Acne in teenagers and adults is a troubling condition, affecting one’s self-esteem and confidence levels. In my clinical practice as a dermatologist, acne vulgaris, colloquially known also as pimples, forms at least 50% of the daily load of patients I see. There are many aspects to be addressed within the dermatology consultation.
This varies from the cause of pimples, to questions about effective acne treatments, DIY formulas, over the counter acne creams and prescription medications. I have sought to share as many of these treatment pearls in the following article as comprehensively as possible, and hope it can help shed some light on the best acne treatments available.
Why do pimples form and what exactly is happening to your skin when a pimple forms
Pimples is the colloquial term for Acne Vulgaris. This refers to an inflammatory condition of the skin that presents with blackheads and whiteheads, otherwise known as closed comedones and open comedones respectively, inflamed papules as well as acne cysts. The cause of Acne Vulgaris is multifactorial.
First of all, it is determined by one’s genetics. Individuals with a family history of acne tend to have a higher chance of developing acne. This is brought on by the onset of puberty which leads to the secretion of the male hormone, testosterone. Testosterone, in turn triggers oil production in both men and women. That being said, sebum, the oily substance secreted by your sebaceous glands, is essential for the entire process of acne formation.
The third thing that occurs due to one’s genetics, is the process of inflammation itself which leads to comedone formation. All pimples whether whiteheads or blackheads arise first as microcomedones under the surface of the skin.
When they reach the surface of the skin, they become visible. The process that drives this is a mix of genetics, the presence of sebum as well as some form of dysregulation of the process of follicular keratinisation i.e. the way your skin retains dead skin cells around your skin pores.
Aside from genetics, there is also the involvement of a bacterium known as Propionibacterium acnes – a heavy commencer in individuals who suffer from acne. Finally, a lot of acne flare-ups can be due to the secondary bacterial infection of existing acne bumps known as gram-negative folliculitis. This tends to present with pus-filled papules and tend to have a yellowish tip.
I have observed that I always get acne in the same spot
While I do hear this coming from my patients quite often, i.e. “I always get this one pimple now and then on my cheek, chin, forehead…”, there is no scientific answer to this. From my personal experience, this could be due to one of the following. Firstly, if you tend to pick at your pimples, there is a condition known as acné excoriée. The entire name of this condition in french is acné excoriée des jeunes filles meaning acne excoriée of young girls.
There is an element of this compulsive picking of acne and this is the main reason why I find my patients having acne at the same spot. They constantly pick at it so even when it is healing, it does not get the chance to heal and picking introduces secondary bacterial infection.
The second reason why is because you are suffering from some form of acne that is related to occlusion. Some people wear helmets or face masks. If acne develops around that area, it is a type of acne known as occlusion acne. It could also be due to the application of comedogenic, hair waxes etc.
The third thing, if you are talking specifically about acne on the chin, you have to consider perhaps it is not acne at all. There is a condition known as perioral dermatitis. Perioral dermatitis looks very similar to acne and if you are seeing a non-specialist, it is very easy to be confused. This is because the bumps look very similar to acne, except that it is a mixture of eczema and inflammation, acne bumps, or it could even be acne rosacea.
All about Acne Creams
When you apply a pimple-clearing product to your pimple, what happens to the spot? What are some of the ingredients that you’d want to look out for in a pimple product, and what should you avoid? Are pimple drying lotions ok for the skin and how do they work?
If you find yourself searching online for answers to these questions, you are not alone. These are some frequently asked questions by sufferers of acne and I shall seek to clarify them here. There are a few categories of pimple-clearing creams. The first being the good old-fashioned creams that simply dry out the skin and reduce sebum production.
Pimple Drying Medications
This category would include topicals that contain the following active ingredients: benzoyl peroxide, salicylic acid, calamine lotion, sulfur-containing lotions. In some mild cases these creams may lead to an improvement in acne itself.
Pimple Creams Containing Antibiotics
The second category of acne treatment creams would be those containing antibiotics. The commonest antibiotic-acne gels would be those which contain clindamycin or erythromycin as an active ingredient.
These work on the premise that a lot of cystic acne is caused by secondary bacterial inflammation. As with all topically applied antibiotics especially in a chronic skin condition like acne which is not primarily due to skin infection, there is a huge problem with using topical antibiotics.
Topical antibiotics work well in a short-term simply because the skin has never been exposed to it. But very quickly the body learns to identify the antibiotic and develops resistance.
