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Prescription Acne Medications

When you have acne, you want it gone—it’s that simple. Using the right over-the-counter acne products can get many cases of acne under control. But for other people who have stubborn, frustrating acne problems, skincare products might not be enough; that’s where prescription medications can save the day.

Topical Prescription Acne Medications

Topical medications make up the majority of the prescription anti-acne treatments available from your dermatologist, and are by far the safest to use. These medications are usually applied to all acne-prone areas once or twice daily, as directed, along with a great anti-acne skincare routine. The following are the most common topical prescription medications used to treat acne.

Retinoids is the name of the general category for all forms of vitamin A (also called retinol). Prescription topical options include tretinoin (Retin-A, Avita, Atralin, and generics) and other vitamin A derivatives, such as tazarotene (Tazorac, Avage) and adapalene (Differin, also available combined with benzoyl peroxide as Epiduo). All of these come in different strengths, which your dermatologist can discuss with you. (Note: Differin Gel is also sold over-the-counter in its lowest concentration, 0.1%)

Prescription retinoids are typically the first line of defense your dermatologist will offer because they often work amazingly well! Retinoids change the way skin cells are formed and how they move through the layers of skin on their way to the surface. This vastly reduces clogged pores, restores a normal flow of oil through the pore lining, and calms inflammatory factors in skin that trigger acne.

Topical tretinoin and many antibacterial/antibiotic agents, which we discuss next, work well together; however, applying both at the same time increases the chance of side effects such as dryness, redness, or peeling. If you experience side effects, discuss with your physician the option of applying the antibacterial product in the morning and the prescription retinoid at night. Contrary to popular belief, benzoyl peroxide does not deactivate modern versions or derivatives of tretinoin.

Prescription topical antibiotics work to kill acne-causing bacteria that lurk deep inside the pore. Research shows some of these can greatly reduce the inflammation and redness of acne lesions. The most typical topical antibiotics include:

  • Erythromycin
  • Clindamycin
  • Minocycline
  • Tetracycline

These can be used alone, but this type of “monotherapy” isn’t considered ideal. Research indicates you’ll get greater benefits by combining one of these antibiotics with benzoyl peroxide. The mix of a topical antibiotic with benzoyl peroxide has been shown to be a far more potent and effective treatment, allowing the antibiotics to act more quickly. Surprisingly, topical antibiotics plus benzoyl peroxide are significantly more effective for reducing inflammation and the number of breakouts, and are better tolerated.

Several brand name and generic antibiotic/benzoyl peroxide combination products are available by prescription, including BenzaClin, Duac, and Benzamycin.

These products typically are applied after cleansing and exfoliating, but you’ll want to follow your dermatologist’s directions for use, especially if more than one topical medication is prescribed.

Dapsone (brand name Aczone) is a topical disinfectant gel available by prescription in 5% strength. It’s related to sulfur, which is why it has antibacterial activity. Interestingly, there’s research showing Dapsone is more effective for women with acne than for men with acne, and also that combining Dapsone with the prescription retinoid Tazorac (active ingredient tazarotene) provides better results than using either one alone.

Azelaic acid (brand names Azelex and Finacea) is believed to work against acne-causing bacteria in concentrations of 15%–20%, and it also packs an anti-inflammatory punch while helping to fade post-acne marks. Azelaic acid is also prescribed to manage the symptoms of rosacea. It’s an ideal prescription to consider if you’re dealing with the wicked combination of both acne and rosacea.

Oral Prescription Acne Medications

Oral antibiotics are the yin and yang of acne treatments: They can be extremely effective in controlling acne, but also pose a risk of serious side effects.

Oral antibiotics systemically kill the bad bacteria triggering acne, but they also kill the good bacteria in the body. Ongoing use can lead to chronic vaginal yeast infections for women, as well as stomach and intestinal problems.

Another downside: the acne-causing bacteria can become immune or resistant to the oral antibiotic you’re taking. 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 (but the negative side effects will continue).

New research about bacterial resistance and adaptation reveals that lower, or “sub-microbial,” doses of oral antibiotics may still be effective to fight acne over the long term, while minimizing—if not potentially eliminating—the problem of the bacteria becoming resistant to the antibiotic.

Another benefit of lower doses of oral antibiotics is they appear to have anti-inflammatory benefits instead of just antibacterial benefits. However, that doesn’t mean zero side effects, so be sure to discuss those with your dermatologist.

Some types of birth control pills and hormone blockers have been shown to reduce acne lesions and oil production, in part by decreasing or blocking 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 androgens in the body, while others block androgen production. Because androgens stimulate oil production, it’s a good thing to block them for those prone to breakouts and oily skin.

