Your treatment plan

Your recommended treatment plan will depend on whether your acne is mild, moderate or severe.

Mild acne is treated using gels or creams (topical treatments) such as:

• benzoyl peroxide,
• topical retinoids,
• topical antibiotics, or
• azelaic acid.

Moderate acne is usually treated using a combination of the medications that are mentioned above. In some cases, antibiotic tablets (oral antibiotics) may also be used.

If you have severe acne, you will usually be referred to a dermatologist (an expert in treating skin conditions). A combination of oral antibiotics and topical treatments (see below) are usually the first treatment option. If this proves to be ineffective, a medication called isotretinoin (Roaccutane) may be prescribed.

Benzoyl peroxide

Benzoyl peroxide works in two ways:

• it helps prevent dead skin plugging up hair follicles, and 
• it kills the bacteria on the skin that can cause plugged follicles to become infected.

Benzoyl peroxide is usually available in cream or gel form and used either once or twice a day. It should be applied, 20 minutes after washing, to all of the parts of your face affected by acne. It should be used sparingly as too much can harm your skin.

Benzoyl peroxide makes your face more sensitive to sunlight, so you should avoid excessive exposure to sunlight and ultra-violet (UV) light, or wear sun cream.

Avoid contact with hair, clothes, towels and bed linen, as benzoyl peroxide can bleach these materials. Wash your hands after you finish applying the medication.

Common side effects of benzoyl peroxide include:

• dry and tense skin,
• a burning, itching, or stinging sensation, and
• some redness and peeling of the skin.

Side effects are usually mild and should pass once the treatment has finished. Contact your GP if side effects become troublesome, as your dose may need to be adjusted.

Most people require a six-week course of treatment to clear most or all of their acne. You may be advised to continue treatment but less frequently to prevent acne returning.

Topical retinoids

Topical retinoids work by reducing the production of sebum while also preventing dead skin cells plugging hair follicles.

Tretinoin and adapalene are used to treat acne. They are available in a gel or cream and usually applied once a day before going to bed. 

Apply it to all of the parts of your face affected by acne, 20 minutes after washing your face.

It is important to apply topical retinoids sparingly and avoid excessive exposure to sunlight and UV.

Topical retinoids are not suitable for use during pregnancy as they carry a risk of causing birth defects.

The most common side effects of topical retinoids are mild irritation and stinging of the skin.

A six-week course is usually required but you may be advised to continue medication after this on a less frequent basis.

Topical antibiotics

Topical antibiotics help kill the bacteria on the skin that can infect plugged hair follicles.

Topical antibiotics are available as a lotion or gel and applied once or twice a day.

A six to eight-week course is usually recommended. After this, treatment is usually stopped as there is a risk that the bacteria on your face could become resistance to the antibiotics. This could make your symptoms worse and cause additional infections.

Side effects are uncommon but can include:

• minor irritation of the skin,
• redness and burning of the skin, and
• peeling of the skin.

Azelaic acid

Azelaic acid is often used as an alternative treatment for acne if the side effects of benzoyl peroxide or topical retinoids are particularly irritating or painful.

Azelaic acid works by getting rid of dead skin and killing bacteria.

It is available in cream or gel form and is usually applied twice a day (or once a day if your skin is particularly sensitive).

The medication does not make your skin sensitive to sunlight so you do not have to avoid sun exposure.

You will usually need to use azelaic acid for a month before you notice a significant improvement in your symptoms.

The side effects of azelaic acid are usually mild and include:

• burning or stinging skin,
• itchiness,
• dry skin, and
• redness of the skin.

Oral antibiotics

Oral antibiotics are usually used in combination with a topical treatment to treat moderate to severe acne.

In most cases, a class of antibiotics called tetracyclines is prescribed. Pregnant or breastfeeding women are usually advised to take an antibiotic called erythromycin, which is known to be safer to use during pregnancy and breastfeeding.

It will usually take about six weeks to notice a significant improvement in your symptoms. Depending on how well you react to the treatment, a course of oral antibiotics can last between four to six months. Treatment is usually stopped after six months to reduce the risk of antibiotic resistance.

Side effects of tetracyclines include:

• nausea,
• vomiting, and
• diarrhoea.

Tetracyclines can make your skin sensitive to sunlight and UV light and also make the oral contraceptive pill less effective during the first few weeks of treatment. You will need to use an alternative method of contraception, such as a condom, during this time.

The most common side effects of erythromycin are:

• nausea, and
• mild stomach pain.

Taking erythromycin with food should help to reduce the severity of these side effects.

Co-cyprindiol

Women with acne who require contraception are advised to take a type of oral contraceptive (the pill) called co-cyprindiol. One of the beneficial side effects of co-cyprindiol is that it helps to improve the symptoms of acne.

You will probably have to use co-cyprindiol for between two to six months before you notice a significant improvement in your acne.

The side effects of co-cyprindiol are similar to other oral contraceptives and include:

• breast tenderness
• weight gain, and
• mood changes, such as irritability or low mood.

Isotretinoin

Isotretinoin works in the same way as topical retinoids but the medication has a much stronger effect. Due to this, isotretinoin can only be prescribed by a dermatologist (an expert in treating skin conditions) and not by your GP.

Isotretinoin is taken in tablet form, with most people taking a four to six-month course. You may find that your acne gets worse during the first seven to 10 days of treatment. However, this is normal and is caused by the medication pushing out bacteria present in the deeper layers of your skin.

Isotretinoin carries a very high risk of causing serious birth defects.

If you are a woman of childbearing age, you will only be prescribed isotretinoin following a negative pregnancy test. This is repeated throughout treatment. 

Contact your dermatologist immediately if you think you might be pregnant, either during treatment or in the first month after treatment.

Common side effects of isotretinoin are listed below.

• Inflammation, dryness and cracking of the skin and lips. This can usually be relieved by applying moisturising cream and lip balm.
• The inside of your nose may become dry, leading to mild nosebleeds. Applying a thin layer of petroleum jelly to the inside of your nose should help.
• Headaches.
• Skin rash. Mild itching and a slight peeling of the skin.
• Inflammation of your eyelids (blepharitis).
• Inflammation and irritation of your eyes (conjunctivitis).
• Back, muscle and joint pain. This is usually worse during and after exercise.
• Blood in your urine.
• You may bleed and bruise more easily.

In recent years, there have been a number of news stories about people committing suicide while taking isotretinoin, prompting speculation that the medication may cause depression and suicidal thoughts.

There is no medical evidence to support this.

You should contact your GP or your dermatologist immediately if:

• you experience a sudden mood change, such as anxiety or depression or, if you are already depressed, a sudden worsening of your depression,
• you experience aggressive or violent thoughts or tendencies,
• you begin to think suicidal thoughts, or
• you begin to act in ways that you would never normally do.

Glossary

Inflammation

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.