Acne Solutions

Acne–Not Just a Teenage Problem

Dermatologists have a nasty name for pimples. The term they use is acne vulgaris. Sounds vulgar, doesn’t it? But vulgaris actually means common in Latin, so the medical term means common facial eruptions.

There are lots of myths about the causes of acne. One of the most prevalent is that only teenagers suffer acne. A related view is that acne is an unavoidable consequence of the hormone surges of adolescence. The fact that 79 to 95 percent of adolescents in places like North America, Europe, Australia and New Zealand are afflicted with acne helps keep that myth alive (Archives of Dermatology, Dec. 2002).

In actuality, though, many adults are plagued with acne well beyond their teen years. Around half of men and women over 25 have some facial acne, although it is more common in women. Stress, anxiety and sleep loss can all contribute to adult acne, which in turn can be extremely distressing (Journal der Deutshcen Dermatologischen Gesellschaft, Oct. 2018). This vicious cycle may lead to hormonal imbalance that also contributes to the severity of adult acne (Indian Dermatology Online Journal, July 13, 2020).

What Causes Acne?

Common skin bacteria (mostly Propionibacterium acnes, now termed Cutibacterium acnes), the production of oils (sebum) by the skin, and even the impact of hormones all seem to play a role in determining who gets acne and how severe it will be. When an oil-producing hair follicle gets plugged up with dead skin cells, normal skin bacteria go to work feasting on the fatty acids trapped inside it. If the skin microbiome gets out of balance, C. acnes, which usually helps to maintain skin health, can turn nasty and trigger inflammation (Microorganisms, Nov. 7, 2020). That’s what makes the pimple so sore and red.

Medicines That Aggravate Acne

Did you know that common medications can contribute to acne? Prednisone and other corticosteroids can trigger blemishes. So can testosterone (or its precursor, DHEA). Women who take this hormone to boost their libido may complain of adult-onset acne. Lithium for bipolar disorder can also affect complexion.

Other Drugs That May Contribute to Acne

Acne Is Not the Same Around the World

Acne is not inevitable. Although it is common in most western nations, especially among teenagers, adolescents in other places aren’t always troubled by zits. Anthropologists report that in Mali, for example, adolescent boys are far less likely to have acne than in the US (Evolution, Medicine and Public Health, Oct. 2016). If these boys do have breakouts, they are much less severe than is common elsewhere. Adolescents in non-Western societies in Papua New Guinea and Paraguay don’t experience acne as American and European teens do, either.

The scientists who reported on the Aché of Paraguay and the Kitavan youngsters of Papua New Guinea hypothesized that diet is an important driver. These populations consume almost no processed foods, dairy, alcohol, coffee, tea or oils. While their meals are high in carbohydrates, they are low in glycemic load. That is, they don’t raise blood sugar and insulin rapidly

An editorial linked to this report points out that dermatologists have changed their attitudes toward diet over the years (Archives of Dermatology, Dec. 2002). In the early 1950s, dermatologists were encouraged to warn patients “to avoid chocolate, fats, sweets, and carbonated beverages.” But by the 1960s and later, dermatologists argued that diet had no role in acne vulgaris.

Home Remedies for Acne

People have tried a lot of home remedies to try to abolish their zits. We have heard about a surprising number of potions people put on their faces as home remedies for blemishes. There’s really no good evidence any of them work, but they might be worth a try. We heard from a man who had tried washing his face with milk every day as a teenager and found it helpful. He wasn’t able to convince his daughter to try the same approach, though. We haven’t seen any evidence that a milk face wash is effective, but it shouldn’t hurt. In India, milk is mixed with ground nutmeg and applied to blemishes as a treatment.

Clay

Another approach is the clay mask. Versions of this are sold in drugstores and at cosmetics counters. We don’t know quite why it would work, but it has been popular for a long time. Clay is not the only traditional “poultice” that has been applied to blemishes. We’ve heard of one home remedy that calls for a teaspoon of powdered nutmeg to be mixed with a teaspoon of honey and put on the zit for 20 minutes.Then it is washed off, just as the nutmeg-milk mixture or the milk would be. Still another variant is a paste of ground cinnamon and honey, applied to the blemishes and left on overnight.

