Sulfur for Acne
Sulfur Is a Useful Aid in the Treatment of Acne, Especially When Combined With Other Medications
The Essential Information
Sulfur is a time-tested topical treatment for acne that people have been using since the 5th century BC for its ability to shed the outer layer of skin cells, which helps pores from becoming clogged. It also helps inhibit the growth of acne bacteria.
However, due to the unpleasant odor of sulfur and the temporary skin-discoloration that it can impart, preparations containing only sulfur rarely are used. Using sulfur combined with benzoyl peroxide or sodium sulfacetamide (a prescription medication) shows increased effectiveness, and can cut down on the unpleasant odor. However, you should not use sulfur combined with sulfacetamide if you are allergic to sulfa drugs.
Side effects of topical sulfur include dryness, peeling of the skin, and occasional cracking/splitting of the skin around the mouth. These side effects can be overcome by using a lower percentage sulfur medication.
Topical application of sulfur has been used to treat various skin conditions since the time of Hippocrates (5thcentury BC). Since the 1960s, science has validated its effectiveness in treating acne, particularly when combined with other ingredients such as benzoyl peroxide.
Sulfur is used to treat a variety of conditions, including acne, seborrheic dermatitis (scaly patches and red skin, usually on the scalp), rosacea, scabies, and fungal infections. It treats acne by shedding the outer layer of dead skin cells, which helps prevent clogging and promotes new skin generation.
In nature, sulfur is a yellow, nonmetallic element found in the Earth's crust. Sulfur is produced in many forms, but colloidal sulfur is the most commonly used and most potent form of sulfur due to the smaller size of its particles, which promotes greater sulfur-to-skin interaction. Sulfur is most effective when combined with other anti-acne medications such as benzoyl peroxide and sodium sulfacetamide.
How Sulfur Works on Acne
Keratin is a protein that is involved in pores when they become clogged. Sulfur is keratolytic, which means that it breaks down keratin, thereby relieving the clog. Sulfur is usually combined with other medications because the keratolytic effect is greater in this way. Combining sulfur with other medications also mitigates some of the unpleasant effects of sulfur alone, such as temporary skin discoloration and its unpleasant smell.2
Scientists have yet to discover exactly how sulfur works. Research suggests that:
- It may work because a reaction between the sulfur and cysteine, an amino acid found in the skin, aids in the formation of hydrogen sulfide ions, which break down keratin in the skin cells.2
- Sulfur inhibits the growth of C. acnes ( Cutibacterium acnes), the bacteria associated with acne.3
Scientists believe that when combined with other medications, sulfur could work in these ways:
- Benzoyl peroxide may facilitate the reaction between sulfur and keratin in skin cells to form hydrogen sulfide.
- Benzoyl peroxide might make keratin more susceptible to the keratolytic effect of hydrogen sulfide.
- Sulfur combined with sodium sulfacetamide demonstrates anti-inflammatory properties.1
Effectiveness of Sulfur in Different Formulations
Because sulfur alone isn't as effective as it is when combined with other medications, and because sulfur alone can produce skin discoloration and has a bad odor, it normally is not used on its own. However, when combined with ingredients such as benzoyl peroxide8 and sodium sulfacetamide7 in the form of lotions, creams, soaps, and ointments that contain sulfur from 1 - 10%, it shows increased effectiveness. A few sulfur-only products, such as Vleminckx's solution and Ress' solution, are infrequently used.4
Sulfur Combined with Benzoyl Peroxide
A 1965 study published in the Canadian Medical Association Journal showed that sulfur combined with benzoyl peroxide is a potent agent against even severe body acne. In this study, sulfur was combined with benzoyl peroxide to treat 286 participants with acne, and the results showed that:
- Mild to moderate acne was suppressed within two weeks and controlled within three to four months.
- Moderately severe acne responded quickly to the treatment, and control over acne symptoms was achieved within four to six months.
- Severe cystic acne was the most resistant, but control was achieved within six to nine months.5
Sulfur Combined with Sodium Sulfacetamide
In a 1993 study published in the International Journal of Dermatology, Breneman and Moira examined the effectiveness of a sodium sulfacetamide (10%) and sulfur (5%) lotion in 60 women aged between 22 - 45 years of age with mild to moderate acne.
