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ACNE OVERVIEW — Acne is a skin condition that causes pimples to develop. Acne is the most common skin disorder in North America, affecting an estimated 85 percent of adolescents.
Effective acne treatments are available to treat existing pimples and prevent new ones from developing. In addition, cosmetic treatments can help to reduce scarring and changes in skin color caused by acne.
HOW DOES ACNE DEVELOP? — There are four basic events involved in the development of acne lesions:
●Hair follicles become blocked with an overabundance of normal skin cells. These cells combine with sebum (an oily substance that lubricates the hair and skin), creating a plug in the follicle.
●The glands that produce sebum, known as sebaceous glands, enlarge during adolescence and sebum production increases. Numerous sebaceous glands are found on the face, neck, chest, upper back, and upper arms.
●The increase in sebum production allows for the overgrowth of a bacterium called Cutibacterium (formerly Propionibacterium) acnes that normally lives on the skin.
●Inflammation occurs as a result of bacterial overgrowth or other factors. This can lead to the rupture of the follicle and the formation of a red or tender pimple.
ACNE CAUSES
Hormonal changes — Hormonal changes during adolescence cause the sebaceous glands to become enlarged, and sebum production increases. In most people with acne, hormone levels are normal, but the sebaceous glands are highly sensitive to the hormones.
Less often, hormone levels in females are affected by an underlying medical problem known as polycystic ovary syndrome (PCOS). (See "Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics)".)
Acne tends to resolve between ages 30 to 40, although it can persist into or develop for the first time during adulthood. Post-adolescent acne predominantly affects females, in contrast to adolescent acne, which predominantly affects males. Acne can flare before the menstrual period, especially in people older than 30 years.
External factors — Oil-based cosmetics may contribute to the development of acne. Oils and greases in hair products can also worsen skin lesions. Water-based or "noncomedogenic" products are less likely to worsen acne.
People with acne often use soaps and astringents. While these treatments remove sebum from the skin surface, they do not decrease sebum production; frequent or aggressive scrubbing with these agents can actually worsen acne.
Diet — The role of diet in acne is controversial. Some studies have found weak associations between cow's milk and an increased risk of acne, perhaps because of hormones that occur naturally in milk. However, there is no strong evidence that milk, high-fat foods, or chocolate increase the risk of acne.
Stress — Psychological stress can probably worsen acne. In several studies of students, acne severity appeared to worsen during times of increased stress.
ACNE TREATMENT — There is no single best treatment for acne, and combinations of treatments are sometimes recommended. Since acne lesions take at least eight weeks to mature, you should use a treatment for a minimum of two to three months before deciding if the treatment is effective.
Acne skin care — Skin care is an important aspect of acne treatment.
Skin hygiene — Wash your face no more than twice daily using a gentle nonsoap facial skin cleanser (eg, Cetaphil, Oil of Olay bar or foaming face wash, or Dove bar) and warm (not hot) water. Some providers recommend avoiding use of a washcloth or loofah, and instead using the hands to wash the face. Vigorous washing or scrubbing can worsen acne and damage the skin's surface.
Do not pick or squeeze pimples because this may worsen acne and cause skin swelling and scarring. It can also cause lesions to become infected.
Moisturizers — Use of a moisturizer minimizes dryness and skin peeling, which are common side effects of some acne treatments. Moisturizers that are labeled as "noncomedogenic" are less likely to block skin pores.
Sun protection — Some acne treatments increase the skin's sensitivity to sunlight (eg, retinoids, doxycycline). To minimize skin damage from the sun, avoid excessive sun exposure and use a sunscreen with SPF 30 or higher that is broad spectrum (blocks both UVA and UVB light) before sun exposure. (See "Patient education: Sunburn prevention (Beyond the Basics)".)
Can I treat my own acne? — If you have mild acne, you can try to treat yourself with nonprescription products initially. Nonprescription acne treatments may include salicylic acid, benzoyl peroxide, sulfur, alpha hydroxy acids, adapalene, or tea tree oil, all of which are available in nonprescription strengths. A combination of these treatments may be more effective than using one single product alone. In rare cases, people have a severe allergic reaction to acne products, so for the first three days, try them on just a small area.
If you do not improve after three months of using nonprescription products or you have moderate or severe acne, consult a healthcare provider for advice on the most effective treatments. (See 'Professional treatment' below.)
