Acne vulgaris (commonly known as acne) is one of the most prevalent skin conditions in the United States, affecting 85% of adolescents and young adults¹. Typically appearing during puberty, acne arises due to chronic inflammation in the hair follicles and oil glands of the skin. In someone with acne, the hair, sebum, and keratinocytes in a hair follicle stick together, preventing keratinocytes from reaching the skin's surface and shedding.
This causes bacteria to multiply in the plugged follicles and leads to pimple growth. When the pimple breaks down, a thick yellow opaque liquid containing dead white blood cells and bacteria (pus) spills into adjacent skin cells, forming more pimples and scars on the skin. The onset of acne can be influenced by many factors such as genetics, environment, and stress. Although it does not pose any severe health risks, it can leave physical and emotional scars that last a lifetime.
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With an estimated 9.4% of the world’s population² suffering from acne, it is clear that the development of acne is a universally distressing experience. This is largely due to the additional effects of low self-esteem and distorted body image, as assessed by emotional well-being questionnaires³. Despite this, only 30%⁴ of acne sufferers seek professional help from either a doctor or board-certified dermatologist. Although the reasons for not seeking help vary, a key reason was that it appeared to be a ‘short-term’ condition⁵ that only occurred in puberty. While this may be the case for some people, it is a very real challenge for others. For many people, acne is a life-changing condition with frequent relapses, each of which may introduce new physical scars and challenges to overcome. It can be equally challenging for clinicians to provide patients with appropriate treatments.
Although acne is a chronic skin condition, effective treatments are available that can be personalized to each person and their needs. Whether your breakouts are small or chronic, there is a range of treatments available either from your doctor/dermatologist or simply from your local supermarket.
But with the sheer number of options, choosing the most effective therapy can be confusing. This article will cover the basics of well-known over-the-counter (OTC) treatments, their effectiveness, and how you can take steps to find the best skin regimen for you.
OTC treatments do not need prescriptions and, because of this, they are the first line of defense to treat mild acne. Treatments can come in many forms, such as creams, gels, and lotions. This makes it hard to keep track, which is why the key to choosing among them lies in selecting the right active ingredients for your skin.
Depending on the component, these can treat acne by killing bacteria, removing sebum, or changing the rate of skin renewal.
Common ingredients strongly recommended for acne include:
Retinoids are a form of vitamin A that can help speed up skin renewal and are considered the first step in treating acne. Available both OTC and through a prescription, retinoids work to reduce follicle blockage by targeting pores with abnormal production of keratin, a protein found in your hair, skin, and nails. As a result, they help reduce inflammation, blackhead and whitehead formation and prevent new lesions from forming. Retinoids also help enhance your skin barrier⁶ to absorb other acne treatments.
The American Academy of Dermatology recommends retinoids for whiteheads and blackheads. In contrast, those with more severe inflamed acne should pair it with an antibiotic or other medication. Retinoids' most common side effects include skin irritation, dryness, and increased light sensitivity⁷, so starting with small amounts is recommended. It is best to use retinoids with a low irritant, pH-balanced, and soap-free cleanser to alleviate irritation. However, retinoids are not recommended for use during pregnancy, so be sure to read labels carefully.
Benzoyl peroxide is an antibacterial agent commonly used for acne treatment, either OTC or prescription. Benzoyl peroxide decomposes when applied to the skin, introducing oxygen into the follicle. Consequently, this kills acne-causing bacteria and improves lesions by removing dead skin cells and excess oil (sebum). OTC benzoyl peroxide comes in varying strengths ranging from 2.5-10%, where 5% is recommended for those with mild to moderate acne.
Common side effects⁸ include peeling and dry skin, alongside possible bleaching of hair and clothes if they come into contact with the solution.
It is safe for pregnant women⁹ and can be used with other treatments to increase effectiveness. However, speaking to your doctor/dermatologist about this is always recommended.
Alpha-hydroxy (AHAs) and Beta-hydroxy (BHAs) acids are fruit- and plant-derived compounds. They are commonly found in chemical exfoliants, a treatment often used to improve the appearance of your skin through 'peeling' layers of your skin. Despite sharing a common function, AHAs and BHAs work differently and, subsequently, have slightly different effects.
AHAs are water-soluble acids that remove dead skin cells while stimulating skin cell renewal through breaking down keratin. As the top layer is removed, AHAs penetrate the next skin layer (dermis) to increase collagen production, which provides elasticity and strength to the skin barrier.
AHAs help treats acne by unclogging pores while stimulating new and smoother skin growth. Of all the AHAs, Glycolic and lactic acid are the most common ingredients found in OTC products due to being well-researched. Despite this, side effects⁸ such as burning, itching, and skin sensitivity towards light could occur if the concentration is high. Wearing sunscreen is recommended to combat the light sensitivity of the skin.
