and many antibacterial agents have complementary actions, and they work well together, but applying both at the same time increases the chance of side effects such as dryness, redness, and/or peeling. If you experience side effects, it’s best to use the two separately, applying the antibacterial product in the morning and the prescription retinoid (be it tretinoin or another type) at night. Benzoyl peroxide does not deactivate newer formulations of tretinoin as it did in the past. [75]
Azelaic acid is believed to work against acne-causing bacteria in concentrations of 15%–20%, and it may also pack an anti-inflammatory punch. [76] Azelaic acid was approved for the treatment of acne in the United States in 2002, and also is prescribed to manage the symptoms of rosacea (some of which are similar to those of acne). It’s definitely on the A-list of prescription options for treating acne—no pun intended. (Azelaic acid is not a prescription treatment in most Asian countries.)
Stay the course! For any topical acne treatment to work, whether prescription or over-the-counter, consistency is vital. Unfortunately, because almost all topical options can be hard on skin (at least at first), it’s even more important to follow our suggestions for gentle skincare. Too often, skincare recommendations, even from dermatologists, include using products with irritating, drying ingredients that cause damage and inflammation. This means you’ll struggle with being able to use acne-fighting treatments successfully. Please don’t make the mistake of reverting to an outdated, problematic way of caring for acne- or breakout-prone skin. The research is clear that irritation makes acne worse, but a lot of salespeople, aestheticians, and physicians ignore or aren’t familiar with this—but now you are!
Oral antibiotics can be extremely effective in controlling acne, but they also pose a risk of serious side effects that you must consider. Oral antibiotics do indeed kill the bad bacteria, but they also kill the good bacteria in the body. Thus, ongoing use can lead to chronic vaginal yeast infections as well as stomach problems. In addition, the acne-causing bacteria can become immune or resistant to the oral antibiotic. [77] That means if you’ve been taking an oral antibiotic to treat your acne for longer than six months, it can, and almost always does, become ineffective against the acne, although the negative side effects—killing good bacteria and causing stomach and other problems—could continue.
However, some research has shown that taking low doses (“sub-microbial” or subclinical doses) to fight acne is moderating the concern about bacterial resistance and adaptation. [68] Taking such low doses of oral antibiotics over the long term can improve acne, while minimizing, if not completely eliminating, the problem of the bacteria becoming resistant. It seems that lower doses of oral antibiotics have anti-inflammatory benefits instead of antibacterial benefits, but they still can kill acne-causing bacteria. That doesn’t mean you won’t suffer from possible systemic effects, though; so, whether you opt for regular or low-dose oral antibiotics, be sure to discuss the pros and cons with your dermatologist.
Birth control pills (some types) have been shown to reduce acne lesions and oil production, in part by decreasing androgens (male hormones), which are largely responsible for causing acne.
Birth control pills are a combination of different synthetic estrogens and progestins (female hormones). Some progestins can increase the amount of androgens in the body, while others block the production of androgens. Because androgens stimulate oil production, blocking androgens for those prone to breakouts and oily skin is a good thing.
As a result, some of the birth control pills that block androgens have been approved by the Food and Drug Administration (FDA) and other regulatory organizations for the treatment of acne. These include Ortho Tri-Cyclen (active ingredient: norgestimate/ethinyl estradiol), YAZ (active ingredient: drospirenone/ethinyl estradioland), Estrostep Fe (active ingredient: norethindrone/ethinyl estradiol). Diane-35 (chemical name: ethinyl estradiol cyproterone acetate) has been approved for such use in Canada.
Keep in mind that there are risks associated with taking any type of birth control pill (especially if you smoke), and you should discuss these matters with your doctor. [78] Birth control pills also should not be the sole therapy for acne; think of them as a partner product for use with a skincare routine designed to reduce acne.
Alternative Acne Treatments
The world of alternative acne treatments is wide and varied. It includes options that are easily obtained at the drugstore, some that you can find at your local health supplement retailer, and even options in your grocery store, particularly if you frequent natural markets. We describe some of these options below.
Tea tree oil has some interesting, though minor, research demonstrating that it’s an effective antimicrobial agent, although it’s not without its drawbacks. In a study comparing tea tree oil with benzoyl peroxide, it was found that a 5% concentration of tea tree oil has an efficacy similar to that of 5% benzoyl peroxide. [33] That sounds as if the two are equally effective, but in the world of skincare it doesn’t work that way. It turns out there aren’t any skincare products that contain 5% tea tree oil. The highest concentration of tea tree oil we’ve ever seen in a cosmetic product is less than 0.5%, which likely makes it ineffective for treating acne. [33] “Pure” tea tree oil is typically only a 3% concentration diluted in a carrier oil, so even that isn’t strong enough, despite the “100% tea tree oil” statement you might see on the label.
Niacinamide and nicotinic acid are derivatives of vitamin B3. There are a handful of studies showing they can be helpful for improving the appearance of acne, which most likely is the result of their anti-inflammatory and barrier-restoring properties. [79,80] When included as part of an anti-acne skincare routine, these B vitamin ingredients can be part of a powerful combination of products and ingredients to combat the series of events taking place in the skin that lead to acne. Niacinamide has anti-aging benefits as well, so it’s a brilliant solution for those struggling with wrinkles as well as acne. [79,80]
Prebiotics and probiotics are microorganisms that occur naturally in the body and are present in many of the foods we eat, such as yogurt. Although they can be helpful when consumed, the research on prebiotics and probiotics related to topical application and their effect on acne is non-existent, so any benefit remains theoretical, although there has been at least one study that indicates they may have potential. [81] There’s no harm in trying this option, via foods and/or supplements. As far as skincare products, we just haven’t seen any that would be able to keep the prebiotics and probiotics stable or contain enough to provide any meaningful benefit.
Fatty acids are an interesting group of ingredients that can have an effect on breakouts, but exactly what that effect is, either positive or negative, isn’t clear; far more research is needed. [82,83] There are only a few studies showing how fatty acids may improve matters but none are conclusive in the least.
Fatty acids, such as lauric, oleic, and palmitic acids, can have an antibacterial effect on P. acnes. However, their stability is an issue: A product that contains a fatty acid must be carefully formulated to ensure the fatty acid can exert its antibacterial action before it breaks down. If these fatty acids are present in skincare products that are packaged in a jar, chances are good they’ll break down before they can really help your skin, because air exposure causes these fatty acids to turn rancid.
Sulfur can have some benefit as a disinfectant for breakouts. [33] However, compared with other options, it’s an overly strong ingredient for skin, potentially causing more irritation than needed to fight acne-causing bacteria. For this reason, using sulfur to manage acne has largely fallen out of favor, so it’s actually hard to find sulfur-based acne products, which in the long run is best for most people’s skin. Nonetheless, when all else has failed, this may be an option to consider.
Diet can have both a positive and negative effect on acne. Reactions to certain foods can cause acne, while other foods may help reduce the frequency of occurrence. [63] Reactions to foods such as dairy products (mostly due to naturally-occurring hormones in dairy)
