Which Prescriptions Do Doctors Prescribe Most Often for Acne?
Retinoids, Benzoyl Peroxide, and Antibiotics Top the List
The Essential Information
The four most frequently prescribed acne medications are:
- Tretinoin - topical retinoid
- Isotretinoin* - oral retinoid
- Clindamycin/benzoyl peroxide combination** - topical antibiotic + benzoyl peroxide
- Minocycline - oral antibiotic
*Isotretinoin comes with severe and potentially lifelong side effects, and is only approved for use in people with severe and scarring acne that does not respond to other treatments. However, because of its effectiveness, doctors sometimes controversially prescribe it for milder acne as well.
**Over the years, combination treatment has become more common, and prescribing topical antibiotics alone has become less common.
Be Your Own Advocate: To avoid a medication merry-go-round, do your own research in order to understand your options. Don't simply accept any prescription your doctor advises. Arm yourself with knowledge on the available options, and ask questions. And make sure you are speaking to a dermatologist who is an expert in acne.
Several studies have looked into the question of which prescriptions are most common for acne. The most recent data comes from a 2014 study that included data from approximately 31 million patient-visits between 2005 and 2010. Here are the top 10 most commonly prescribed medications:
In this article, we will discuss in more detail the top four most commonly prescribed medications, and then consider changes that have occurred over the years in prescribing practices.
The Four Most Commonly Prescribed Acne Medications
Despite providing only moderate benefit to acne, tretinoin is the single most frequently prescribed acne medication. Various treatment guidelines, such as those recommended by the American Academy of Dermatology, consider topical (applied to the skin) retinoids, such as tretinoin, to be the preferred treatment for acne, except in severe cases. Many guidelines continue to recommend topical retinoids as the first choice of treatment for mild-to-moderate acne and also for acne maintenance once a patient clears his skin.
Tretinoin has been one of the primary acne treatments for over 40 years, largely because of its ability to:
- Help skin cells shed, thus keeping the skin turning over properly and preventing clogged pores
- Treat mild acne lesions as well as papules and pustules, which are inflamed "pimples" or "zits," when used in combination with other medications
- Reduce skin inflammation
- Prevent acne-induced scarring
- Prevent disease progression - in other words, preventing acne from getting worse2
The following guidelines and studies from the Journal of the American Academy of Dermatology, American Journal of Clinical Dermatology, and Journal of Dermatological Treatment speak about how retinoids help unclog pores, and can help clear acne when used alongside other medications.
Expand to read details of studies
The American Academy of Dermatology's guidelines of 2016, published in the Journal of the American Academy of Dermatology, states, "Retinoids are the core of topical therapy for acne because they [open clogged pores], resolve the precursor microcomedone lesion, and are antiinflammatory. These agents enhance any topical acne regimen and allow for maintenance of clearance after discontinuation of oral therapy. Retinoids are ideal for comedonal acne and, when used in combination with other agents, for all acne variants."1
A 2003 article in the American Journal of Clinical Dermatology notes, "Preclinical data suggest that topical retinoids and retinoid analogs may also have direct anti-inflammatory effects. A wealth of clinical data confirms that topical retinoids and retinoid analogs significantly reduce inflammatory lesions."2
Despite the fact that dermatologists consider topical retinoids to be the preferred therapy for acne, and the fact that guidelines have recommended since 2003 that all patients who have mild to moderate acne be treated with a topical retinoid, a 2013 study in the Journal of Dermatological Treatment found that doctors prescribed topical retinoids only to 40% of patients. This study found also that doctors were more likely to prescribe a topical retinoid to young patients and also to female patients, regardless of their age. The authors noted, "Based on the strong clinical evidence, acne management guidelines have recommended since 2003 that almost all acne patients should be treated with a topical retinoid except for those with the most severe cases. Nevertheless, according to our findings from the most recent data available, the frequency of topical retinoid use for acne vulgaris remains low."3
Isotretinoin, often known by its brand name Accutane®, is the second-most prescribed acne medication. It is a highly effective oral medication which typically is only approved for the most severe cases of acne. Patients take isotretinoin usually for 15 - 20 weeks, and in that time it successfully shrinks skin oil glands, usually permanently. Because of its long-lasting effects, it can offer long-term relief from acne symptoms in the majority of people who take an adequate dosage. In 14.6 to 52% of people, acne returns to some degree after isotretinoin treatment, but often the acne that comes back is less severe than before treatment.
Because of isotretinoin's effectiveness, doctors increasingly prescribe it for mild to moderate acne as well. This practice is highly controversial because isotretinoin is such a powerful medication that it can cause severe birth defects if a patient takes it when pregnant. It also can cause severe, sometimes long-term, side effects. The FDA (U.S. Food and Drug Administration) recommends isotretinoin only for severe nodular acne.
The combination of clindamycin and benzoyl peroxide, either as a single product that combines both substances (one popular brand name is BenzaClin®) or as two separate products, is the third-most frequently prescribed acne medication. Previously it had ranked lower on the list of medications prescribed for acne. However, doctors prescribe it more frequently now because recent evidence has shown that combination treatment is more effective than either clindamycin or benzoyl peroxide alone.
