Acne vulgaris (simply called acne) is a common and often frustrating skin condition that affects millions of people worldwide. From occasional breakouts to severe, persistent cases, acne presents in many forms, requiring tailored treatment approaches. According to the American Academy of Dermatology (AAD), acne impacts up to 50 million people in the U.S. alone, making it the most prevalent skin disorder in the country. The annual cost of acne treatment exceeds $3 billion, reflecting its burden on healthcare systems.
For those struggling with acne, the physical and emotional toll can be overwhelming. However, conventional treatments have long been the foundation of acne management, offering proven, practical solutions for many. This article will explore the most common conventional treatment options available today, from over-the-counter topical solutions to prescription medications, providing insight into how each approach works to control and reduce acne symptoms.
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Over-the-Counter (OTC) Treatments
Countless products are available for OTC acne treatments, but not all are equally effective. To get the best results, start with a product containing one of the following active ingredients, each supported by substantial clinical evidence for its acne-fighting abilities.
Benzoyl Peroxide
Topical application of benzoyl peroxide once or twice daily has been a staple in acne treatment for decades. It kills acne-causing bacteria and removes excess oil and dead skin cells contributing to breakouts. (10, 25)
Over-the-counter benzoyl peroxide products range in strength from 2.5% to 10%. Studies indicate that lower concentrations are just as effective as higher-strength formulations but with a reduced risk of side effects, so it's generally recommended to begin with a lower-strength, water-based product. (10, 25)
The most common side effect of benzoyl peroxide is mild skin irritation, which may include dryness, redness, and fine scaling. Contact dermatitis, an allergic reaction, has been reported in 1-2% of users. Additionally, benzoyl peroxide can bleach clothing and bedding. (10, 25)
Salicylic Acid
Salicylic acid is a beta-hydroxy acid (BHA) that treats acne by loosening the bonds between dead skin cells and helping the skin shed dead cells more easily. This process prevents the buildup of debris that can lead to blackheads and whiteheads. (10)
Salicylic acid is available in OTC products in concentrations of 0.5% to 2% without a prescription. Studies show that it is as effective (if not more) as benzoyl peroxide for treating comedonal acne (whiteheads and blackheads) (26, 27).
Applying 0.5% salicylic acid twice daily to acne-prone skin for 12 weeks also treats inflammatory acne, which manifests as papules (solid, inflamed bumps) and pustules (pus-filled bumps).
Retinoids (Adapalene)
Retinoids are a first-line treatment indicated for treating mild comedonal acne or in combination with other therapies for treating moderate-to-severe acne. They are anti-inflammatory vitamin A derivatives that speed up skin cell turnover, preventing pores from getting clogged.
The United States FDA has approved several retinoids for treating acne, but adapalene (Differin) is the only one available OTC without a prescription (21). Adapalene comes in a 0.1% gel or solution that can be applied to the skin once daily in the evening. (25).
The main side effects associated with adapalene are skin irritation (e.g., redness, dryness, itching, stinging) and sensitivity to the sun. The concurrent use of sunscreen is recommended with retinoids to prevent sunburn. (25)
Prescription Topical Treatments
Prescription treatments are often necessary for more severe cases of acne, particularly those involving large, painful bumps or inflammatory lesions that can lead to scarring. While some ingredients like benzoyl peroxide and retinoids are available in both OTC and prescription forms, prescription options offer stronger formulations and a wider range of options.
Topical Retinoids (Tretinoin, Tazarotene)
As discussed earlier, topical retinoids promote skin cell renewal and remove dead skin cells, making them one of the most effective treatments for all types of acne and scarring prevention. They have been a cornerstone of acne therapy for over 25 years.
Tretinoin (Retin-A) and tazarotene (Tazorac) are the other two topical retinoids approved by the US FDA for acne treatment. Available in strengths ranging from 0.025% to 0.1%, these retinoids are applied once daily. Unlike adapalene, both tretinoin and tazarotene require a prescription. (25)
Tazarotene is considered the most effective topical retinoid, but adapalene is the least likely to cause skin irritation. Tretinoin is now available in a new formulation (Retin-A Micro) that reduces irritation. Gradually increasing the strength and regularly applying a moisturizer can also help minimize skin irritation. (21)
Topical Antibiotics (Clindamycin, Erythromycin)
Topical antibiotics treat mild-to-moderate acne through their anti-inflammatory and antibacterial effects. Cutibacterium acnes is the bacteria predominantly implicated in acne pathogenesis, triggering inflammation and infection within clogged pores.
Topical antibiotic options include erythromycin, clindamycin, minocycline, and dapsone (24). Clindamycin is often the preferred choice, given the increasing rates of antibiotic resistance associated with other options.
Almost all topical antibiotics are associated with a minor risk of skin irritation (25).