Milk of Magnesia

Putting milk of magnesia on the blemishes is another improbable but popular method for treating acne. One reader wrote that she volunteers in the theater program of the local high school. She’d suggested to some of the students that they apply milk of magnesia to their faces:

“One parent even told me it was a life-saver for his son. They had spent a small fortune on treatments with a dermatologist. When the father told the dermatologist that MoM worked better than prescribed medications, the physician was not happy.”

Milk of magnesia does not appear prominently in the dermatology literature. We were able to find one letter published in a medical journal decades ago: it was a patient reporting success with topically applied MoM (Archives of Dermatology, Jan. 1975). We regret that it has never been properly studied.

Listerine

Numerous readers tell us that the old-fashioned mouthwash, amber Listerine, can be very helpful against acne. We suspect that the essential oils it contains affect the balance of microbes living on the skin. Thymol, for example, has antibacterial effects (Molecules, Aug. 28, 2018). It discourages the overgrowth of Propionibacterium acnes (now called Cutibacterium acnes) and Staphylococcus epidermidis, two types of bacteria that are more abundant on blemished skin. Thymol isn’t the only essential oil in Listerine that might be beneficial. Eucalyptol interferes with the inflammatory reaction these skin bacteria cause (International Journal of Molecular Sciences, July 17, 2019). To use Listerine, people dab it on affected areas with a cotton ball once or twice daily.

Tea Tree Oil

One natural product that has been studied is tea tree oil in a 5 percent gel. An Australian study compared such an extract of the Australian tree Melaleuca alternifolia to a standard over-the-counter acne treatment, benzoyl peroxide (Medical Journal of Australia, Oct. 15, 1990). The study included 124 patients to see if the antimicrobial activity of the tea tree product would be useful. The scientists found that although the initial response was slower, the benefits were comparable for non-inflamed lesions after three months of treatment.

Benzoyl peroxide was significantly better at reducing inflamed lesions, but it also produced significantly more undesirable effects such as skin dryness, stinging, itching, burning and redness. If you can’t find a water-based gel, look for a cleanser with tea tree oil. That should be readily available. Some people are allergic to tea tree oil, so it makes sense to try a bit on the inside of your forearm first, to make sure you can handle it.

Over-The-Counter Acne Treatments

Benzoyl Peroxide

Benzoyl peroxide is the primary ingredient in most over-the-counter acne treatments. This compound has antimicrobial activity and is usually pretty effective for mild acne. Such nonprescription products use low concentrations, such as 2.5%, which is just as effective and less irritating than the higher concentration 10% products (Expert Opinion on Pharmacotherapy, Oct. 2009). Benzoyl peroxide seems to discourage acne-causing bacteria without leading to resistance.

You’ll find benzoyl peroxide in a number of different products, from cleansing bars and cleansers to lotions and even shaving creams. Read the instructions on the label and follow them; the procedure varies a little for the different forms. Benzoyl peroxide can be drying and cause irritation. If that happens, use it a little less frequently or look for a less concentrated product. Some people may have an allergic reaction to this compound and break out in hives or swelling, so it makes sense to try it out on the forearm first to make sure you will not react badly.

While benzoyl peroxide may be used in combination with topical antibiotics in prescription lotions or gels, it should not be used together with other OTC products such as resorcinol or salicylic acid. The one-two punch could be far too irritating.

Alpha Hydroxy Acids

Some topical OTC acne products contain either lactic acid or glycolic acid. These alpha hydroxy acids reduce inflammation and help clear away dead skin cells that can plug pores. They may also be found in some anti-wrinkle products.

Sulfur

Sulfur is a very old-fashioned acne remedy, but it is still available. Many people have found it helpful. One reader told us about her experience:

“I am a 41-year-old woman who never experienced acne until the past few years. I tried several medications, soaps and creams, but I found nothing to be particularly effective.

“Recently, a friend recommended sulfur soap. I find it on the Hispanic product aisle.

“After using it for a few weeks, my face is starting to clear up. Is this product safe, and how could a bar of soap costing less than $3 be more effective than salicylic acid or benzoyl peroxide?”

Topical sulfur has antibacterial activity that may explain its effectiveness against acne. Like the alpha hydroxy acids, it also helps eliminate dead skin cells (Journal of Drugs in Dermatology, Jul-Aug. 2004).

