non-comedogenic is a totally unhelpful claim; the term was coined under test conditions that are not even remotely applicable to how you, or anyone else for that matter, use beauty products.

How did the non-comedogenic myth get started? It stems from a 1979 study published in the British Journal of Dermatology. [65] This study examined the potential of various ingredients (cocoa butter, for example) to clog pores and lead to the formation of comedones (a fancy word for blackheads and whiteheads). This potential was determined by applying a pure amount of an ingredient to the skin on a rabbit’s ear.

Here’s the kicker: Each ingredient was layered five times per application over a period of two weeks, without cleansing the skin at any time. [65] Can you imagine? This methodology easily dispels the entire notion of these tests relating in any way to how skincare products or makeup are actually formulated (it’s the rare skincare product that contains only one ingredient) and to how people really use them.

What really determines whether an ingredient in a makeup (or skincare) product is likely to trigger a breakout is how much of an ingredient is present in the formula. A tiny amount of an ingredient, even mineral oil or a thickening agent, in your moisturizer, blush, foundation, or concealer is not going to cause or exacerbate a breakout. By the way, the researcher largely credited for developing the concept of comedogenic, Albert Kligman, said as much in his 1972 study, “Acne Cosmetica”:

“It is not necessary to exclude constituents which might be comedogenic in a pure state. The concentration of such substances is exceedingly important. To exile such materials as lanolin, petroleum hydrocarbons, fatty alcohols, and vegetable oils from cosmetics would be irrational. What is ultimately important is the comedogenicity of the finished product.” [66]

Like most of the beauty advice from the 1970s (for example, when we used baby oil to increase the effects of the sun to get a deeper tan while sunbathing), it’s time to retire the whole concept of “non-comedogenic.” It’s just not helpful, and how many of us have bought products claiming they won’t cause breakouts—yet we broke out anyway?

What to Avoid

OK, so we know that no one can say with certainty whether or not a product will or won’t exacerbate a breakout if you’re already prone to acne. What we can do is make your search easier by helping you identify the biggest culprits—namely irritating ingredients and products with thick, waxy textures. If you start experimenting by eliminating these from your skincare routine, we’re sure you’ll see important changes for the better.

Avoiding products that contain irritating ingredients is critical for everyone, but especially for those who have oily, acne-prone skin, because inflammation can worsen breakouts and oiliness.

The tricky part about irritation is that research has demonstrated that you don’t always need to see or feel irritation or inflammation for your skin to suffer damage.[2] Just because you don’t see redness on the surface doesn’t mean that damage isn’t taking place underneath the surface, silently hurting the skin in a variety of different ways. This fact explains why some people can use irritant-laden, anti-acne products, yet not suffer obvious signs of irritation.

It’s also important to understand that the effect of inflammation on skin is cumulative, and repeated exposure to irritants contributes to a weakened skin barrier, slower healing (including of red marks from acne), and a dull, uneven complexion. [67]

If that weren’t enough, inflammation in the skin plays a major role in increased breakouts and making oily skin oilier. [28,29] It’s really, really important to avoid alcohol-based or fragrance-loaded skincare and makeup products.

As discussed above, it’s also helpful to avoid any product with a thick, heavy, or creamy texture, such as some moisturizers and makeup products. If you’re acne-prone, thick or solid makeup products such as stick, pancake, cream, or cream-to-powder compact foundations and concealers should be on your “must avoid” list—or at least avoid using them on areas where you’re prone to breaking out. The problems with these kinds of products are that they’re harder to remove from skin and because the heavier waxes they contain can become stuck inside the pore lining, creating a clog.

The same goes for bronzers or blushes in stick, cream, or cream-to-powder forms. The types of ingredients that keep these products in a solid form are iffy for use by those with breakout-prone skin.

Over-the-Counter Acne Treatments That Work

When you’re battling acne breakouts, the key is to look for ingredients that are proven to combat acne effectively, yet gently. The two best over-the-counter acne-fighting ingredients, as demonstrated by peer-reviewed medical and scientific research, are salicylic acid (also known as beta hydroxy acid or BHA) and benzoyl peroxide. [33,68] Research has shown that these two ingredients are as beneficial, if not more so, as prescription-only acne medications for mild to moderate acne.

