What is it: Made under the brand name "Differin," it is a topical retinoid gel which is applied once a day.1-2It comes in .1% and .3% strength. Learn more from the U.S. National Library of Medicine.
What it does: Acne is thought to be caused by the skin cells inside the follicle shedding too fast and clogging pores. Differin gel slows down the accumulation of skin cells inside the follicle that plug the pores.1-2It also has anti-inflammatory effects.3
Considerations: Exposure to sunlight should be minimized.1-2About 10-40% of patients experience redness, dryness, scaling, burning, or itchiness. Other adverse reactions were also reported.1-2,4
Brand names: Differin.
What is it: Made under the brand name "Azelex." Azelex is a cream containing 20% azelaic acid, a naturally occuring acid found in whole grain cereals and animal products. It is normally applied twice daily.1 Learn more from the U.S. National Library of Medicine.
What it does: Azelaic acid is thought to help the skin to renew itself more quickly and prevent the buildup of cells that can plug pores, therefore reducing pimple and blackhead formation. It also helps to kill acne bacteria,1 and has anti-inflammatory effects.2
Considerations: Side effects are generally mild and short lived. Most common, in 1-5% of people are itching, burning, stinging, and tingling. Other side effects were reported in less than 1% of people. There have been a few reports from darker skinned people of lightening of the skin. Azelaic acid has not been well studied in people with dark complexions.1
Brand names: Azelex.
What it is: Benzoyl peroxide is available in prescription and over-the-counter medications, in cream, gel, and wash form. It is an anti-bacterial agent.1-2,4-5 Learn more from the U.S. National Library of Medicine.
What it does: Benzoyl peroxide is the only known substance which can bring oxygen under the skin surface. Since bacteria cannot survive in the presence of oxygen, when used in an adequate dosage, benzoyl peroxide eradicates 99.9% of these bacteria almost immediately. It also exerts a mild drying and peeling effect, which is thought to help prevent breakouts.1-6 Benzoyl peroxide also helps lessen inflammation.7-9 2.5% benzoyl peroxide is just as effective as higher concentrations with less side effects.6,10
Considerations: Benzoyl peroxide is able to produce complete clearing of acne only when used in an adequate dosage and within a properly applied benzoyl peroxide regimen. Some dryness, redness, and itchiness is to be expected in the first few weeks of use.6 Scientists call this initial period the "hardening effect" of benzoyl peroxide. About 1-3% of people are allergic to benzoyl peroxide and experience an inflammation of the skin or severe crusting.3This should not be confused with the "hardening effect" of benzoyl peroxide. Benzoyl peroxide, like any other peroxide, can bleach hair and fabric.1
Prescription names: Benzac AC, Brevoxyl, Triaz, Benzaclin (benzoyl peroxide + clindamycin). Note: Benzoyl peroxide is also available over-the-counter.
What it is: Clindamycin is a topical antibiotic which usually comes in a solution, gel, foam, or lotion, and is normally applied twice daily.1-2 Learn more from the U.S. National Library of Medicine.
What it does: Clindamycin phosphate is an antibiotic which kills P. Acnes (acne bacteria).1
Considerations: Burning, itching, peeling, redness, and dryness are the most reported side effects, particularly at the onset of treatment.1,3 Diarrhea, bloody diarrhea, and inflammation of the colon have been reported.1,3
Brand names: Cleocin T, Clinda-derm, Clindets, Benzaclin (clindamycin + benzoyl peroxide).
What it is: Made under the brand name "Aczone." Aczone is a 5% topical gel that is normally applied twice daily. Learn more from the U.S. National Library of Medicine).
What it does: Dapsone targets the inflammatory component of acne by helping to inhibit the body's inflammatory response. It also possesses antioxidant and minor antibacterial properties.1Dapsone reduces acne lesion count by approximately 30-45%. Initial studies point toward better efficacy in female patients than in male patients.2
Considerations: Unlike oral dapsone which is sometimes prescribed for leprosy and other skin infections, topical dapsone does not come with potentially dangerous blood related side effects.4-5Side effects of topical dapsone are normally mild in nature and can include dryness, rash, and burning.6
Brand names: Aczone.