Those enrolled in the study were instructed to avoid topical acne medicines, antibacterials, steroid creams, comedogenic cosmetics (cosmetics that clog pores), and medicated soaps and shampoos prior to treatment. Additionally, participants were instructed to stop using facial moisturizers and sunscreens for seven days prior to treatment.8
The medication used in the study was dispensed to patients over a 12-week study period, and participants' acne lesions were examined following 1, 4, 8, and 12 weeks of treatment. The results found that:
- Using sodium sulfacetamide (10%) and sulfur (5%) lotion for 12 weeks for mild to moderate acne effectively decreased total acne lesions by 78%.
- Physician Global Assessment (PGA) scores showed that 53 of 54 patients (98.2%) were "moderately better" and "much better" after 8 weeks of treatment, and by week 12 all 54 patients showed similar improvement.8
While uncommon, adverse effects of topical sulfur-products include unpleasant odor, temporary discoloration of skin, and drying, peeling, and swelling of the skin.2,5,6Sulfur is a category C drug, which means there are no adequate studies performed on humans but potential benefits may warrant its use in pregnant women despite the potential risks.6
While preparations containing sulfur alone normally are well tolerated, preparations combined with sulfacetamide are not recommended for patients with a sulfa allergy.9Sulfa allergies can cause a number of symptoms varying in severity. The most common symptoms are skin reactions such as
- Erythema (redness)
- Maculopapular rash (a rash that contains both a discolored area of skin and small, raised bumps)
- Morbilliform rash (small lesions that may combine to form larger lesions and hives and itching).11
These reactions occur generally within a few days of treatment and cease promptly after discontinuation. Although uncommon, patients with sulfa allergies can experience anaphylaxis (a life-threatening allergic reaction). Symptoms of anaphylaxis include hives, swelling of the lips and around the eyes, swelling of the windpipe, constriction of respiratory pathways, gastrointestinal disturbances, and low blood-pressure.11
- Keri, J. & Shiman, M. An update on the management of acne vulgaris. Clin Cosmet Investig Dermatol 2, 105 - 110 (2009). https://www.ncbi.nlm.nih.gov/pubmed/21436973
- Lin, A. N., Reimer, R. J. & Carter, D. M. Sulfur revisited. J Am Acad Dermatol 18, 553 - 558 (1988). https://www.ncbi.nlm.nih.gov/pubmed/2450900
- Abramovits, W. & Kennedy, A. J. Sulfur/sodium sulfacetamide preparations. Skinmed 3, 95 - 101 (2004). https://www.ncbi.nlm.nih.gov/pubmed/15010636
- Kaminsky, A. Less common methods to treat acne. Dermatology 206, 68 - 73 (2003). https://www.ncbi.nlm.nih.gov/pubmed/12566807
- Pace, W. E. A Benzoyl Peroxide-Sulfur Cream for Acne Vulgaris. Can Med Assoc J 93, 252 - 254 (1965). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1928665/
- Akhavan, A. & Bershad, S. Topical acne drugs: review of clinical properties, systemic exposure, and safety. Am J Clin Dermatol 4, 473 - 492 (2003). https://www.ncbi.nlm.nih.gov/pubmed/12814337
- Davis, S. Topical treatment of acne: skin care. SA Pharmacist's Assistant 13, 42 - 44 (2013). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3997205/
- Breneman, D. L. & Ariano, M. C. Successful treatment of acne vulgaris in women with a new topical sodium sulfacetamide/sulfur lotion. Int J Dermatol 32, 365 - 367 (1993). https://www.ncbi.nlm.nih.gov/pubmed/8505165
- Feldman, S., Careccia, R. E., Barham, K. L. & Hancox, J. Diagnosis and treatment of acne. Am Fam Physician 69, 2123 - 2130 (2004). https://www.ncbi.nlm.nih.gov/pubmed/15152959
- Russell, J. J. Topical therapy for acne. Am Fam Physician 61, 357 - 366 (2000). https://www.ncbi.nlm.nih.gov/pubmed/10670502
- Kelly, T. E. & Hackett, P. H. Acetazolamide and sulfonamide allergy: a not so simple story. High Alt Med Biol 11, 319 - 323 (2010). https://www.ncbi.nlm.nih.gov/pubmed/21190500
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