Salicylic Acid: Also known as beta hydroxy acid (BHA), salicylic acid is an amazing multifunctional ingredient that treats acne in several ways. It not only has potent anti-inflammatory properties, but also exfoliates to remove the buildup of dead skin cells on the surface of the skin as well as inside the pore. Salicylic acid also has mild antibacterial properties. [33,34]

Because salicylic acid is a derivative of aspirin (both are salicylates; aspirin’s technical name is acetylsalicylic acid), it also has some of aspirin’s anti-inflammatory properties. That means it reduces inflammation, redness, and swelling, helping skin heal. [33] This in turn helps prevent scarring, while also decreasing the chance of further breakouts. Salicylic acid’s antimicrobial properties also help kill the bacteria that cause acne. [69] Together, these properties make salicylic acid an MVP in the game of you versus your acne—a game we want you to win!

For salicylic acid formulas to be effective, they must have a concentration of at least 0.5%, although 1% to 2% is far more effective; plus, the formula’s pH is a critical factor, with a pH of 3 to 4 being optimal. [70] Surprisingly to us, many salicylic acid products for acne don’t meet these requirements, so they don’t work well, if at all, on acne and clogged pores.

In addition, the product must not contain any irritating ingredients because such ingredients cause inflammation as we’ve stated so many times (because it’s so important), potentially delaying healing and increasing oil production deep within the pore, keeping you on an endless cycle of clear skin–more acne, clear skin–more acne…Fortunately, well-formulated salicylic acid products do exist, and you’ll find them from Paula’s Choice and from other brands recommended at the end of this chapter.

Benzoyl peroxide is considered the most effective over-the-counter choice for a topical antibacterial agent in the treatment of acne. It penetrates into the pore and kills acne-causing bacteria, thus reducing inflammation. It does present a risk of irritation, but the risk is low compared with the benefits, and unlike antibiotics used to treat acne, it doesn’t have the potential to create bacterial resistance. [33]

The concentration of benzoyl peroxide in products usually ranges from 2.5% to 10%. A 2.5% benzoyl peroxide concentration is far less irritating than a 10% concentration (not irritating skin is always the goal), and it can be just as effective. If your skin doesn’t respond to the 2.5% concentration within a week or so of daily use, try a 5% concentration. [33]

Generally speaking, if your acne doesn’t respond to a 5% concentration of benzoyl peroxide, then the next step is to consider topical prescription options (such as a topical antibiotic mixed with smaller concentrations of benzoyl peroxide) before trying a product with 10% benzoyl peroxide. Concentrations of benzoyl peroxide over 5% have been shown to tip the scale in favor of irritation, causing dry, flaky, and inflamed skin. Not surprisingly, this causes more problems than it helps. [71]

Note: Research shows that combining benzoyl peroxide with topical antibiotics reduces the risk of the bacteria developing resistance to the antibiotic, which means the antibiotic will be effective over a longer period of time. [72] This combination also has been shown to reduce inflammation, making it a good ingredient in some prescription options for stubborn breakouts that aren’t responding to over-the-counter treatments such as benzoyl peroxide and salicylic acid. There are numerous topical prescription products that contain benzoyl peroxide + an antibiotic. Your dermatologist can help you determine which one is best for you.

Important note: When you’re struggling with acne, you must be consistent with your anti-acne treatments. For many, breakouts are an ongoing problem, not a “one and done”–type deal. Ongoing, consistent use of anti-acne treatments is required to maintain the results and to keep new breakouts from forming. Daily adherence to a treatment routine is essential for success!

When OTC Acne Treatments Aren’t Enough

Some cases of stubborn acne just won’t go away with over-the-counter medications alone, no matter how well-formulated they are. Instead of spending more money on product after product, if you notice your acne isn’t improving after several weeks of being consistent with your skincare routine, it’s time to see a dermatologist.

A dermatologist has numerous topical and oral prescription options to treat acne, from retinoids like tretinoin or Differin® to antibiotics and oral vitamin A (isotretinoin, formerly sold under the brand name Accutane). Each has its share of pros and cons, which you should discuss with your doctor. Following is an overview that will help you understand the options your doctor may suggest.

Important reminder: Using prescription-only products for your acne doesn’t change the basic skincare routine you need to follow. Bar soaps, harsh cleansers, abrasive scrubs, and products that contain irritating ingredients or overly waxy products will still harm your skin and increase the likelihood of your skin not being able to tolerate these prescription treatments.

Prescription topical antibiotics are an option if you haven’t gotten good results using over-the-counter treatments containing salicylic acid and benzoyl peroxide.