What it is: Erythromycin is a topical antibiotic packaged in gel, ointment, pledgets (little take-along packets), and solutions, and is usually applied twice a day.8It is often combined with benzoyl peroxide. Learn more from the U.S. National Library of Medicine).
What it does: Erythromycin is an antibiotic which kills P. Acnes (acne bacteria).1-2
Considerations: Ask your doctor before using any other products on your skin while using erythromycin, as it may be too irritating. This includes other prescriptions, over-the-counter medicines (including those listed on this site), and harsh or abrasive cleansers, perfumes, or make-up.2 People report burning as the most frequent side effect, and also peeling, dryness, itching, redness, and oiliness, among others.2
Brand names: Benzamycin (erythromycin + benzoyl peroxide), Akne-Mycin, A/T/S, Emgel, Erycette, Eryderm, Erygel, Erymax, Ery-Sol, Erythra-Derm, ETS, Staticin, Theramycin Z, T-Stat.
What it is: Originally under the brand name "Accutane" but now available only in generic form, isotretinoin is a derivative of vitamin A taken in pill form for 15-20 weeks. Doctors normally prescribe it for people with "severe nodular acne" that does not respond to other treatments. Nodules are inflammatory lesions with a diameter of 5mm or more. A single course of 15-20 weeks has been shown to result in complete clearing and long-term remission of acne in many people.1-2 Learn more on the Accutane page of acne.org.
What it does: Reduces the amount of oil produced by the oil glands.1
Considerations: THERE IS AN EXTREMELY HIGH RISK THAT A DEFORMED INFANT CAN RESULT IF PREGNANCY OCCURS WHILE TAKING ACCUTANE IN ANY AMOUNT AND EVEN FOR SHORT PERIODS OF TIME. FEMALES WHO ARE PREGNANT OR WHO MAY BECOME PREGNANT WHILE UNDERGOING TREATMENT SHOULD NOT TAKE ACCUTANE. There are many other warnings as well.1-3 Side effects of Accutane are many, some of which include dry and cracked lips, dry skin, dry nose and mouth, mild to moderate muscle or joint aches.1-2,4-7
Brand names: Accutane, Roaccutane, Accutane Roche.
What it is: Oral antibiotics are taken in pill form usually once per day. (Learn more about Doxycycline, Minocycline, Levofloxacin, Co-trimoxazole AKA sulfamethoxazole/trimethoprim from the U.S. National Library of Medicine)
What it does: Oral antibiotics help stop the growth of P. Acnes (acne bacteria), from the inside out.1Antibiotics also have an anti-inflammatory effect.2-4
Considerations: Regardless of the type of antibiotic prescribed, only about one half of patients respond. When antibiotics do produce results, these results are moderate at best.5-8 Oral antibiotics should be used for only a short period of time, up to 6 months. However, even within this short time frame, antibiotics have been implicated in the proliferation of resistant colonies of bacteria. Some antibiotics cause increased sensitivity to sunlight. Exposure to the sun could cause a rash, itchiness, or redness, and you may be burnt more easily, so you'll want to wear protective clothing and sunscreen.2 Side effects may include upset stomach, diarrhea, nausea, headache, vomiting, dizziness, or light-headedness as your body becomes accustomed to it.2 Minocycline is less prescribed because it works no better than any other antibiotic and comes with safety concerns, including the possibility of irreversible skin pigmentation.8-10
Brand names: Vibramycin (doxycycline), Minocin (minocycline), Bactrim/Septra (co-trimoxazole AKA sulfamethoxazole-trimethoprim).
Oral Contraceptives (Birth Control Pills)
What it is: Birth control pills contain progesterone and estrogen. Learn more.
What it does: Birth control pills help decrease testosterone levels, which in turn decreases the severity of acne in women. Studies show on average a 30-60% decrease in total "lesions."1-4
Considerations: Cigarette smoking with oral contraceptive use increases the risk of serious heart disease.2 There are many negative side effects and positive side effects to taking birth control pills for acne. Talk to your doctor to decide if it is right for you.1-3 While it is a widely held belief, evidence does not show a correlation between pregnancy rates and concurrent administration of birth control pills and oral antibiotics. [With the exception of anti-tuberculosis drugs like rifampin.]