Combination Therapies
Topical antibiotics should always be used as part of combination therapy to reduce the risk of antibiotic resistance. Examples include:
- Benzoyl Peroxide 5%/Erythromycin 3% (Benzamycin)
- Benzoyl Peroxide 5%/Clindamycin 1% (Benzaclin)
Combination products of benzoyl peroxide with a topical antibiotic are more effective at decreasing acne lesions than either active agent used alone (5).
Patients can also combine a topical retinoid with benzoyl peroxide or a topical antibiotic to enhance treatment efficacy by simultaneously targeting multiple causes of acne. Examples include (11, 13):
- Adapalene 0.1%/Benzoyl Peroxide 2.5% (Epiduo)
- Adapalene 0.3%/Benzoyl Peroxide 2.5% (Epiduo Forte)
- Tretinoin 0.1%/Benzoyl Peroxide 3% (Twyneo)
- Tretinoin 0.025%/Clindamycin 1.2% (Ziana or Veltin)
Oral Medications for Acne
Topical treatments alone may not be enough to achieve clear skin for moderate-to-severe acne. Taken by mouth, oral medications work from within to target deeper causes of acne, such as hormonal imbalances or bacterial infections.
Oral Antibiotics (Doxycycline, Minocycline)
The AAD recommends adding oral antibiotics to topical therapies to enhance effectiveness in treating moderate-to-severe acne. To prevent antibiotic resistance, oral antibiotics should be limited to the shortest duration, typically no more than 3-4 months. Topical retinoids should be used to maintain acne remission once systemic antibiotic therapy has been completed. (21, 24)
Antibiotics belonging to the tetracycline class are typically used in treating acne. Examples include doxycycline, minocycline, and sarecycline. Tetracyclines are contraindicated in pregnancy, lactation, and children younger than nine years due to concerns of tooth discoloration and enamel hypoplasia. Common side effects include nausea, vomiting, diarrhea, and sun sensitivity. (21, 24)
Hormonal Therapies (Oral Contraceptives, Spironolactone)
Hormonal acne is responsive to therapies that modulate hormone levels, treating testosterone, progesterone, and estrogen imbalances that can trigger acne breakouts in women.
Androgens, including dehydroepiandrosterone (DHEA), testosterone, and dihydrotestosterone (DHT), are a class of hormones that drive hormonal acne because they upregulate sebum (oil) production, which clogs pores and creates an ideal environment for bacteria to thrive on the skin.
Combined oral contraceptives (birth control pills) contain estrogens and progestins that have an overall antiadrenergic effect by reducing androgens in circulation. It may take three menstrual cycles after starting an oral contraceptive to begin seeing acne lesion count reductions. There are currently four FDA-approved combined oral contraceptives for treating acne:
- Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen)
- Ethinyl estradiol/norethindrone acetate/ferrous fumarate (Tri-Legest FE 28) Drospirenone/ethinyl estradiol (Yaz)
- Drospirenone/ethinyl estradiol/levomefolate calcium (Beyaz) (21)
Spironolactone is a diuretic with additional androgen receptor-blocking effects, which helps reduce excess sebum production. Due to these antiandrogenic effects, spironolactone is often prescribed off-label to treat hormonal acne in women. According to the AAD, spironolactone, typically dosed between 50-200 mg daily, can reduce acne by 50-100%.
Isotretinoin (Accutane)
The AAD recommends isotretinoin (Accutane) for treating severe nodulocystic acne that is
unresponsive to other treatments or associated with psychosocial burden or scarring. It is an oral retinoid that treats acne by acting on all four mechanisms of acne development. It:
- Reduces the size and secretion of sebaceous glands
- Normalizes skin cell hyperkeratinization
- Indirectly prevents C. acnes colonization
- Reduces inflammation (24)
Studies show that isotretinoin, dosed at 1 mg/kg/day for 4-5 months, is highly effective in treating acne, often resulting in complete or near-complete acne clearance in most patients. Additionally, it is associated with low rates of relapse after the therapy is discontinued. (16)
Despite its high efficacy in treating acne, isotretinoin is reserved for the most severe cases due to its potential for serious side effects. These side effects can include:
- Severe skin dryness
- Chronic dry eyes and mouth
- Increased sensitivity to the sun
- Potential for birth defects (requires strict birth control measures in women of childbearing age)
- Elevated liver enzymes (necessitates regular monitoring of liver function)
- Increased cholesterol and triglycerides
- Mood changes or depression
In-Office and Advanced Dermatological Procedures
For individuals whose acne has left behind scarring or who are experiencing significant psychosocial distress, in-office and advanced dermatological procedures can improve the cosmetic appearance of the skin.