There are several topical antibiotics to consider; the main ones to discuss with your dermatologist are erythromycin, clindamycin, minocycline, and tetracycline. These can be used alone, but a good deal of research indicates that you can derive greater benefit without some of the side effects by combining one of these antibiotics in lower doses with benzoyl peroxide to create a far more potent and effective treatment.

Dapsone is a topical disinfectant gel available by prescription in 5% strength. The brand name for this anti-acne drug is Aczone. A recent study involving 347 adolescents and 434 adult women showed dapsone 5% gel used twice daily was effective in reducing inflammatory and noninflammatory acne lesions in both adolescent and adult women, but was even more effective for adult women. [73]

Retinoids, such as prescription tretinoin (Retin-A, Avita, Atralin, and generics) and other vitamin A derivatives, such as tazarotene (Tazorac®, Avage®) and adapalene (Differin®), can play a significant role in an anti-acne treatment routine. [74]

Retinoid is the name of the general category for any and all forms of vitamin A. Prescription retinoid options are viable treatments for breakouts because they change the way skin cells are formed in the layers of skin as well as in the pore, improving how skin cells shed while unclogging pores, thereby significantly reducing inflammatory lesions. Retinoids also have anti-inflammatory action, making them even more compelling.

Topical tretinoin and many antibacterial agents have complementary actions, and they work well together, but applying both at the same time increases the chance of side effects such as dryness, redness, and/or peeling. If you experience side effects, it’s best to use the two separately, applying the antibacterial product in the morning and the prescription retinoid (be it tretinoin or another type) at night. Benzoyl peroxide does not deactivate newer formulations of tretinoin as it did in the past. [75]

Azelaic acid is believed to work against acne-causing bacteria in concentrations of 15%–20%, and it may also pack an anti-inflammatory punch. [76] Azelaic acid was approved for the treatment of acne in the United States in 2002, and also is prescribed to manage the symptoms of rosacea (some of which are similar to those of acne). It’s definitely on the A-list of prescription options for treating acne—no pun intended. (Azelaic acid is not a prescription treatment in most Asian countries.)

Stay the course! For any topical acne treatment to work, whether prescription or over-the-counter, consistency is vital. Unfortunately, because almost all topical options can be hard on skin (at least at first), it’s even more important to follow our suggestions for gentle skincare. Too often, skincare recommendations, even from dermatologists, include using products with irritating, drying ingredients that cause damage and inflammation. This means you’ll struggle with being able to use acne-fighting treatments successfully. Please don’t make the mistake of reverting to an outdated, problematic way of caring for acne- or breakout-prone skin. The research is clear that irritation makes acne worse, but a lot of salespeople, aestheticians, and physicians ignore or aren’t familiar with this—but now you are!

Oral antibiotics can be extremely effective in controlling acne, but they also pose a risk of serious side effects that you must consider. Oral antibiotics do indeed kill the bad bacteria, but they also kill the good bacteria in the body. Thus, ongoing use can lead to chronic vaginal yeast infections as well as stomach problems. In addition, the acne-causing bacteria can become immune or resistant to the oral antibiotic. [77] That means if you’ve been taking an oral antibiotic to treat your acne for longer than six months, it can, and almost always does, become ineffective against the acne, although the negative side effects—killing good bacteria and causing stomach and other problems—could continue.

However, some research has shown that taking low doses (“sub-microbial” or subclinical doses) to fight acne is moderating the concern about bacterial resistance and adaptation. [68] Taking such low doses of oral antibiotics over the long term can improve acne, while minimizing, if not completely eliminating, the problem of the bacteria becoming resistant. It seems that lower doses of oral antibiotics have anti-inflammatory benefits instead of antibacterial benefits, but they still can kill acne-causing bacteria. That doesn’t mean you won’t suffer from possible systemic effects, though; so, whether you opt for regular or low-dose oral antibiotics, be sure to discuss the pros and cons with your dermatologist.

Birth control pills (some types) have been shown to reduce acne lesions and oil production, in part by decreasing androgens (male hormones), which are largely responsible for causing acne.

Birth control pills are a combination of different synthetic estrogens and progestins (female hormones). Some progestins can increase the amount of androgens in the body, while others block the production of androgens. Because androgens stimulate oil production, blocking androgens for those prone to breakouts and oily skin is a good thing.

