What doctors wish patients knew about acne treatment

AMA News Wire

What doctors wish patients knew about acne treatment

Oct 27, 2023

Acne is a skin condition that affects millions of people worldwide and has long been a source of frustration and self-consciousness. The good news is there are acne treatments provided by physicians that can offer new hope to patients seeking clear and radiant skin. Whether you are a teenager navigating the challenges of adolescence or an adult grappling with stubborn breakouts, knowing what to do to improve acne is key. 

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The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two physicians took time to discuss what patients need to know about acne treatment. They are:

• Lauren A. Fine, MD, a dermatologist and cosmetic surgeon at The Derm Institute of Chicago.
• Hillary Johnson-Jahangir, MD, PhD, a dermatologist in Coralville, Iowa, and a delegate for the American Academy of Dermatology Association.

“While we commonly imagine teens and young adults as the ages with acne, acne vulgaris can continue or start in older adulthood,” Dr. Johnson-Jahangir said, noting “it can change with age due to flux in hormone balances.

“Older individuals are also more likely to develop a different form of acne called acne rosacea that comes with different triggers and treatments,” she added.

“With patients who are seeing me for more moderate, severe forms of acne, there’s a good chance that one of their parents or family members has also suffered from acne,” Dr. Fine said, noting “we know that there are a lot of associations and things that may make you more predisposed to getting acne.”

For example, “at the more cellular level, we know that acne develops from the actual clogging of the pore or excessive oil production,” she said. “And once that pore is clogged and there’s excessive oil, that can be a perfect breeding ground for bacteria to grow within the sebaceous gland.

“What that triggers is more of an inflammatory cascade, which then you’ll get more bacteria, more inflammation,” Dr. Fine added.

“There is no cookie cutter treatment for acne—not everyone gets the same four ingredients or products,” Dr. Fine said. “So, doing a good physical exam and a full history will enable you to figure out what’s best.”

“Guidelines stratify treatment options for acne vulgaris depending if the acne is mild, moderate or severe and where the acne is located on the body,” Dr. Johnson-Jahangir said. “Mild acne is often treatable using an over-the-counter acne cleanser that contains benzoyl peroxide, which reduces acne-causing bacteria like Propionibacterium acnes and breaks down clogged pores.

“Newer formulations can be more moisturizing and less irritating,” she said, noting “benzoyl peroxide is often combined with a topical retinoid medication that ranges from over-the-counter adapalene to a variety of prescribed options.”

Additionally, “retinoid creams are best for ‘comedonal acne’ that appear as small bumps or pores filled with dead skin cells,” Dr. Johnson-Jahangir said. “Topical antibiotics, usually clindamycin, when used, should only be used in combination with benzoyl peroxide to prevent antibiotic resistance that rapidly develops when topical clindamycin is used alone.”

“For moderate or severe acne, oral antibiotic medication can be considered for a brief course to provide quicker relief by more rapidly reducing skin inflammation for clearing deeper bumpy skin lesions,” she said. But “we don't use oral antibiotics long term due to health risks such as altered microbiome and antibiotic resistance.”

“When a hormonal trigger is identified, select oral contraceptive medications or androgen reducing medication such as spironolactone is considered,” Dr. Johnson-Jahangir said. “Oral isotretinoin is offered for moderate or severe acne in many situations when other treatments are ineffective or not tolerated, to address incipient scarring, psychosocial distress or other needs.” 

The downside is there can be some disruptions to care due to prior authorization.

“For some insurances, it can be a step process to get to and some of the requirements are illogical and inappropriate,” Dr. Johnson-Jahangir said. For example, “some of them require prescription of oral antibiotics for mild acne in order to get a retinoid cream, which is illogical because the proper treatment is not antibiotics, and they are riskier.”

“So, there’s some insurance required processes for some of them that are not what you would think makes sense and not in step with treatment guidelines,” she said. “Unfortunately, it just highly depends on the type of insurance, which can vary for different states and regions.

“And for each insurance, sometimes there’s no prior authorization, sometimes there is and sometimes there’s step therapy requirements. It just varies,” Dr. Johnson-Jahangir added.

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“Oral isotretinoin, commonly known as Accutane, has been used for the effective treatment of severe acne for over 30 years,” Dr. Johnson-Jahangir said.

But while questions around the association between inflammatory bowel disease (IBD) and certain acne medications come up a lot, this association is simply “not true,” Dr. Fine said, noting “a recent meta-analysis from 2022 looked at this very question and there is not an association.”

“The American Academy of Dermatology has concluded there is not enough evidence to show a relationship between taking isotretinoin and getting IBD,” Dr. Johnson-Jahangir said. “It's possible there is a relationship between having acne and getting IBD, and this is an area of research.

“Dermatologists continue to prescribe isotretinoin safely for appropriate patients,” she added.

“Common side effects of many topical acne medications are tendency to cause skin irritation that can limit tolerability,” Dr. Johnson-Jahangir said. That is why “it can take finesse and practice to optimize use.”

“A physician and their team can help give best instructions for use to help manage expected effects and set up for success,” she said, noting “oral medications should be prescribed under the care of a physician who will address each medication's specific concerns.”