This is particularly concerning because the resistance doesn’t just take place in the skin level. Exposure of the topical antibiotics on the skin level leads to resistance systemically as well. For example, it could lead to antibiotic resistance when one is older.
The main thing about antibiotics is that it is a mere short-term fix and does not work after some time. There are other combinations of antibiotic gels, such as clindamycin combined with benzoyl peroxide which is the active ingredient present in the OXY pimple cream. The benzoyl peroxide component has been proven to reduce the emergence of bacterial resistance.
Prevention Creams – Retinoids for Acne Treatment of Whiteheads and Blackheads
The third category of pimple creams which I consider more preventive rather than treatment sort of cream is the retinoid category. These are the vitamin A derivative creams. We have heard of creams like tretinoin and adapalene which may have differing trade names. Both these creams are Vitamin A derivatives and they work via preventing microcomedone formation.
However, when you apply these creams, you should not apply it to inflamed active pimples as this can worsen the inflammation process. Rather they should be used in conjunction with active acne treatments prescribed by a dermatologist which is proportionate to the severity of your acne as preventive treatment. When you start applying a retinoid cream for example, you only get to see the result 2-3 weeks later.
A Dermatologist’s Recommendation of the Ideal Pimple Cream – New Generation Anti-Inflammatory, Anti-Sebum Pimple Creams
The fourth category of acne treatment creams is actually what I actively advocate now and which we have formulated in a highly effective Blemish Spot Cream under Dr.TWL Dermaceuticals. It is targeted at reducing inflammation itself. I am very convinced that botanicals have a prominent role to play in cosmeceuticals.
Cosmeceuticals are no longer just confined to the realm of having anti-ageing properties but are also adjuncts for the treatment of many medical skin conditions. I have used botanicals extracts successfully in the treatment of rosacea for example.
For acne, I incorporate an algae extract from chlorella vulgaris which actively reduces the oil gland activity. This is combined with amino acids such as methionine and serine that help to heal the skin when you apply it. The main thing is that when you try to dry up an active pimple, very often you get more inflammation as you are burning the skin around it.
What you need to do is to try to get the pimple to heal as quickly as possible. This is so that you minimise the risk of scarring. At the same time, this also treats the underlying problem of acne pimples which keep forming.
Are there different pimple creams best suited for the different types of acne (eg blackheads whiteheads, red swollen pimples)?
For tretinoin and adapalene which are the two main available form of vitamin A creams, these should not be used for red, painful, swollen acne treatment. They are best suited for comedonal acne which would be your blackheads and your whiteheads. For drying pimple creams, like benzoyl peroxide, salicylic acid, calamine lotion, I don’t recommend applying these to areas that have broken skin.
If you apply these to broken skin, the irritation and drying potential is just going to be multiplied. Potentially, you are going to end up with something that looks like a chemical burn. That is something much redder with a lot of peeling flaking and bad scarring.
Instead, I would recommend using an anti-inflammatory product with botanical-based extract that doesn’t contain anything irritating like salicylic acid. For example, the one we use is based on an algae. There is no issue applying this over areas with broken skin, although it also really depends on the formulation itself.
In addition, for a correctly labelled and medicated acne cream, i.e. not just a cosmetic product, there would be very clear indications of use available.
Does my skin ever get used to pimple-clearing products – is that why my pimple never seems to heal?
If you are using a medication like clindamycin and erythromycin, then yes because you develop real bacterial resistance which stops the medication from working. If you are using something which is drying such as the first category I spoke about earlier, or something anti-inflammatory, there is no evidence that your skin can actually develop a form of resistance to that. It is simply that the severity of acne has progressed or in the first place it wasn’t sufficient acne treatment.
Adult Acne Treatment
For patients with mild acne, they will have approximately 3-5 pimples every month and they tend to be of the teenager age group. Once you are past your teenage years, from the age of 21 onwards, it is a different ballgame of what dermatologists term as adult acne. If you still suffer from acne then, meaning having an average of more than 5 pimples every month after the age of 18, it is at the minimum, a case of moderate acne.
Moderate severity acne means that while you don’t have severe scarring or cystic acne, it is still very persistent and would need to be treated medically by an accredited dermatologist. In my clinical experience, moderate acne does not respond well to topicals only regimens. Topicals are only useful as an adjunct in the treatment of moderate acne.
On the other hand, using appropriate cleansers and pimple-clearing gels works well and is sufficient for mild acne. It may be a selection bias by default, given that attendances at a dermatologist practice would be moderate cases.
This is because the mild cases perhaps get treated at the GP level before they do get to us. Moderate cases of adult acne would need more treatment than just topicals. According to international dermatology guidelines, there are two options for the treatment of adult cystic acne.
