Updated: Sep 6, 2021
If you're reading this, you're likely experiencing a difficult breakout. It may be emotionally draining, painful, and downright annoying. There are so many simple tips suggested on the internet for acne, but this isn't a simple tip. It is an all inclusive, fully informative breakdown of how to treat your acne for your skin type, the way you want to.
First, you should identify your skin type. We can classify this as sensitive or not-sensitive, and dry, combination, or oily. This will help guide which ingredients will work best for you.
There are many classifications of acne. We are going to keep it simple. There are blackheads, whiteheads, papules or pustules, and cysts or nodules. We will focus on these.
Here are some other identifiers to keep in mind. Teenage acne often consists of whiteheads and blackheads. Hormonal acne more commonly occurs on the lower face, and often consists of papules and cysts.
It is important to treat the active acne first, then damage caused by the acne, such as hyperpigmentation and scarring can be treated.
I like to break down treatment options as over the counter skin care, prescription topical medications, and prescription oral medications. It is always appropriate to begin with less invasive options first.
Over The Counter Skin Care
The most common ingredients or products to treat acne are retinols, chemical exfoliants, and topical antibiotics. All skincare products can be delivered by means of washes, foams, gels, serums, creams, and more. Keep in mind, some types of products are meant to cause more action. Face washes sit on the face for a few seconds or minutes, and will not change the skin as much as an overnight serum or gel. Toners often also tend to be gentle. Any type of product may also be formulated with products that combat irritation, like creams formulated with emollients (like glycerin or petrolatum) or humectants (like ceramides or hyaluronic acid).
Before considering ANY treatment for acne, SPF (minimum 30) every two hours is a must. The skin needs to be protected, because most acne treating products will cause sensitivity. Some sensitive skin types are only sensitive because of not protecting the skin enough with proper SPF.
It is also important to understand how to care for irritated skin. When irritated, take a break from actives (below) and replace them with gentle moisturizers and SPF.
Vitamin A is used for skin cell turnover. Retinoids are vitamin A derivatives. Retinoids describe the family of derivatives, including over the counter and prescription retinoids. Retinol is best for blackheads and whiteheads. If you are new to retinol, start with a low percentage like 0.025%-0.05%, and apply it 1-2 times a week at night, or every other night. Increase frequency once you find your skin is not as sensitive and can tolerate more. Then a greater percentage can be used. Those with very oily, non-sensitive skin types may be able to start with a 0.05-0.1% 1-2 times a week at night. SPF is a must to protect the new skin cells, even if there is no sun. The general rule for retinol is to start low and slow and increase over time.
A very affordable retinoid over the counter is adapalene. Common drugstore brands are differin gel and ROC retinol, and some drugstores offer generics.
If you prefer a more 'natural' route, Bakuchiol offers effects similar to retinol with less irritation, but also has less studies.
Chemical exfoliants are acids that get rid of dead skin cells, and include AHA (alpha hydroxy acid), BHA (beta hydroxy acid), and PHA (poly hydroxy acid). Chemical exfoliants are to be used at night.
BHA includes the very common salicylic acid, and tropic acid. Salicylic acid is a common acne treatment that works by unclogging pores and removing sebum. This works well for mild acne. Paula's Choice offers a wide selection of BHA products for acne.
AHA includes glycolic, lactic, citric, mandelic, and malic acid. Glycolic acid is a small molecule that can penetrate more thoroughly and is better suited for non-sensitive skin types. Lactic acid is an option better suited for sensitive skin types. The Inkey List offers an affordable glycolic acid, and The Ordinary offers an affordable lactic acid.
PHA includes gluconolactone, galactose, and lactobionic acid. PHA molecules are larger and do not irritate the skin as much. PHA is a great option for sensitive, dry skin types, and is found more in Korean skincare. Glossier offers an affordable PHA product. The popular Bakuchiol by Herbivore also includes PHA.
Dicarboxyl Acid includes Azelaic acid, and is fairly gentle compared to glycolic and salicylic acid, but less gentle than PHA. Azelaic acid brightens the skin and kills bacteria responsible for inflammatory acne. This is a great option for those with moderate to severe acne with sensitive or non-sensitive skin types. My favorite azelaic acid is by Naturium, though it does have an interesting smell.
Antioxidants like niacinamide help for redness and hyperpigmentation. Niacinamide is a great option for sensitive skin types, though it is possible to break out from niacinamide if you have never used antioxidants. Vitamin A, C, and E are also antioxidants. Antioxidants reverse and prevent free radical damage. If you break out from antioxidants, use it less frequently or use less product, and blend it with a gentle moisturizer. The Ordinary, The Inkey List, and Naturium have great niacinamide products.
Benzoyl peroxide can be purchased over the counter without a prescription. This treats and prevents acne by unclogging pores and attacking bacteria on the skin. This is the best non-prescription option for more severe acne, but also comes with more irritation. The stronger the percentage, the more action and irritation. Drugstore brands include Cerave, La Roche Posay, PanOxyl, and Clearasil.
Retin-A or Tretinoin is the most common prescription retinoid. Presciption retinoids work better for more severe acne types like cystic, and also often yield more irritation. Epiduo gel combines adapalene and benzoyl peroxide. Altreno combines retinol and and hyaluronic acid for more sensitive skin types. Retinoids are also commonly prescribed with topical antibiotics.
Topical antibiotics can only be used for three months at a time to decrease the likelihood of antibiotic resistance. Clindamycin and erythromycin are the most commonly used topical antibiotics. These work better for moderate to severe inflammatory acne, but not as well for non-inflammatory lesions.
Topical anti androgens are the newest type of medication for acne. It works similarly to oral anti-androgens (see below) by inhibiting the effects of male hormones on the skin. The two options include topical Spirinolactone and topical Clascosterone. Clascosterone has been proven to be very effective, similar to the efficacy of oral spironolactone with less side effects.
Prescription Oral Medications
Birth control can adjust hormonal levels and decrease acne.
The least invasive oral medication for acne is Spirinolactone, also known as Aldactone. This is a diuretic used for its anti-androgenic (anti-male hormone) properties. Side effects include peeing a lot (and dehydration from losing fluid), high potassium and loss of sodium, and period changes. This works best for hormonal cystic acne but should not be utilized for men.
Common oral antibiotics include minocycline, doxycycline, erythromycin, and azithromycin. These kill bacteria and reduce inflammation. This works best for moderate to severe acne. Side effects include sun sensitivity, skin redness and irritation, and upset stomach.
Isotretinoin should be reserved as a last resort for severe acne. This is a six month regimen that either cures acne, or requires further treatment. It stops acne by shrinking the oil glands in the skin. Side effects include extremely dry skin, vision issues, and joint pain. This requires use of birth control.
Once the acne is treated, topical products and treatments can be used to repair scarring, treat hyperpigmentation, and fade redness.