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What are the topical acne treatments for mild acne?

Updated: May 19, 2023



 

Disclaimer: The information in this article is not meant as specific individual medical advice. Please consult your dermatologist or other medical professional about your skin or medical condition.

 

Acne affects many teenagers and adults. As many as 85% of teenagers and 12% of adult women have acne. [1] The reason why we treat acne is because it can cause permanent scarring, poor self-image and sometimes depression and anxiety.


What is acne?


Acne is a chronic skin problem that affects the pores (hair follicles) and oil glands (sebaceous glands) of the skin.


It is characterized by having blackheads, whiteheads and red painful pimples, usually on the face and sometimes over the upper body.


When acne is severe, a person can have large nodules and cysts.


What type of acne do you have?


Acne is considered to be mild when a person mainly has blackheads and whiteheads (called comedones), and a few pimples. This type of acne is also called comedonal acne.


Acne is considered to be moderate when a person has more red bumps, zits, pus bumps or pimples. This type of acne is also called inflammatory acne.


Acne is considered to be severe when a person has large nodules and cysts. This type of acne is also called nodulocystic acne.


Some women may have hormonal acne, which is not discussed in this article.


What causes acne?


Acne is caused by plugging of pores by thickening of the skin, debris and oil production. This causes blackheads and whiteheads (comedones).


In addition, a bacterium, called Proprioniacterium acnes (P acne), grows in acne lesions and causes inflammation. This causes red bumps, zits, pimples or pus bumps (inflammatory leisons).


There are also genetic factors that determines the number and size of the acne lesions and the amount of inflammation that happens.


Sometimes, acne can be caused by raised androgen levels (such as testosterone and DHEA).


There is increasing evidence that suggest that food rich in carbohydrates (high glycemic index diets) may be associated with acne. In some small studies, people who follow a diet with low carbohydrate load experienced improvement in acne severity.


There are also some studies that show that consuming cow’s milk, especially skim milk, may increase the risk of developing acne.



Topical treatment for acne


‘Topical’ refers to treatments that you can apply on the skin, as opposed to treatments that you have to consume by mouth.


There are many topical treatment options for acne. They come in the form of cleansers, gels, lotions and creams.


The benefit of using topical treatments, over oral treatments, is that topical treatment have lower risk of internal side effects.


On the other hand, topical treatments are sometimes not strong enough to treat people with severe acne.



Commonly used topical acne treatments for mild acne


The most commonly used topical treatments for acne are:

o Benzoyl peroxide

o Topical antibiotics, such as clindamycin and erythromycin

o Topical retinoid, such as adapalene, tretinoin and tazarotene

o Azelaic acid

o Topical dapsone

o Salicylic acid


Most of these treatments are best suited for teenagers and adults with mild to moderate acne.


Combining the use of some of these topical treatments is also helpful for people with moderately severe acne. More information on treatment options for severe acne can be found on my guide to treatment of severe acne.


Benzoyl peroxide


Benzoyl peroxide is antibacterial treatment that kills the P acnes bacteria, which causes inflammation. [2] This means it is helps for treating inflammatory lesions (zits, pimples or pus bumps).


In the United States, benzoyl peroxide is sold over-the-counter as topical wash, foam, cream and gel. The strengths available range from 2.5% to 10%.


These treatments are usually meant to be applied about once a day to the areas where there are inflammatory lesions.


Improvement can normally be seen by a month of use, with maximum improvement around 2 to 3 months of use.


Continued use of benzoyl peroxide is usually required to maintain the improvement.


Benzoyl peroxide can sometimes cause drying of the skin and skin irritation. The chance for skin irritation is higher at higher concentrations. If you have sensitive skin, you may wish to use the lower concentration (2.5%) wash-off products.


It can also cause staining and bleaching of clothing.


Benzoyl peroxide is also effective in prevention of bacterial resistance and is recommended to be used in combination with topical antibiotics, which we will discuss next.


Topical antibiotics


Topical antibiotics work by accumulating in the hair follicles (pores) and has anti-bacterial and anti-inflammatory effects.


Currently, clindamycin 1% is the preferred topical antibiotic.[3]


This is available as a prescription treatment, in the form of a lotion, gel or solution.


This is considered to be a safe treatment for most teenagers and adults. There are rare reports of inflammation of the colon (called Clostridium difficile-related colitis) but the risk appears to be low.


Topical erythromycin 2% is an alternative prescription treatment. It is also available as a cream, gel or lotion, as well as combined with benzoyl peroxide. This is usually prescribed when a person is not able to tolerate topical clindamycin.


Topical antibiotics are usually applied once or twice a day to the inflammatory lesions.


Treatment with topical antibiotics alone is not usually recommended because antibiotic resistance may develop. Antibiotic resistance means that a bacterial infection does not respond to a specific antibiotic treatment.