Prescription Pills

When topical antibiotics don’t do the job, dermatologists may prescribe oral pills to get the antibiotic into the entire bloodstream, rather than on the surface of the skin. Some experts urge doctors to use systemic (oral) medicine as soon as they find that topical treatments are not providing enough benefit (Expert Opinion on Pharmacotherapy, Feb. 2017).

Tetracycline and clindamycin have been widely prescribed, but some acne-causing bacteria have developed resistance to them. Now, dermatologists may be more likely to prescribe minocycline. Although this antibiotic works against acne, it is not clear that it is more effective than other oral antibiotics or less likely to cause undesirable reactions (Cochrane Database of Systematic Reviews, Aug. 15, 2012).

Anyone who’s prescribed oral antibiotics needs to know when to take them and whether to hold off on other treatments such as supplements or antacids for a few hours. Patients should discuss all the pros and cons of oral (systemic) antibiotic therapy with the doctor who is prescribing it. Certain drugs may cause rare but potentially serious side effects, such as the diarrhea and abdominal pain of pseudomembranous colitis with clindamycin.

Some unanticipated effects may result just from taking antibiotics. One study found that people using antibiotics (oral or topical) to treat their acne were more likely to come down with an upper respiratory tract infection or a sore throat (Archives of Dermatology, March 2012). Now, colds and flu and similar upper respiratory tract infections are usually self-limited and rarely a serious threat to health. But it makes sense to determine that the acne is in fact affecting your life so much that you’d be willing to trade it for a cold. It might not make sense to take an antibiotic for mild acne that was not too bothersome. Presumably, the antibiotics disrupt the microbial balance of the respiratory system just as they affect the microbiota of gut. This could leave people more susceptible to infection.

Dermatologists also worry about the development of bacterial resistance to antibiotics as a result of widespread use. Consequently, they are looking for other ways to treat acne without antibiotics. For women, medications that alter hormonal balance such as spironolactone or oral contraceptives offer promise (Journal of the American Academy of Dermatology, Sep. 2017). Laser and other light-based therapies are also getting a closer look (Journal of the American Academy of Dermatology, Feb. 2019).

After completing a course of antibiotic treatment, acne patients may be able to keep their skin clear by using tretinoin gel or a similar product. Either adapalene or tazarotene gel may be useful for this purpose. Using such topical medicine as a follow-up therapy can reduce the amount of antibiotic exposure.

Prescriptions Gels & Lotions

Topical Antibiotics

Dermatologists often prescribe topical antibiotic gels or lotions in addition to or instead of benzoyl peroxide. Erythromycin and clindamycin (Cleocin T, Clinda-Derm, Evoclin Topical Foam) are old standbys. Because they have been so widely used, however, bacteria have begun to develop resistance to them. As a result, dermatologists have been backing off their use and turning to other approaches a bit more often.

They may start by trying a prescription that combines benzoyl peroxide with an antibiotic. Benzaclin or Duac Gel (clindamycin plus benzoyl peroxide) and Benzamycin (erythromycin plus benzoyl peroxide) can be effective. Anyone using clindamycin needs to be vigilant: if they develop bloody diarrhea, they should contact the physician immediately. Although it is less likely with topical use, this antibiotic can disrupt the microbes in the digestive tract and leave a person vulnerable to C. diff infection.

Azelaic Acid

One other prescription medication that is being prescribed is azelaic acid (Azelex, Finevin). Like benzoyl peroxide, this topical treatment seems to keep pores from clogging and discourage the multiplication and spread of bacteria. It too may result in burning, stinging, redness or dryness of the skin. In rare instances, dark skin may develop lighter patches where it has been exposed to azelaic acid. If cold sores or fever blisters get worse, notify the prescribing physician immediately.

Tretinoin

Tretinoin (Altreno, Renova, Retin-A) or a similar compound in the vitamin A family can be very effective in treating acne and reducing the inflammation associated with severe acne. Those who use topical vitamin A-like compounds (retinoids) early in the course of their acne problem are less likely to develop scarring, a complication of the condition. Some doctors prescribe tretinoin together with benzoyl peroxide or with an oral antibiotic such as doxycycline to get skin clear faster. Because it works at the lower levels of the skin and speeds up cell turnover, it can also bring pimples to the surface more quickly. This means acne may seem to be getting worse at first rather than better, but with patience the condition should clear up. Tretinoin is also used to counter wrinkles due to sun damage.