“Most commonly used medications are well tolerated, but some do have potentially serious risks to consider,” Dr. Johnson-Jahangir said.

“Treatments work better at preventing new acne instead of clearing up what's there,” Dr. Johnson-Jahangir said, noting “it often takes a few months to see improvement, and most medicines will need to be continued long term to keep up the benefit.

“Physicians will see acne patients back to check if the medication can be used long term or if a change is needed,” she added, noting that “oral isotretinoin therapy is the only medication that can lead to long term resolution after a course of the therapy.”

“If you’re getting any sort of acne that’s leaving significant marks or scars, it really does need to be treated because certain types of scarring can be permanent,” Dr. Fine said. “Even mild acne can cause significant discoloration in darker skin types, and it is often the post inflammatory color change that can take the longest to fade and be the most bothersome to the patient. Rarely, acne can clear up on its own or by using over-the-counter acne treatments alone.”

"Hormones and stress are the most common triggers for adult-onset acne, but there are other factors to consider,” she said. “While dietary factors are not strongly linked to most acne cases, there is clear evidence that excessive daily intake as well as over consumption of foods with a high glycemic index can cause flaring for certain people." 

That is why “it is imperative to obtain a thorough history to determine if lifestyle or dietary factors are playing a role,” Dr. Fine said. “Another reason it is important to see a board-certified dermatologist—even for mild cases—is to educate the patient as to what and what not to be doing. 

"Usually once a patient is in my office, they have tried over 10 different acne treatments. Yet they are still in my office,” she added, noting “successful treatment involves first going through a patient's current regimen and explaining what is and what is not needed.”

“Often, I'll find they are using 3 different products that contain ingredients that serve to exfoliate. While all may be effective choices, using all three products together will cause excessive dryness and irritation and further exacerbate the issue,” Dr. Fine said. “When the skin barrier is compromised from over doing it with products it will just trigger more inflammation and make any medication less effective."

This is important. When a pimple first appears, most people immediately try to pop it. Don’t do that.

“When you pop a pimple, essentially what is happening is you’re putting this pressure that typically ends up driving the sebum or oil deeper into the skin and can actually lead to more inflammation and then make the pimple more likely to sprout friends,” Dr. Fine said. “So, if you have a very painful pimple that is really coming to a head, it’s juicy, you see that whitehead, use a warm compress.

“Gently lay it on the skin for a few minutes and then apply very mild pressure not directly to the lesion but to the skin around the lesion. That is as close to popping as I will ever advocate,” she added.

“Gentle skin care is key. To maintain a healthy skin balance, use a gentle skin cleanser (no harsh soaps) daily, an oil-free facial skin moisturizer and broad-spectrum facial sunscreen of at least SPF 30 or combination sunscreen and moisturizer,” Dr. Johnson-Jahangir said. “These all work to keep skin healthy without scrubbing or drying out. That can make acne worse. Products designed for use on the face are tested to not make acne worse, called non-comedogenic.”

“Avoid aggressive exfoliation or treatments designed to strip the skin of its natural oils,” she said. “Harsh soaps or aggressive use of toners or exfoliation can have the opposite effect of irritating the skin, stimulating increased skin oil production and acne.”

Additionally, “some over-the-counter acne preparations are chemical exfoliants like salicylic acid or glycolic acid and work by breaking up dead skin cells but need to be used with care to avoid over-exfoliation, skin irritation and worsening of acne. They are not tolerated by everybody.”

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“Dietary factors and stress are not direct causes of acne. They certainly play a strong role, especially if people are predisposed to acne,” Dr. Fine said. “There have been studies that do conclusively show that for certain individuals, excessive dairy intake and foods that have a high glycemic index—junk food, sugary foods, foods that make your blood sugar go up very fast and then drop very fast—can play a role in acne.”

“There is a correlation between those two food groups. So, if you are predisposed to acne and if you had a very dairy-rich, junk-food diet, yes, that could worsen acne,” she said. “I’m never going to recommend doing crazy elimination diets or completely cutting out any food group, but if you’re someone who maybe has a smoothie every day, eats a lot of yogurts, be more aware of those two.”

“Stress isn't a direct cause of acne but is theorized to worsen acne if increases in cortisol alter the hormone balance or neurogenic pathways that affect the skin,” Dr. Johnson-Jahangir said.

“Stress affects every part of your body in ways that most people don’t even realize,” Dr. Fine. “Because inflammation is one of the key factors in the acne process, stress bumps your inflammation pendulum towards a more proinflammatory state.”

“In my practice, I do a lot of treatment of severe scarring from severe acne, which can really go on to affect someone’s whole life—their confidence, their ability to feel comfortable around other people,” Dr. Fine said, noting that any acne that’s bothersome should be treated by a physician “because now more than ever, the skin-care market is crazy and it’s ever expanding.”

“It’s very hard—even with mild acne—to go into the drug store and know what products you should use to treat your acne,” she said. “There are great drug-store products you can treat some acne with … but it does require a visit to the doctor to explain what’s going on, what you need and what you don’t need.”