BHAs are oil-soluble acids that can penetrate hair follicles' skin surface and roots to reduce sebum production and remove dead skin cells. This is achieved by softening keratin, allowing for greater penetration of other acne treatments.
Because of its ability to remove excess sebum and dead skin cells from the follicle, BHAs are recommended for mild to moderate acne or congestion-prone skin. Although primarily used for exfoliation, BHAs can also help improve skin complexity while reducing the appearance of wrinkles and fine lines on the skin.
The most common form of BHA is salicylic acid, and it is often used interchangeably with BHAs, given its prevalence in cleansers, lotions, and creams. Despite working differently to AHAs, their side effects include mild stinging, skin irritation, and rashes.
There are mixed opinions¹⁰ regarding the combined use of AHAs and BHAs as they could irritate the skin. However, alternating the use¹¹ of AHAs and BHAs in your morning and evening routines or on different days could be a potential option. Should you want to use both products to target various skin concerns. In that case, it is recommended to consult your doctor/dermatologist beforehand.
Azelaic acid is a naturally occurring ingredient in grains such as barley, rye, and wheat. Additionally, it is combined with other acne treatments to clear pores and reduce inflammation.
Similar to the actions of AHAs and BHAs, azelaic acid is a chemical exfoliator that dissolves dead skin cells. As it also penetrates the surface layer of the skin, it can remove existing blockages alongside excess dead skin cells and sebum to prevent recurring acne breakouts.
Unlike AHAs and BHAs, azelaic acid is often used as a complementary treatment due to its antibacterial properties. Aside from gentle exfoliation, azelaic acid also reduces hyperpigmentation¹² by interfering with melanin production, a natural pigment found in skin cells.
Although it is a gentle alternative to AHAs and BHAs, side effects of azelaic acid include burning/tingling of the skin, peeling, and dryness. Users of azelaic acid should also be mindful to apply SPF, as the shedding of the surface layer of skin can lead to it becoming sensitive to light.
Like azelaic acid, sulfur is a treatment option usually combined with other acne treatments to clear clogged pores and excess sebum. In keratin-producing skin cells, sulfur becomes hydrogen sulfide, a compound that breaks down keratin. When combined with benzoyl peroxide, it forms pantothenic acid, a bacteria-killing agent.
Despite its effects on acne, the odor is unpleasant and is not primarily involved in acne treatments. Other than an unpleasant smell, side effects of sulfur include dry skin, irritation, and itchiness of the skin.
Choosing a suitable treatment can be tricky, and it can depend on several factors, such as the acne type, acne severity, and skin type. Some general questions to help you include:
What is my skin type?
Do you have oily, normal, or combination skin? Some products may work better with different skin types, whereas some may do more harm.
Have I tried any of the active ingredients before?
If you do not react well with any of the ingredients above, do not use them again and consider alternatives.
What strength do I need?
All active ingredients come in different strengths. If your skin is easily irritable or sensitive, starting with the lowest concentration is recommended. Stronger is not always better, as some have seen improvements with concentrations as low as 0.5%.
If you are looking to try new acne treatments, the best way to help maximize its effects is by establishing a routine. Depending on the active ingredient used, results can appear anytime between three weeks to three months. Some good ways to help find out how you can best use your OTC products include:
Deciding when you would like to apply treatment
Active ingredients for acne treatments are found in cleansers, toners, lotions, and face creams. Determining whether you would like a wash-off treatment or something more long-lasting may help you stick to a routine.
Starting with the lowest strength
Allows you to try an active ingredient while reducing your chances of experiencing severe bouts of skin redness, drying, and peeling.
Not using too much
Applying too much of an active ingredient may do more harm than good. It is best to apply enough to cover the problem area(s) only in accordance with the stated directions for use.
Because many of the active ingredients can cause your skin to become more sensitive to the sun, it is recommended to use sunscreen to prevent further burning and discoloration.
Trying different products with varying active ingredients may help speed up the process of finding the proper treatment. Alternating between other products during the day and night is one example of how you can experiment.
If you are not seeing results after three to four months, or if your skin is not responding to treatments, contact your healthcare provider/dermatologist as soon as possible.
Your healthcare provider will have excellent knowledge and experience in treating acne, and they will help prescribe more potent strength products if necessary. Additionally, they can refer you to a dermatologist, who may provide other therapies such as chemical peels or extraction therapies.
Alternatively, you can contact them to ask about the active ingredients to determine if they are right for you.
Acne is a common inflammatory skin condition, but it may cause physical scarring and severe psychological stress without appropriate treatment. Regardless of the breakout severity, many safe and effective treatments are available to help treat acne. Any and all decisions made should take into consideration your skin type, acne severity, and any possible reactions.
Treating acne requires patience, but if you are not seeing results after a few months of consistent usage, it may be time to make an appointment with your doctor or dermatologist.
Skin conditions by the numbers | American Academy of Dermatology Association
Topical treatment of melasma (2009)
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