As a result, some of the birth control pills that block androgens have been approved by the Food and Drug Administration (FDA) and other regulatory organizations for the treatment of acne. These include Ortho Tri-Cyclen (active ingredient: norgestimate/ethinyl estradiol), YAZ (active ingredient: drospirenone/ethinyl estradioland), Estrostep Fe (active ingredient: norethindrone/ethinyl estradiol). Diane-35 (chemical name: ethinyl estradiol cyproterone acetate) has been approved for such use in Canada.

Keep in mind that there are risks associated with taking any type of birth control pill (especially if you smoke), and you should discuss these matters with your doctor. [78] Birth control pills also should not be the sole therapy for acne; think of them as a partner product for use with a skincare routine designed to reduce acne.

Alternative Acne Treatments

The world of alternative acne treatments is wide and varied. It includes options that are easily obtained at the drugstore, some that you can find at your local health supplement retailer, and even options in your grocery store, particularly if you frequent natural markets. We describe some of these options below.

Tea tree oil has some interesting, though minor, research demonstrating that it’s an effective antimicrobial agent, although it’s not without its drawbacks. In a study comparing tea tree oil with benzoyl peroxide, it was found that a 5% concentration of tea tree oil has an efficacy similar to that of 5% benzoyl peroxide. [33] That sounds as if the two are equally effective, but in the world of skincare it doesn’t work that way. It turns out there aren’t any skincare products that contain 5% tea tree oil. The highest concentration of tea tree oil we’ve ever seen in a cosmetic product is less than 0.5%, which likely makes it ineffective for treating acne. [33] “Pure” tea tree oil is typically only a 3% concentration diluted in a carrier oil, so even that isn’t strong enough, despite the “100% tea tree oil” statement you might see on the label.

Niacinamide and nicotinic acid are derivatives of vitamin B3. There are a handful of studies showing they can be helpful for improving the appearance of acne, which most likely is the result of their anti-inflammatory and barrier-restoring properties. [79,80] When included as part of an anti-acne skincare routine, these B vitamin ingredients can be part of a powerful combination of products and ingredients to combat the series of events taking place in the skin that lead to acne. Niacinamide has anti-aging benefits as well, so it’s a brilliant solution for those struggling with wrinkles as well as acne. [79,80]

Prebiotics and probiotics are microorganisms that occur naturally in the body and are present in many of the foods we eat, such as yogurt. Although they can be helpful when consumed, the research on prebiotics and probiotics related to topical application and their effect on acne is non-existent, so any benefit remains theoretical, although there has been at least one study that indicates they may have potential. [81] There’s no harm in trying this option, via foods and/or supplements. As far as skincare products, we just haven’t seen any that would be able to keep the prebiotics and probiotics stable or contain enough to provide any meaningful benefit.

Fatty acids are an interesting group of ingredients that can have an effect on breakouts, but exactly what that effect is, either positive or negative, isn’t clear; far more research is needed. [82,83] There are only a few studies showing how fatty acids may improve matters but none are conclusive in the least.

Fatty acids, such as lauric, oleic, and palmitic acids, can have an antibacterial effect on P. acnes. However, their stability is an issue: A product that contains a fatty acid must be carefully formulated to ensure the fatty acid can exert its antibacterial action before it breaks down. If these fatty acids are present in skincare products that are packaged in a jar, chances are good they’ll break down before they can really help your skin, because air exposure causes these fatty acids to turn rancid.

Sulfur can have some benefit as a disinfectant for breakouts. [33] However, compared with other options, it’s an overly strong ingredient for skin, potentially causing more irritation than needed to fight acne-causing bacteria. For this reason, using sulfur to manage acne has largely fallen out of favor, so it’s actually hard to find sulfur-based acne products, which in the long run is best for most people’s skin. Nonetheless, when all else has failed, this may be an option to consider.

Diet can have both a positive and negative effect on acne. Reactions to certain foods can cause acne, while other foods may help reduce the frequency of occurrence. [63] Reactions to foods such as dairy products (mostly due to naturally-occurring hormones in dairy) or excess sugar intake can have varying degrees of influence on acne breakouts, depending on the individual. [59,60,61,62] Identifying which, if any, are true for you can lead to a significant and relatively rapid improvement in your skin. It takes experimentation to see what’s true for your acne. Links to dietary factors such as shellfish, gluten, or peanuts are anecdotal, and haven’t yet been demonstrated in research, but if you’re wondering if this is true for you it’s easy enough to experiment by eliminating one or all of these to see how your skin reacts. [84]