Professional treatment — A health care provider can recommend treatment based on the type(s) of acne
you have and how severe it is. Some treatments are particularly helpful for treating noninflammatory acne (eg, whiteheads or blackheads without redness or skin swelling (picture 1 and picture 2)). Other treatments are more helpful for acne that is associated with skin inflammation (picture 2 and picture 3 and picture 4) or for people who have both noninflammatory and inflammatory acne lesions. For many people, a combination of medications is more effective than treatment with one medication alone.
Acne medications include both topical medications (medicines you apply to the skin) and oral medications (pills or tablets you take by mouth). Oral medications, such as antibiotics, hormonal treatments (eg, birth control pills or spironolactone), or a retinoid known as isotretinoin, are often prescribed for people with moderate to severe acne. Topical medication may be used in combination with some oral medications. (See 'Topical acne medications' below and 'Oral acne medications' below.)
Topical acne medications — Examples of topical acne medications your health care provider may recommend include topical retinoids, benzoyl peroxide, antibiotics, clascoterone, salicylic acid, glycolic acid, and azelaic acid.
Topical retinoids — Topical retinoid medications are often recommended for acne. Examples of these medications include tretinoin (sample brand names: Retin-A, Avita, Atralin, Altreno) and tazarotene (sample brand names: Tazorac, Arazlo, Fabior), which require a prescription, and adapalene (sample brand name: Differin), which is available both by prescription and over the counter.
Retinoids are usually applied once per day, although people who develop skin irritation can reduce this to every other day or less, then increase as tolerated over time. Most people become more tolerant of retinoids over time.
Most retinoids are available in a gel or cream. People with oily skin may prefer gels because they have a drying effect, while people with dry skin may prefer a cream.
Retinoids can cause skin irritation and may make you more likely to sunburn. While using topical retinoids, you should apply a sunscreen with SPF 30 or greater before sun exposure.
Benzoyl peroxide — Benzoyl peroxide is usually applied once or twice per day. Some topical acne products contain benzoyl peroxide in combination with a retinoid or antibiotic. Benzoyl peroxide can irritate the skin, sometimes causing redness and skin flaking, and it can bleach clothing, towels, bedding, and hair.
Topical antibiotics — Topical antibiotics control the growth of acne bacteria and reduce inflammation. Topical antibiotics include clindamycin, erythromycin, sulfacetamide, minocycline, and dapsone. Topical antibiotics are usually applied once or twice per day.
Topical clascoterone — Topical clascoterone is a medication that is thought to improve acne by blocking certain effects of androgens (hormones responsible for acne development) in the skin. Clascoterone is usually applied twice per day. The medication may cause skin irritation. A hormonal imbalance related to the adrenal glands may be a rare side effect.
Other topical acne products — People who cannot tolerate retinoids may try other topical medications, such as salicylic acid, glycolic acid, or azelaic acid (Azelex, Finacea). All of these treatments can be helpful in reducing noninflammatory acne, and azelaic acid may reduce acne-related darkening of skin.
Oral acne medications — Examples of oral acne medications include antibiotics, isotretinoin, and hormonal therapies (birth control pills and spironolactone).
Oral antibiotics — Oral antibiotics work to slow the growth of acne-producing bacteria. However, oral antibiotics can have bothersome side effects, including vaginal yeast infections and stomach upset. Examples of oral antibiotics used for acne include doxycycline, minocycline, and sarecycline. They cannot be used during pregnancy or in children less than nine years of age.
Oral isotretinoin — Oral isotretinoin (sample brand names: Amnesteem, Claravis, Absorica) is a potent retinoid medication that is extremely effective in the treatment of severe acne. It cures or significantly improves acne in the majority of people. Oral isotretinoin is effective in treating the most disfiguring types of acne. Isotretinoin used to be sold as Accutane, but that brand name is no longer available.
Oral isotretinoin is usually taken in pill form once or twice daily with food for several months, then stopped. In some cases, acne can initially worsen before it improves. To reduce the risk for this initial flare of acne, isotretinoin is sometimes given at a lower dose for the first month of treatment.
Side effects and risks — Despite its effectiveness in treating severe acne, oral isotretinoin can have serious side effects and should be used with caution.