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, including*:

  • Ortho Tri-Cyclen (active ingredient norgestimate/ethinyl estradiol)
  • YAZ (active ingredient drospirenone/ethinyl estradiol)
  • Estrostep (active ingredient norethindrone/ethinyl estradiol)
  • Diane 35 (chemical name ethinylestradiol 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), so be sure to discuss them with your doctor.

Hormone blockers have their own set of issues to discuss with your dermatologist. They’re typically reserved for very stubborn or severe types of acne, oily skin, and other health issues women can experience. Examples include:

  • Spironolactone, a prescription diuretic drug that has a disruptive effect on androgens. It is sometimes prescribed with birth control pills.
  • Flutamide, a drug that blocks key receptor sites on cells that bind with androgens. Low doses taken for a year or more have a good safety record, but monitoring of liver enzymes is required.
  • Cyproterne acetate, a synthetic steroid that may be prescribed with birth control pills to control acne and oily skin, especially if the acne is believed to be triggered by polycystic ovary syndrome (PCOS). As with flutamide, monitoring of liver enzymes is required during treatment.

*Note that these combinations of hormone-disrupting medications are prescribed under a variety of brand names. The examples above are among the most common.

Isotretinoin (formerly Accutane™, now available under different brand names): is considered a last resort medication due to its serious, sometimes permanent side effects and the risk to a fetus should you become pregnant while taking it.

On the upside, one or two short-term, low-dose courses with this oral form of vitamin A can potentially cure chronic acne and oily skin. That’s right, you could conceivably never struggle with acne again. Or, or at the very least, have it become an occasional, minor issue. If your dermatologist recommends isotretinoin, be sure he or she details all the side effects and adherence guidelines, and follow those to the letter.

Adding Prescription Products to Your Skincare Routine

There’s a great deal of research about how topical prescription products work to clear acne, but surprisingly little information on how you’re supposed to incorporate these prescription products into your daily skincare routine.

There isn’t any agreement among dermatologists as to what non-prescription skincare products you’re supposed to use with your topical prescription-only medications or about the order in which to apply them. Even more shocking is the lack of consensus or suggestions about how to avoid some of the most typical reactions prescription acne medications can cause, such as redness, irritation, dryness, and inflammation.

The following is a step-by-step guide on how to maintain your regular skincare routine and incorporate your prescription acne product. The six steps are meant as helpful guidelines; if this information conflicts with your physician or pharmacist’s advice, please consult them before making any changes.

Morning Routine

  • Step 1: Cleanser
  • Step 2: Gentle, alcohol-free toner
  • Step 3: AHA or BHA exfoliant, with BHA (salicylic acid) preferable for acne
  • Step 4: Antioxidant serum and/or anti-aging or skin-lightening treatment
  • Step 5: Topical prescription product, applied as directed to affected areas
  • Step 6: Daytime moisturizer with sunscreen rated SPF 30 or greater

Evening Routine

  • Step 1: Cleanser
  • Step 2: Gentle, alcohol-free toner
  • Step 3: AHA or BHA exfoliant, with BHA (salicylic acid) preferable for acne
  • Step 4: Antioxidant serum and/or anti-aging or skin-lightening treatment
  • Step 5: Topical prescription product, applied as directed to affected areas
  • Step 6: Nighttime moisturizer

Note: Many people ask us about using an over-the-counter retinol product, such as a serum, and a prescription retinoid like Retin-A. It’s fine to use both; generally, you should apply the over-the-counter retinol product first, followed by your prescription retinoid. Do you need both? No, but some people see greater benefit from the combination, or they simply like to alternate a stronger and weaker retinol product. Pay attention to how your skin responds and adjust your routine accordingly.

Your Prescription for Clear Skin

It can take time and patience, but the right combination of over-the-counter acne skincare products and prescription products can be a turning point that seems nothing short of miraculous—so don’t give up! You can have clear skin, even if you’ve reached a point where you just don’t believe it’s possible.

References for this information:

Medicine, June 2017, pages 386-389
International Journal of Women’s Dermatology, June 2017, pages 111-115
Clinics in Dermatology, March-April 2017, pages 173-178
Canadian Family Physician, May 2016, page 409
Journal of the American Board of Family Medicine, April 2016, pages 254-262
Journal of the European Academy of Dermatology and Venereology, June 2015 Supplement, pages 14-19
Dermatologic Therapy, May-June 2015, pages 166-172
Journal of the American Academy of Dermatology, June 2016, Pages 1,252-1,254; and September 2014, pages 450-459
European Journal of Dermatology, May-June 2014, pages 330-334
The Journal of Clinical and Aesthetic Dermatology, February 2014, pages S3-S21
Skin Pharmacology and Physiology, Volume 27 Supplement, 2014, pages 9-17
Journal of Drugs in Dermatology, December 2012, pages 1,417-1,421; June 2011, pages 647-652; and July 2011, pages 783-792
American Journal of Clinical Dermatology, December 2012, pages 357-364