Clindamycin, also known as clindamycin phosphate, is an antibiotic and is prescribed in its topical form to reduce skin inflammation. However, current guidelines recommend that topical antibiotics not be used alone and that they be used only for a maximum of three months. The reason for these restrictions is that bacteria can become resistant to antibiotics over time. It should also be noted that clindamycin does not work for everyone.
Benzoyl peroxide is a mainstay of acne treatment and works by quickly and almost completely killing acne bacteria as well as drying the skin and shedding skin cells, thus keeping pores from becoming clogged. It is available by prescription as well as over-the-counter, in up to 10% strength. One benefit of benzoyl peroxide is that bacteria cannot become resistant to it.
Minocycline is the fourth-most commonly prescribed acne medication. It is an oral antibiotic that belongs to the class of antibiotics known as tetracyclines, which are the most widely prescribed oral antibiotics for acne because of their effectiveness against acne bacteria and their anti-inflammatory effects. As with topical antibiotics, oral antibiotics should be used for a maximum of three months, and do not work for everyone. When they do work, they only provide moderate benefit, and can come with many side effects, particularly gastrointestinal discomfort.
Other oral tetracycline antibiotics exist (such as doxycycline and tetracycline), but minocycline is prescribed more often because, as is discussed in the following 2011 article in The Journal of Clinical and Aesthetic Dermatology, it may have enhanced penetration into the skin, providing for better acne-killing properties and lowered risk of creating resistant bacteria. In addition, it may be better absorbed in the gut and have less food interactions compared with other oral tetracyclines. On a downside, it comes with more side effects, so doctors often prescribe the extended-release form of minocycline to reduce these unwanted effects.
A 2011 article in The Journal of Clinical and Aesthetic Dermatology found that minocycline accumulated in skin tissue in significantly greater amounts than did other tetracyclines. It also noted that in a six-week study comparing minocycline to other tetracyclines, minocycline decreased C. acnes levels 10 times more than did the other tetracyclines, the reduction in C. acnes persisting three weeks after the course of treatment. These results may be due to minocycline's enhanced ability to penetrate skin tissue, thereby reducing the development of resistant bacteria. The authors noted, "Minocycline treatment may have an advantage compared with tetracycline or doxycycline because enhanced tissue penetration may be accompanied by a lower incidence of emergence of resistant C. acnes strains."6
The same article described another study that tested antibiotic resistance in 73 strains of C. acnes. Compared to other antibiotics, minocycline was the only one that effectively targeted all 73 strains. This result demonstrates that minocycline is effective against most antibiotic-resistant strains of C. acnes, which increases its viability.6
Minocycline possesses other characteristics that make it better than other oral antibiotics:
- It is absorbed into the gastrointestinal tract better than other oral antibiotics, which increases the amount of medication available.
- It doesn't interact with as many foods as other oral antibiotics.
Prescribing Practices Change Over Time
Prescribing practices for the top 10 most frequently prescribed acne medications have changed. A comparison of data from the National Ambulatory Medical Care Survey database for the date ranges, 1989 - 2009, 2007 - 2009, and 2005 - 2010, shows us several trends:
- There has been no change in the prescribing of tretinoin, which consistently has been the most frequently prescribed acne medication for at least 21 years.
- There has been a decline in the prescribing of benzoyl peroxide and clindamycin as single therapies but an increase in the prescribing of clindamycin/benzoyl peroxide in combination.
- Though topical and oral treatment both consistently have been among the top 10 most commonly prescribed medications, topical therapy still is prescribed more often than oral therapy.
- Prescribing of minocycline declined briefly from 2007 - 2009, yet consistently has remained one of the four most commonly prescribed medications.4
- Zaenglein, A. et al. Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology (2016). https://www.ncbi.nlm.nih.gov/pubmed/26897386
- Millikan, L. The Rationale for Using a Topical Retinoid for Inflammatory Acne. American Journal of Clinical Dermatology 4, 75 - 80 (2003). https://www.ncbi.nlm.nih.gov/pubmed/12553848
- Tan, X. et al. Factors associated with topical retinoid prescriptions for acne. Journal of Dermatological Treatment 25, 110 - 114 (2013). https://www.ncbi.nlm.nih.gov/pubmed/23802699
- Hoover, W. et al. Topical antibiotic monotherapy prescribing practices in acne vulgaris. Journal of Dermatological Treatment 25, 97 - 99 (2013). https://www.ncbi.nlm.nih.gov/pubmed/24171409
- Leyden, J. et al. Comparison of the Efficacy and Safety of a Combination Topical Gel Formulation of Benzoyl Peroxide and Clindamycin with Benzoyl Peroxide, Clindamycin and Vehicle Gel in the Treatments of Acne Vulgaris. American Journal of Clinical Dermatology 2, 33 - 39 (2001). https://www.ncbi.nlm.nih.gov/pubmed/11702619
- Leyden, J. & Del Rosso, J. Oral Antibiotic Therapy for Acne Vulgaris: Pharmacokinetic and Pharmacodynamic Perspectives. The Journal of Clinical and Aesthetic Dermatology 4, 40 - 47 (2011). https://www.ncbi.nlm.nih.gov/pubmed/21386956
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