As such, topical antibiotics such as clindamycin is usually used in combination with benzoyl peroxide to reduce antibiotic resistance. There are products of benzoyl peroxide/clindamycin and benzoyl peroxide/erythromycin for easy application.


People allergic or sensitive to topical antibiotics may experience skin irritation.


Retinoids


Topical retinoids are treatments derived from vitamin A. Retinoids work by breaking up blackheads and whiteheads and reduce plugging of pores. They also reduce inflammation.


This means retinoids are most helpful for people with blackheads and whiteheads (comedones).


Retinoids are also useful for maintaining clear skin after stopping other acne treatments.


Retinoids can be used on their own, or in combination with benzoyl peroxide and topical antibiotics.


There are three main topical retinoids available – tretinoin (Retin-A®), adapalene (Differin®) and tazarotene (Tazorac®).


Topical adapalene 0.1% is sold over-the-counter in the United States.


The other two retinoids, as well as the higher strength adapalene 0.3%, are only available as a prescription.


Most retinoid products, especially tretinoin, are best applied in the evening. This is because sun exposure can sometimes deactivate the active ingredient.


If you are using both a retinoid and benzoyl peroxide, it is recommended that the two products be used at different times because the retinoid may also be inactivated by benzoyl peroxide.


Retinoids can cause dryness, peeling, irritation and redness of the skin. These effects increase with the strength of the treatment. If this happen, using a lower concentration option or applying the treatment less frequency can help.


Retinoids can also increase sun sensitivity, so it is important to take sun protective actions to reduce the risk of sunburn.


Retinoids are not recommended to be used during pregnancy because of the risk of possibly causing birth defects.


Azelaic acid


Azelaic acid (Finacea®) is a naturally occurring dicarboxylic acid found in cereal grains. It has both anti-bacterial and anti-inflammatory effects in acne.[4]


This means it is helpful mainly for reducing comedones and inflammatory lesions.


It is also helpful for lightening skin discoloration caused by acne.


Azelaic acid is a mild treatment and usually does not cause skin irritation, and is better tolerated by people with sensitive skin.


Azelaic acid is available only as a prescription, and is usually used about once to twice a day.


Dapsone


Topical dapsone (Aczone®) gel is helpful for reducing inflammation in acne.[5]


This means it is most helpful when used on inflammatory lesions like pus bumps.


It also appears to be more beneficial to adult women.[6]


Topical dapsone is available only as a prescription treatment. It is usually applied about once a day.


It is not recommended to use both dapsone and benzoyl peroxide at the same time because it can cause brown discoloration of the skin, although this can be washed off.


Topical dapsone is also not recommended for use during pregnancy.


Salicylic acid


Salicylic acid can be helpful for reducing small whiteheads and blackheads. Hence, it is most useful in people with mild comedonal acne.


This treatment is available over the counter in strengths between 0.5% to 2%. Salicylic acid is frequently included in acne cleansers.


Dryness, redness or skin peeling may occur when using salicylic acid. This is especially so if you are already using another topical treatment, like a retinoid or benzoyl peroxide, which can also cause skin dryness or irritation.


Salicylic acid use is not recommended during pregnancy and nursing.


Combination treatment


It is common to combine topical treatments to maximize its benefits.


However, this is best done under the advice of your dermatologist.


I hope this article is helpful in empowering you in making choices for your acne treatment.



Please be sure to consult your dermatologist before making treatment decisions for your acne.



[1] Bhate K. Williams H.C. Epidemiology of acne vulgaris. Br J Dermatol. 2013; 168: 474-485 [2] Fulton Jr., J.E. Farzad-Bakshandeh A. Bradley S. Studies on the mechanism of action to topical benzoyl peroxide and vitamin A acid in acne vulgaris. J Cutan Pathol. 1974; 1: 191-200 [3] Becker L.E. Bergstresser P.R. Whiting D.A. et al. Topical clindamycin therapy for acne vulgaris. A cooperative clinical study. Arch Dermatol. 1981; 117: 482-485 [4] Cunliffe W.J. Holland K.T. Clinical and laboratory studies on treatment with 20% azelaic acid cream for acne. Acta Derm Venereol Suppl (Stockh). 1989; 143: 31-34 [5] Draelos Z.D. Carter E. Maloney J.M. et al. Two randomized studies demonstrate the efficacy and safety of dapsone gel, 5% for the treatment of acne vulgaris. J Am Acad Dermatol. 2007; 56: 439.e1-439.e10 [6] Tanghetti E. Harper J.C. Oefelein M.G. The efficacy and tolerability of dapsone 5% gel in female vs male patients with facial acne vulgaris: gender as a clinically relevant outcome variable. J Drugs Dermatol. 2012; 11: 1417-1421

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