This leaflet describes topical (rub-on) treatments for acne. A topical treatment is commonly used if your acne is mild to moderate in severity. You may need to take treatment for several months to clear spots. There is a separate leaflet called Antibiotic Tablets for Acne, which describes antibiotic tablets sometimes used to treat more severe acne. There is also a separate leaflet called Acne, which talks about acne generally.
Topical preparations for acne
Various gels, lotions, and creams are used to treat acne. Different preparations work in different ways. The following briefly describes the different types. However, always read the leaflet in the packet because how to apply it, and precautions vary between preparations. One general point is that you should apply topical treatments to all the affected area, and not just to each spot.
This is a common topical treatment. It has three actions - it kills bacteria, reduces inflammation, and helps to unplug blocked pores. Therefore, it often works well to clear inflamed spots and helps to clear comedones (blackheads and whiteheads). You can buy benzoyl peroxide at pharmacies, without a prescription. It comes in different brand names and strengths - there is a 2.5%, 4%, 5%, and 10% strength. Benzoyl peroxide:
- Works best if you wash the skin 20-30 minutes before use.
- May bleach hair, bed linen, or clothes that come into contact with it.
- Commonly causes mild skin irritation. If your skin does become irritated then stop using it until the irritation goes. Then try again with a lower strength, or reduce the time it is left on your skin before washing off. To prevent skin irritation, the following may help:
- Use the lowest strength at first. In many cases the 2.5% preparation works just as well as the 10% preparation, but causes the least irritation. If you wish to increase the strength, do it gradually.
- Use a water-based preparation (rather than an alcohol-based one).
- Apply once daily at first, and wash off after several hours.
- Gradually increase the length of time left on the skin.
- Aim to put on twice daily when you get used to it.
These are good at unplugging blocked pores. They include adapalene, tretinoin, and isotretinoin which come in various brand names. They also have some effect on reducing inflammation. Therefore, one is often used early on in acne to help to unblock pores and to treat blackheads or whiteheads (comedones) and mildly inflamed spots. You need a prescription for all retinoid preparations. When you use a topical retinoid:
- You may develop some skin redness and skin peeling. This tends to settle over time.
- The spots sometimes get a little worse before improving.
- Your skin may be more sensitive to sunlight. Therefore, it is best to apply at night and wash off in the morning. A sun protection cream may also help if you are out in the sun.
- The most common side-effects are burning, irritation, and dryness. Therefore, you may be advised at first to use a low strength, less frequent applications, and to use for a shorter duration.
- You should not be pregnant, or intend to become pregnant, as there is a slight risk of harm to unborn babies. Discuss contraception with your doctor if necessary.
This is an alternative that mainly works by unplugging blocked pores. Therefore, like retinoids, it is good at clearing blackheads and whiteheads. It has some effect on reducing inflamed acne too, but probably not as much as antibiotics (see below) or benzoyl peroxide. However, it may cause less skin irritation than benzoyl peroxide.
There are various topical antibiotic preparations. They reduce the number of bacteria and reduce inflammation. However, they have little effect on unplugging blocked pores. So, they are usually good at treating inflamed acne, but blackheads and whiteheads may remain. You need a prescription to get a topical antibiotic. They may cause mild irritation, but generally cause fewer side-effects than the other topical preparations.
A single topical preparation is often used alone to treat mild acne. Some topical preparations contain a mixture of ingredients - for example, benzoyl peroxide plus an antibiotic, or a retinoid plus an antibiotic. These may work better than either ingredient alone. Sometimes a topical preparation is advised in addition to other treatments (such as antibiotic tablets) for moderate or severe acne.
How long is treatment needed?
Whatever treatment is used, it is normal to take up to four weeks for there to be any noticeable improvement in the skin. There is often a good response to treatment by six weeks. However, it can take up to four months (sometimes longer) for maximum response to a treatment, and for the skin to be generally free of spots. The most common reason for a treatment failure is because some people think that treatment is not working after a couple of weeks or so, and give up.
Therefore, continue with any treatment for at least six weeks before deciding if it is working or not. If there is no improvement after six weeks of taking a treatment regularly and correctly, do not despair. Adding in another treatment, or a change to a different or more powerful treatment, will usually be advised, and is likely to work. Although treatment can usually clear most spots, there is no treatment that will make your skin perfect, and the odd spot may remain.
Will acne return after treatment?
Once the spots have cleared, acne commonly flares up again if you stop treatment. Therefore, after the spots have gone or are much reduced, it is common to carry on with a maintenance treatment to prevent acne from flaring up again. It is common to need maintenance treatment for 4-5 years to keep acne away. This is typically until the late teens or early 20s. In a small number of cases, acne persists into the 30s, or even later. For these people it is possible to continue to treat the skin to keep it under control.
Maintenance treatment is usually with either benzoyl peroxide or a topical retinoid. These can both be used indefinitely. The dose used to prevent spots from returning is often lower than that used to treat acne. For example, one application to the skin every other day with a low-strength preparation may be sufficient to keep spots from returning.
It is not usual to use topical antibiotics (or antibiotic tablets) as maintenance treatment once the spots have cleared. This is because long-term use of antibiotics can lead to resistance of germs to the antibiotics. Also, azelaic acid, another topical treatment, is only licensed for treatment periods of six months. Therefore, if at first you are treated with an antibiotic or azelaic acid, you may be advised to switch to benzoyl peroxide or a topical retinoid for maintenance treatment.
Further reading & references
- Acne vulgaris; NICE CKS, June 2009
- Guideline on the Treatment of Acne, European Dermatology Forum (September 2011)
- Fulton J, Acne Vulgaris, Medscape, Aug 2011
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Laurence Knott
Dr Hannah Gronow