This afternoon, it’s the second and final part of my series on Adult Acne treatment, you can read part 1 here. I hope the first part gave you a bit more information and most of all motivated you to make an appointment with your GP to discuss your skin if it is a problem for you. Please don’t be put off if things haven’t worked in the past or if you have met an unsympathetic ear. Try a different GP or go back to your preferred one and have an open conversation about your concerns and what you would like to do about them. A good GP will guide your decisions by informing you about the options that are best suited to you.
Today I’m talking you through the treatment options and hope to give you some understanding of who they are best suited to and why.
Lotions and Potions
The first option for treatment is a topical medicine, ie one that you apply directly to the skin in the form of a gel or cream. Don’t be fooled by the formulation, these can be as effective as oral treatments (tablets) when you find the right one.
The catch? ALL acne treatments take 2-4 months to reach their maximum effectiveness and you are a key factor in that. You need to be religious about applying it as prescribed (all over the face, not just on spotty areas,) and patient while you wait to see a difference. A rule of thumb I give my patients is to expect a 10 % reduction in acne per month and no difference for the first month. (So bear in mind if you have only a few spots, it can take a while to see even one less.) Patient and pharmaceutical info varies but most suggest around 12 weeks use to assess results. Pretty disheartening, but if you’re prepared for the long haul you’re often pleasantly surprised by the results.
The topical treatments broadly speaking have three different mechanisms of action: Those aimed at stripping the top layers of skin, those containing antibiotics and those containing Vitamin A derivatives, along with combinations of two types. Some commonly used preparations include Benzoyl Perozide (PanOxyl) Benzoyl Peroxide plus an antimicrobial (Duac, Quinoderm) Antibacterials, (Zineryt, Dalacin T,) and topical retinoids, (Differin, Isotrex, Isotrexin, Retin-A.)
Acne and The Oral Contraceptive Pill
Lots of women blame their acne on starting the pill, others want to start the pill as a treatment method. In truth, acne occurs at a time of life when many women need contraception, thereby implicating the pill in the problem, often falsely. In terms of using the pill as a treatment for acne, opinion varies.
My personal opinion is that if you have acne, treat the acne, if you need contraception, take it. Only in circumstances where women come needing contraception as a priority and hoping to improve their skin as a secondary concern, do I offer the pill. The reason for this is simple. There is no guarantee that the pill will clear up your skin. If it does, then great, but it is equally likely to increase your spots by upsetting your hormone balance or increasing skin oiliness.
From a medical point of view, the recommendation is trying a standard pill with a specific combination of hormones, like Microgynon 30, Brevinor or Loestrin 30. Of course, all the normal discussions should take place with your doctor or nurse about your suitability for the medication. Yasmin, (a different combination of oestrogen and progesterones) is often heralded by the media as the ultimate pill for skin sufferers, however it is not recommended as a first choice of treatment due to a lack of evidence for its effectiveness against acne.
Dianette is another second line option for treating acne, which is an anti-androgen and reduces oil production. Although it has a contraceptive effect, it should not be used solely for contraception and carries the usual risks of combined oral contraceptives that your doctor will check before prescribing it to you.
Lastly, the progesterone only pill and progesterone only methods of contraception can cause acne or make it worse. You may have to weigh this up against your need for contraception if the combined pill is not an option for you (if you have migraines for example) and decide which is more important.
As I said above, oral antibiotics (in tablet form) aren’t necessarily the next step for acne treatment but are often used as a ‘step up’ option. One indication for choosing oral antibiotics is the need for treating wider areas than just the face, for example acne on the chest or back, where it is hard to apply a topical cream. They can also be useful where compliance is an issue. For example, you might choose not to use a cream because it feels uncomfortable on your face, or maybe you’re that person who doesn’t take their make-up off at night… not conducive to remembering a cream too! You do need to take them for just as long, I usually review patients at 4 months before considering a change of antibiotic or type of treatment. You can combine oral antibiotics with topical treatments too.
Some of the popular preparations we use are Lymecycline, Oxytetracycline and Erythromycin. I prefer Lymecycline as it has good effectivity, low resistance against it and is a once a day preparation.
A word on antibiotic resistance. Resistance to antibiotics (and this goes for other situations they are used in too,) is only an issue when using the same antibiotic for long periods of time, so can be a problem in acne. There is an increasing amount of resistance to Erythromycin for example and we don’t recommend the use of topical creams that contain antibiotics after the acne has cleared up or for more than 6 months – switch to something without antibiotics for long term maintenance.
Specialist referral and Roaccutane.
Once all of the above treatments have been tried then your doctor might feel that you need a specialist opinion from a hospital Dermatologist. You should be prepared that your GP is likely to try and treat you without referring you (depending on their level of confidence at treating acne,) for several reasons. Firstly, many acne sufferers can get good relief from ordinary prescription drugs, secondly, it can take some time to find the right one for you and thirdly, there are strict criteria for starting a patient on Roaccutane. Although we as GP’s are not allowed to prescribe Roaccutane (because of the monitoring that needs to be done for patients who are on it,) we are aware of those criteria and there is no point referring someone who doesn’t fit them. However, if you are not being referred and your acne is leaving lasting scars or producing hard inflamed cystic lumps on your skin that take weeks to resolve, you should ask to be referred.
Roaccutane is a retinoid and Vitamin A derivative which works by reducing the skins oil production. Less serious side effects include extreme dryness of the skin and peeling or flaking, particularly on sensitive areas like the lips. Skin can also be very sensitive to light so should be protected even on cloudy days with sunscreen. Roaccutane is teratogenic, which means it can cause birth defects in babies of women who become pregnant whilst taking the drug. Female patients must have fool proof contraception (i.e. a coil or implant) in place before starting to avoid pregnancy. The bit that has received media attention however is the effect on mood. There are rare cases of Roaccutane causing: depression, anxiety, aggression or hallucinations, sometimes even leading to thoughts of self harm or suicide. Sadly there have been a few high profile cases reported in the media of teenagers who have committed suicide on the drug. What we don’t know is if they would have had depressive tendencies even without taking it. The important thing to remember is that this is a very rare side effect. With every medicine available we weigh up the potential risks of taking it against the benefits the patient might experience. Many many people achieve good clearance of their acne and minimal side effects but only you can decide whether it is the right treatment for you and a risk you are prepared to take.
I hope this helps some of you consider your options – please do pass it on to any friends you have who suffer with their skin. If it can help just a few of you, I’ll be very happy.
In the meantime, again, although I can’t give individual medical advice here and I would encourage you to visit your GP (I know, I know, broken record!) I’ll do my best to answer any questions. I think some of the questions which went unanswered last week are addressed in todays post too. I’d also be interested to hear if there are any other medical issues that you would like to see covered – I’ve already had an email suggesting one topic and whilst it won’t be a regular series and I can’t guarantee it will be suitable for coverage here, I’ll do my best
Here’s to clear skin!
- This article was complied using my knowledge and day to day practice. I also referenced the NHS website Clinical Knowledge Summaries, GP Notebook and the BNF.
- British Association of Dematologists patient information leaflet: Acne
- Patient.co.uk Patient information leaflet: Acne
Disclaimer: Although written by a qualified GP, this article does not substitute you attending your own GP and should not be used for individual medical advice. No liability can be accepted for decisions made on the strength of information contained here or elsewhere on Florence Finds.