In addition, taking isotretinoin during pregnancy can cause miscarriage and life-threatening abnormalities in a developing baby. For these reasons, there are strict rules in the United States for healthcare providers, pharmacists, and patients regarding the use and prescription of oral isotretinoin. Prescriptions of isotretinoin are regulated by the iPLEDGE program, which requires the following:
●Anyone who is taking isotretinoin must receive counseling from a healthcare provider about the risks associated with the drug.
●Anyone who could become pregnant (ie, "females of reproductive potential") must have two negative pregnancy tests before receiving a prescription, and then they must have monthly pregnancy tests throughout the course of treatment.
●Anyone who could become pregnant must fill their prescription within seven days of receiving it; after this time, a new prescription must be written.
●Anyone who could become pregnant must use two forms of birth control. Both forms must be used for at least one month before starting isotretinoin, while taking isotretinoin, and for one month after stopping the drug. At least one of the forms of birth control must be a highly effective method, such as an intrauterine device (IUD), a hormonal method (such as the pill, patch, injection, implant, or vaginal ring), or a permanent procedure (ie, tubal ligation in the female or vasectomy in the male partner). (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)".)
●People who cannot become pregnant (ie, females of nonreproductive potential, males) must also participate in iPLEDGE but do not require pregnancy testing or use of birth control.
You should not donate blood while taking isotretinoin or for a month after stopping. This is because it could cause harm if a pregnant person receives blood donated by someone with the drug in their system.
Information about oral isotretinoin can be found at the US Food and Drug Administration (FDA) website (www.accessdata.fda.gov/drugsatfda_docs/label/2010/018662s060lbl.pdf).
Other side effects may also occur during isotretinoin therapy:
●Dryness or peeling of skin, soreness and cracking of the lips, itching, muscle pain, nosebleeds, difficulty wearing contact lenses, and sensitivity to the sun may occur during treatment.
●There is concern about the relationship between isotretinoin and depression and suicidal behavior. While there is not enough evidence to conclude that it causes depression or suicidal behavior, patients taking isotretinoin should report any sadness, depression, or anxiety to their healthcare provider immediately.
●Isotretinoin can cause increases in blood levels of triglycerides (fatty substances related to cholesterol), liver damage, pancreatitis, and changes in the blood counts.
While many of these side effects can be managed without stopping the drug, others can be dangerous and require that you immediately stop taking it. Stay in touch with your doctor and follow instructions for getting blood tests to check triglycerides or liver function.
Hormone therapy — The hormone estrogen can help to offset the effect of androgens (hormones responsible for acne development). Estrogen treatment in the form of a birth control pill is sometimes recommended for females with acne. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)
Not all oral contraceptives should be used for the treatment of acne; some can actually worsen acne. Certain types of IUDs and some injectable forms of birth control also may worsen acne. Discuss the best options with your healthcare provider. (See "Acne vulgaris: Management of moderate to severe acne in adolescents and adults", section on 'Oral hormonal therapies'.)
Spironolactone is another medication that can be used to treat acne in females. Spironolactone reduces the effects of androgens.
The benefits of birth control pills and other hormonal medications may not be noticeable until three to six months after treatment is started. Treatment with hormonal medications is not recommended during pregnancy.
Acne and pregnancy — Many acne treatments are not safe for use during pregnancy. Anyone who is pregnant or intending to become pregnant should consider stopping all acne treatments before trying to get pregnant. If acne therapy becomes necessary, discuss the options with your healthcare provider.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Acne (The Basics)
Patient education: Rosacea (The Basics)
Patient education: Normal puberty (The Basics)
Patient education: Keloids (The Basics)
Patient education: Sertoli-Leydig cell tumor (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics)
Patient education: Sunburn prevention (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Light-based, adjunctive, and other therapies for acne vulgaris
Oral isotretinoin therapy for acne vulgaris
Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris
Acne vulgaris: Overview of management
Acne vulgaris: Management of moderate to severe acne in adolescents and adults
The following organizations also provide reliable health information.
●American Academy of Dermatology
(https://www.aad.org/public/diseases/acne)
●Skin of Color Society
(https://skinofcolorsociety.org/patient-dermatology-education/dermatology-educationacne-in-skin-of-color/, available in Spanish)
●National Library of Medicine
(https://medlineplus.gov/acne.html, available in Spanish)
●National Institute of Arthritis and Musculoskeletal and Skin Diseases
(https://www.niams.nih.gov/health-topics/acne, available in Spanish and Chinese)
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