Brand names: Ortho Tri-Cyclen, Estrostep, Yaz.
What it is: Sodium Sulfacetamide is a "sulfonamide," which was a wonder drug before other antibiotics and penicillin came into existence. It is still used for its antibacterial activity. It is used topically on the skin.1,3 Learn more from Wikipedia.
What it does: Sodium Sulfacetamide curbs the growth of acne bacteria. It also has anti-inflammatory effects.1-4
Considerations: People have died due to severe reactions to sulfonamides, although rarely.4Side effects in clinical trials were experienced by less than 2% of patients, and include irritation, stinging and burning.4
Brand names: Klaron, Novacet, Sulfacet-R.
What it is: Spironolactone is a prescription medication in tablet form used to treat certain patients with hyperaldosteronism (the body produces too much aldosterone, a naturally occurring hormone), low potassium levels, and in patients with edema (fluid retention) caused by various conditions.1 Learn more from the U.S. National Library of Medicine.
What it does: Spironolactone is a potassium-sparing diuretic that has been used as an androgen-receptor blocker to treat acne and hirsutism in women (excessive hair growth).1-2
Considerations: Side effects include muscle weakness, pain or cramps, lack of energy, loss of appetite, unusual bleeding or bruising, and more.1
Brand names: Spironolactone, Aldactone.
What it is: Made under the brand name "Tazorac." Tazorac is a retinoid gel that contains tazarotene, a vitamin A derivative, in 0.05% or 0.1% concentration and is usually applied to the skin once per day. It is used for both psoriasis and acne.1It can be used in conjunction with other topical treatments.2 Learn more from Wikipedia.
What it does: Like other retinoids, tazarotene is thought to mediate inflammation and help pores from becoming clogged.3 Trials show on average about a 50% improvement in "lesion" counts after 12 weeks.4-6
Considerations: Because tazarotene is a retinoid (vitamin A derivative), like Accutane, it should not be used by women who are pregnant because of potential harm to the fetus. Exposure to sunlight should be avoided. Wind or cold may be more irritating when taking tazarotene. Side effects occured in 10-30% of patients and included dry peeling skin, burning, stinging, dry skin, redness, and itchiness.
Brand names: Tazorac.
What it is: You may have heard of tretinoin in reference to "Retin-A" wrinkle treatments. Tretinoin is retinoic acid and vitamin A acid combined, and comes in various strengths in creams, gels, and liquids for topical use on the skin. It is used to treat acne and also to treat sun damaged skin or wrinkles and is usually applied once per day.1Learn more from the U.S. National Library of Medicine.
What it does: It is thought to help unplug follicles and keep pores clear. It also increases the speed at which surface skin cells are replaced and helps reduce inflammation. A study done on Retin-A Micro, a particular brand of tretinoin, showed a 32-45% reduction in total "lesions."2
Considerations: Despite the frequent referencing of an initial flare of acne when starting is tretinoin, there is no science evidence to back this up. You should not expect an initial worsening of acne.3-4 Exposure to sunlight should be minimized as you may be more sensitive to its rays. Ask your doctor before using other medication on the skin, especially anything containing sulfur, resorcinol, or salicylic acid, as the combination may be too irritating. Abrasive soaps and cleansers should be used with caution for the same reason. Side effects can include skin irritation, swelling, lightening or darkening of the skin, an increase in acne sores, excessive redness, and crusted or blistered skin.
Brand names: Retin-A, Retin-A Micro, Avita, Renova.
How to Wash Your Face
Whatever medication you decide to use, it is important to properly wash your skin before treating.
1 Wash your face only twice per day, morning and evening. Excess washing can cause irritation.
2 Use only your bare hands to wash, and wash for 10 seconds or less. Washcloths and hand-held cleansing devices are unnecessarily irritating. Consider the act of washing as simply prepping your skin for medication, nothing more. Washing itself does not clear breakouts since dirt does not cause acne, so there is absolutely no need to scrub.
3 Pat dry. Do not rub dry. Rubbing the skin is irritating, and excess irritation can perpetuate the acne cycle. Gently pat dry.