Adapalene

Another compound that works on the same principles as tretinoin is adapalene (Differin). A review of clinical trials in the journal Therapeutics and Clinical Risk Management (Aug. 2007) concluded:

“The topical retinoids a play very important role in the treatment of acne vulgaris. However, their use is limited due to skin irritation. A new generation product, adapalene is a good choice in the treatment of acne vulgaris with less side effects and high efficacy confirmed by numerous clinical studies.”

The Anti-Acne Diet

It now seems likely that a diet high in processed foods that push blood sugar and insulin up quickly may also lead to a cascade of other hormonal changes that can affect the skin.

A review of studies concluded, on the other hand, that milk and other dairy products are strongly associated with the prevalence of acne (International Journal of Dermatology, March 19, 2009). A Norwegian study confirmed an association between high milk intake and acne in high school students (Journal of the European Academy of Dermatology and Venereology, March 2017). Also, a meta-analysis concluded that “any dairy, such as milk, yogurt, and cheese, was associated with an increased OR [Odds Ratio] for acne in individuals aged 7-30 years” (Nutrients, Aug. 9, 2018).

Several years ago a mother shared this story about her son, reinforcing the latest research:

“My son recently returned from a 5-day camping trip where he didn’t have milk or any of his acne medicine. To my surprise, his face looked beautiful. Maybe there’s a connection between clear skin and no milk. The dermatologist suggested eliminating milk to see what happens.”

We don’t know exactly how dairy products increase the risk of acne, but some researchers have suggested that the high levels of the amino acid leucine found in milk may drive the production of excess fatty acids in hair follicles (Dermatoendocrinology, Jan. 1, 2012). They proposed that controlling acne could best be achieved by lowering levels of the enzyme mTORC1: “An attenuation of mTORC1 signaling is only possible by increasing the consumption of vegetables and fruit, the major components of vegan or Paleolithic diets.”

Other scientists looking at the causes of acne vulgaris agree that the mTORC1 (mammalian target of rapamycin complex 1) is among the most important factors (Archives of Dermatological Research, July 2019). A diet low in processed foods and dairy products and high in vegetables can dampen this enzyme’s activity and should prove helpful for clear skin.

Conclusions

Blemishes are a common part of adolescence, but they also trouble many people well into adulthood. Changes in hormone levels seem to aggravate acne. Most treatments are aimed at killing or slowing down bacteria commonly present on the skin, and this usually works well until or unless the bacteria develop resistance.

Stress seems to make acne worse (which is why college students have more zits the week of final exams), but given the fact that stress is so hard to avoid, almost no treatments focus on controlling it. There are many approaches to acne treatment; if self-care does not prove effective, the dermatologist should be able to prescribe a therapy that will help.

• Change your diet. A low-glycemic-index diet with very little sugar or refined carbohydrate might improve skin significantly, and will have other health benefits as well. Other things to avoid: trans-fatty acids found in margarine and shortening, and milk. A study of dairy products and acne is currently underway.
• Facial masks of clay may remove excess oil and help skin clear. Other topical treatments to try include nutmeg mixed in milk or in honey to make a paste for pimples. A tea tree oil gel (5%) is worth trying.
• Wash morning and evening with a gentle non-soap cleanser. Using a harsh or abrasive product may aggravate acne.
• Ask your doctor about applying a topical antibiotic such as clindamycin or erythromycin. They can sometimes be helpful, but in some regions, skin bacteria have developed resistance to these drugs.
• Check with the doctor regarding a prescription for Retin-A. Be vigilant about protecting skin from the sun or any other source of ultraviolet radiation while you are using this medicine.
• Ask about Nicomide-T gel. This vitamin-based topical medicine can reduce inflammation and may be almost as effective as some topical antibiotics.
• Oral antibiotics may work even when topical antibiotics do not. Be sure to ask the doctor about side effects and interactions, and follow the dosing instructions carefully.
• Women may benefit from birth control pills. Sometimes the diuretic spironolactone provides additional anti-acne power.