Acne: more tips from the experts

In this part of our blog on acne  we will talk about oral treatments and peels. Catch up with part one of Acne: tips from the experts.

Oral treatments

Antibiotics

When topical (cream) treatments are not enough, oral treatments are usually the next step in treatment.  Antibiotics are often the first type used.  Tetracyclines are most commonly prescribed.  Whilst they do reduce some of the bacteria that contribute to acne, their main function is to reduce inflammation.  They have to be used for several months.  It often takes a few weeks before you start noticing an improvement so be patient – one of the main reasons patients think that they don’t work is because they don’t try them for long enough or on a regular basis.

You might be worried about taking antibiotics for such a long time.  It’s true that they can have a number of different side effects just as with all tablets so its best to try and get topical treatment to work for you. If it doesn’t and the acne is bothering you or causing scarring then the benefits often outweigh the risks.

Antibiotics aren’t a cure for acne but they can suppress it until such time your own body ‘grows out’ of it.  You start to develop antibiotic resistance after just a few weeks and so you should be reviewed by your dermatologist after around 3-4 months whilst you are on these.  Your doctor might switch you over to another one or try a different treatment.  Experienced dermatologists can give a combination of oral drugs where standard treatments have failed. Antibiotics shouldn’t really be given by themselves (monotherapy) as this can increase the chance of resistance and should be combined with topical treatment like retinoids to reduce resistance.

Hormonal medications

The combined oral contraceptive (COC) pill has been shown to be effective for all types of acne vulgaris – the red pus-filled spots as well as blackheads and whiteheads.  No particular COC has been shown to be more effective than any other.  Many patients do find that ones containing cyproterone are more effective though there isn’t good research to support this.  They can carry higher risks of complications such as blood clots so can only be given for limited periods in selected patients under supervision

Spironolactone is also a hormonal medication.  Its main purpose is actually something else – it’s a drug used in heart failure!  It’s used by dermatologists to varying degrees for acne and also for controlling female hair loss particularly when related to polycystic ovarian syndrome (PCOS), a condition that can worsen or trigger acne.  There is no evidence to support its use but I think that’s more a reflection on the quality of the studies than the drug.  I have found a lot of women benefit hugely from it, including some who haven’t responded well to isotretinoin.  It does have some side effects – it can alter blood pressure and the electrolytes in the blood and so needs be given under the supervision of an experienced doctor.

Isotretinoin

This is part of a group of drugs known as retinoids.  It’s an oral medication that has been used to treat severe scarring acne for many years and can be hugely effective in many patients.  It’s often the last line of treatment where other treatments have failed.  A course of treatment, which lasts around 4-6 months, can completely clear active acne and after stopping many patients do not get a significant recurrence.  However it can have significant risks – you can’t get pregnant whilst on it and for some time after as it will cause severe birth defects.  It can alter mood such as an increase in depression, effect the liver and fat levels in the blood, cause muscle aches, dry lips – the list is long.  It therefore needs to be given under close supervision with monitoring.  It’s usually a drug only prescribed under the supervision of a consultant dermatologist, though a few experienced GPs do also prescribe.

Isotretinoin is a very controversial drug – it has been banned in some countries and there have been calls to ban it here largely because of concerns over its effects on mood – some children have even committed suicide whilst on it.  There have also been reports in the press of association with severe inflammatory bowel disease. None of these links has been confirmed in clinical studies and more research is needed.

My own view is that much of the media have not been proportionate in their assessment of isotretinoin and that it has done more good than harm overall in the treatment of acne. Acne itself can have a huge impact on a patient’s self-esteem, mood and confidence which can have dramatic knock-on effects in life.

I think that each patient needs to be looked at on an individual basis – some with moderate acne can find it very distressing whist some with severe acne are not concerned at all.  But undoubtedly the risks need to be fully explained and closely monitored if isotretinoin is chosen.  Not all patients respond (those with purely whiteheads do poorly), recurrences are known and the acne can certainly become worse initially so it has to be given at the right time and the right patient.

Chemical peels

These can be used to smooth out the skin surface and even the tone.  There are many different peels out there but the main ones are superficial (those that don’t go very deep in the skin) such as glycolic acid, salicylic acid and pyruvic acid.  They can be particularly helpful for whiteheads and blackheads and might reduce these by up to 50%[1] particularly if combined with an effective topical regime at home.  You often need a course of treatment.  They are relatively safe but do carry some risks, notably skin discolouration and so timing and sun exposure need to be carefully managed.

Device treatments

There are lots of devices out there now the claim to treat acne – light based devices, lasers, suction devices, photodynamic therapy and some home devices.  They haven’t been well studied much at all and more work needs to be done.

Probably the best studied have been photodynamic therapy and a form of pulsed dye-laser (Regenlite).  There is reasonable, though not overwhelming, evidence that both of these work well in selected patients.  The advantage is that there are little or no internal side effects compared with oral medication.  The down sides are that they may require regular visits to clinics (apart from the home devices) and can work out more expensive than other treatments (though not necessarily depending on how much you spend on creams that don’t work)

Certainly there are some clinics that will suggest these as a first line treatment perhaps for commercial reasons but there is no evidence to suggest they are more effective than the more conventional treatments.  We would largely recommend them where the other treatments fail or cause intolerable side effects or where the devices might be effective at treating co-existing conditions such as sun damage or redness.

I hope some of this has been useful for you!

Dr Nisith Sheth is a Consultant in the Dermatology Surgery and Laser Unit of St John’s Institute of Dermatology. He trained in the UK, Canada and the USA. He sees and treats all skin conditions.  Read more about Dr Nisith Sheth over on our About us page.

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Notes:

[1] Bhate K, Williams HC What’s new in acne? An analysis of systematic reviews published in 2011-2012 Clinical and Experimental Dermatology (2014) 39, pp273–278