Cortisone Injections
The AAD recommends intralesional corticosteroid injections as an adjunctive therapy for improving the appearance of nodulocystic acne. The procedure involves injecting a corticosteroid, typically triamcinolone, directly into the acne lesion. This helps to rapidly reduce inflammation, pain, and swelling of the nodule or cyst within 3-7 days. While effective, this treatment must be used judiciously to prevent thinning of the skin, systemic absorption of the steroid, and adrenal gland suppression. (24)
Chemical Peels
Chemical peels are a skin resurfacing treatment that involves applying a chemical solution to exfoliate and remove the outer layers of the skin. This controlled skin destruction encourages regeneration, improving the appearance of active acne lesions, scarring, and post-inflammatory hyperpigmentation (discoloration). The depth of skin penetration depends on the type and concentration of the peel used, the duration of contact, and other ingredients in the formulation. (6)
Common agents used in chemical peels for acne include:
- Salicylic acid
- Glycolic acid
- Jessner's solution (a combination of salicylic acid, lactic acid, and resorcinol) (6)
Chemical peels can reduce acne lesions, minimize the appearance of scars, and even out skin tone (6).
Light and Laser Therapy
Light- and laser-based therapies have emerged as effective options for treating acne, particularly for those seeking non-invasive alternatives:
- Blue light therapy kills Cutibacterium acnes to treat mild-to-moderate acne, especially inflammatory lesions.
- Red light therapy penetrates deeper into the skin and is primarily used to reduce inflammation and promote healing. It's often combined with blue light to address both bacterial and inflammatory aspects of acne.
- Intense pulsed light uses a broad spectrum of light to target deeper layers of the skin, reducing inflammation, oil production, and acne scarring.
- Pulsed dye laser uses targeted bursts of light to reduce inflammation in acne by selectively heating and destroying small blood vessels that contribute to redness and inflammation in the skin.
- Photodynamic therapy combines a photosensitizing agent with light exposure to target and destroy acne-causing bacteria, reduce oil production, and shrink sebaceous glands.
Extractions and Drainage Procedures
Popping or picking pimples can cause skin trauma, leading to increased inflammation, infection, scarring, and potentially worsening acne. Dermatologists use safe and sterile extraction techniques, such as comedone extraction, where blackheads and whiteheads are gently removed using specialized tools, and drainage procedures for larger cysts or nodules. In these cases, a dermatologist may make a small incision to drain pus or fluid from the lesion, which helps reduce the size and pain while preventing further complications like scarring or infection. (23)
When to Consider Conventional Treatments
For mild-to-moderate acne, it's often best to start with OTC treatments. Products containing benzoyl peroxide, salicylic acid, or retinoids can help manage breakouts and prevent new lesions from forming. If acne persists after several weeks of consistent use, or if the inflammation worsens, it may be time to discuss prescription treatments with your doctor. (20)
Severe or cystic acne often requires early intervention with prescription topical and oral medications to prevent scarring and long-term skin damage. Conditions like nodulocystic acne can lead to deep, painful lesions that heal poorly if left untreated. Oral medications like antibiotics, hormonal treatments, or isotretinoin are typically necessary to control inflammation and reduce the risk of permanent scarring. In-office procedures like corticosteroid injections or laser treatments may also be recommended for quicker relief. (20)
If acne doesn't improve after trying standard treatments, it's time to consult an integrative dermatologist for a personalized treatment plan. Dermatologists can evaluate the underlying causes of stubborn acne and tailor treatment therapies to improve skin health when traditional and first-line options fail.
The Importance of Consistency and Patience in Acne Treatment
Acne treatments take time to show results, so staying consistent and patient with your skincare routine is important, even though it can be difficult. Using a new product for at least six to eight weeks is recommended before determining its effectiveness, as it typically takes this long to notice fewer breakouts. Full clearing of acne can take up to 16 weeks after starting a medication. Sticking to a consistent routine allows the treatment to work properly and prevents premature switching, which can disrupt progress. (4)
Regular follow-up appointments with a dermatologist are also helpful in monitoring the skin's response to treatment and making necessary adjustments to the plan. Consistent care ensures that the treatment remains effective and can be tweaked to address any new or persistent concerns.
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Key Takeaways
- Conventional treatment options for acne range from over-the-counter solutions, such as benzoyl peroxide and salicylic acid, to prescription-strength topical retinoids, oral medications, and in-office procedures.
- The right treatment plan depends on the type, severity, and individual skin needs. Starting with OTC products can be effective for mild-to-moderate acne, while more severe or resistant cases may require prescription therapies or advanced dermatological interventions.
- If acne isn't improving with basic treatments or if you're experiencing severe symptoms, it's important to seek professional advice. A dermatologist can provide personalized care to help manage breakouts and prevent long-term skin damage.
- With the right combination of treatments, acne can be effectively controlled, restoring both skin health and confidence.
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