This leaflet describes rub-on (topical) 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.
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 such things as how to apply it and precautions vary between different preparations. One general point is that you should apply rub-on (topical) treatments to all the affected area of skin and not just to each spot.
Benzoyl peroxide is a common topical treatment. It has three actions - it kills germs (bacteria), reduces inflammation and helps to unplug blocked pores. Therefore, it often works well to clear inflamed spots and it helps to clear blackheads and whiteheads (comedones). 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:
- Most people can tolerate the 5% preparation but if it irritates then try the 2.5% once the irritation settles. 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.
Retinoids 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, whiteheads 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 become 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 application and 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.
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 obtain a topical antibiotic. They may cause mild irritation but generally cause fewer side-effects than the other topical preparations. Topical antibiotics are usually prescribed in combination with other medicines (see below). Using them alone can increase the risk that the germ will become used to the antibiotic and make the treatment less effective.
Azelaic acid is an alternative that mainly works by unplugging blocked pores. So, 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 or benzoyl peroxide. However, it may cause less skin irritation than benzoyl peroxide.
Some 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.
How long is treatment needed?
Whatever treatment is used, it is normal to take up to four weeks for there to be any improvement that you can see. 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. Note: 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 rub-on (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 as maintenance treatment once the spots have cleared. This is because long-term use of antibiotics can lead to resistance of germs (bacteria) to the antibiotics. Azelaic acid 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.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines, you can report this on the Yellow Card Scheme. You can do this online at the following web address:www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that your medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication and/or the leaflet that came with it with you while you fill out the report.
Further reading & references
- Guideline on the Treatment of Acne; European Dermatology Forum (September 2011)
- Acne vulgaris; NICE CKS, September 2014 (UK access only)
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