Oral Acne Treatments
Firstly, the oral pathway for which I must emphasise that there are many oral medications that are safe and effective that have been widely prescribed by dermatologists internationally for decades. Examples of commonly prescribed medications include low dose oral antibiotics like doxycycline, erythromycin. These function primarily as anti-inflammatory medications to prevent comedone formation.
Minocycline is less frequently used these few years as it has been linked to a few rare cases of hypersensitivity syndrome, on top of potentially causing blue-grey skin discolouration.
Erythromycin in particular is safe for pregnant and lactating individuals. Oral contraceptive pills such as Diane-35 and Estelle-35 contains estrogen as well as cyproterone, which blocks androgen (testosterone activity). Androgens are male hormones that trigger off oil production, exacerbating adult hormonal acne.
Women with a history of irregular menstrual periods with cystic acne may have undiagnosed polycystic ovarian syndrome (PCOS). Such individuals will benefit from joint management of a dermatologist and a gynaecologist. Treatment of PCOS is with hormonal therapy, which will benefit adult acne treatment as well as preventing infertility.
Non-Oral Acne Treatments and Physical Therapies
Secondly, we have the non-oral pathway for acne treatment which involves physical therapies that have to be administered in a clinic setting. For example the usage of LED wavelengths, blue-light, two times a week for one month.
Blue light is therapeutic for treating acne that is especially worsened by the bacteria Propionebacterium Acnes. This has been proven to be effective in a regimen of twice weekly 30 minutes duration for a one month regimen.
Chemical Peels and Lasers for Acne Treatment – Can they be used independently?
I always recommend those with persistent moderate acne to go for a short course of a safe antibiotic such as erythromycin or doxycycline in conjunction with any of these physical therapies. This is the most cost-effective option that targets inflammation that goes on in acne rather than blindly treating it from the surface.
What about Isotretinoin for Cystic Acne ?
For severe acne, you may suffer from deep painful cysts which often involve pus and bleeding and there will be a lot of scarring. The treatment for this is very straightforward, our first line is always this medication called isotretinoin.
The medication is also known as accutane or oratane which are brand names of the forms of isotretinoin available. Isotretinoin is an extremely effective oral medication which works essentially by shrinking your oil glands.
Without oil, your skin simply doesn’t produce acne. However, isotretinoin use does come with drawbacks like increased sun sensitivity, dryness of the lips and eyes. One also has to monitor your liver function and cholesterol levels whilst on isotretinoin.
Time taken by Acne to heal with a pimple cream
A lot of patients in my practice have asked me to gauge the number of days to determine if an acne product works and my answer is simply this.
The Wound Healing Process of a Pimple’s Life Cycle
When a pimple forms it is best viewed as an injury caused by inflammation to the skin. You may go by the principles of wound-healing, especially when it only involves the top two layers of the skin (the epidermis and dermis).
Within the first 2-3 days of a cyst, there should be signs of pus draining. Should there be blood coming out of it, soon one should observe the redness and swelling resolving as well.
Acne That Does Not Heal
Acne may progressively accumulate and get larger instead of reducing in size. For example, the acne may get more painful, accumulate more pus and blood that doesn’t seem to be draining. When this occurs, one has to consider that there is an underlying cyst forming.
What is An Acne Cyst?
The formation of an acne cyst involves the collection of haemoserous material – blood, sebum, dead skin, keratin and debris. These substances subsequently get “cordoned off” by the body with a wall around it. This is part of the immune system’s response to inflammation. Acne cysts do not respond well to any topical treatment.
Proper Treatment of An Acne Cyst
Acne treatment of cysts involves a combination of the following. Firstly, an injection known as an intralesional steroid injection helps to reduce inflammation locally. It is injected right into the centre of the nodule and within 3 days, swelling will reduce the underlying swelling.
It is very important for the injection to be administered. This is because untreated acne cysts can lead to more severe problems like facial abscesses with drainage of pus.
Furthermore, it can spread to other parts of your face which is rare but has been documented. Concurrently, large painful acne cysts should be treated with an oral antibiotic such as amoxicillin, sufficient to treat the secondary bacterial infection that causes this reaction.
In the light of the Covid lockdown, our clinic is open to TeleDermatology services for acne treatment. This includes complimentary doorstep courier of prescription, contactless delivery within 3 working days. Same day delivery can also be arranged.
If you suffer from mild to moderate acne, you may try these over the counter cosmeceuticals proven for acne treatment.