North Shore Laser and Cosmetic Dermatologist Sydney
My Detailed Guide To Treatment options for Acne
Acne is a chronic skin condition that requires a long-term strategy to manage effectively and prevent permanent skin damage and scarring. It affects many people and can significantly impact self-confidence. By the time most patients see me, they have tried numerous treatments and often feel frustrated and hopeless.
Your First Visit
When you come to see me, you’ll fill out a questionnaire detailing your acne history and medical background. Together, we’ll design a personalised treatment plan that suits you.
Key Points About Acne
Causes: Acne is primarily due to genetics, hormones, and stress. Diet and skincare routines have minimal influence.
Antibiotics: These do not cure acne; it often returns once antibiotics are stopped.
Skincare & Diet: These are not standalone treatments for acne.
Not Just for Teenagers: Acne can persist into adulthood and cause lasting skin damage.
The Root Cause of Acne
Acne involves the sebaceous glands in the skin, which produce oil. When these glands are overactive, they can clog pores with excess oil and dead skin cells, leading to pimples, whiteheads, blackheads, or cysts. Hormones, genetics, and stress trigger this process. Effective treatment often involves shrinking these glands and unclogging pores.
Complications of Acne
Even after acne subsides, it can leave behind red lesions (post-inflammatory erythema), brown spots (post-inflammatory hyperpigmentation), scars, and psychological distress. Early and effective treatment can prevent these complications.
Medical Treatment Options
Acne treatment is personalised, considering factors like age, sex, acne severity, and response to previous treatments.
Diet and Skincare
Diet: Evidence is weak, but a low-glycemic, low-protein, and low-dairy diet might help. Avoid protein supplements, especially those with leucine. Eat plenty of fruits and vegetables.
Skincare: Keep skincare simple, avoid abrasive treatments, and refrain from picking at spots. Wash affected areas twice daily with gentle cleansers.
Topical Medications
Usage: Apply a small amount to all affected areas, not just individual spots. Use with a moisturiser to reduce irritation.
Side Effects: Initial dryness and irritation are common. If severe irritation occurs, pause use and consult a pharmacist for a mild steroid cream.
Start slowly, using a pea sized amount together with a moisturising cream.
They often cause dryness particularly in the first 2–4 weeks of use. This is partly how they work. The skin usually adjusts to this.Start every second or third day and then increase to daily if tolerated.
Apply to all areas affected by acne, rather than just put on individual spots. These creams are not spot treatments. Apply them like a moisturising cream or sunscreen to the entire affected areas eg cheek, chin, forehead.
If they are irritating you, back off for a day or two and slowly restart or use more moisturiser with them.
Creams work largely on the blackheads and whiteheads (but combinations with antibiotics help inflammatory lesions)
Benzoyl peroxide can bleach clothing and sheets so watch for this.
It may take several weeks or even months to see convincing improvement.
Discontinue using a product if severe irritation results. You should not be red all over. If you have tanned skin this could lead to post inflammatory hyperpigmentation. Go to a chemist and get a mild steroid cream to apply and cease use.
Common brands:Benzac Benzoyl peroxide (BPO), Differin Adapalene 0.1% Retin A Tretinoin 0.1%, ReTrieve Tretinoin 0.05%,Stieva- A Tretinoin 0.1% (0.025 & 0.5% ceased), Epiduo Adapalene (0.1%) + Benzoyl Peroxide (2.5%) Epiduo Forte Adapalene (0.3%) + Benzoyl Peroxide (2.5%) Acnatac Clindamycin 1% + Tretinoin 0.25mg Duac Clindamycin 1.2% + Benzoyl Peroxide 5%, Aklief Trifarotene 0,005% (4th generation) *Clascoterone: new antiandrogen topical >9yo, not yet in Australia
Treatments that are Safe in PREGNANCY: BPO, Duac, Clindamycin, Azelaic acid , Salicyclic acid (in small amounts) are safe
Oral Antibiotics
Common Antibiotics: Doxycycline, Minocycline (with rare side effects like vertigo and autoimmune hepatitis).
Usage: Often combined with topicals to enhance benefits and reduce resistance. Limited to 12 weeks of continuous treatment.
Take time to work (6-8 wks) and usually limited to 12 wks of continuous treatment
Minocycline has rare SE: vertigo, autoimmune hepatitis, skin hyperpigmentation, drug induced lupus, hypersensitivity syndrome.
Not to be ued in children <8yo or pregnancy
NOT A CURE for acne and acne will return when ceased.
On completion of course, the idea is to use topicals to sustain remission and to maintain results
Isotretinoin
Usage: Highly effective for moderate to severe acne. Requires monitoring due to potential side effects and is often prescribed for 12-18 months.
Considerations: Not suitable during pregnancy or breastfeeding. Requires regular follow-up and blood monitoring.
Oral Vit A. Low and slow treatment is safe
Skin is better around 3 months in in most, but red spots from where acne has been will remain. You need to remain on it for a period of time (can be 12-18mths or longer in some)
50% have a long-lasting response after a single course of isotretinoin. In others, acne may recur a few months to a few years after the medication has been discontinued. Relapse is more common in females than in males, and in patients > 25 years of age. These patients may receive further courses of isotretinoin
Works by shrinking the sebaceous gland and reducing pore blockage (white heads/black heads). It also helps inhibit bacteria growth and has anti-inflammatory properties.
Commercial pilots may be subject to flying restrictions if they take isotretinoin.
High dose isotretinoin in growing children has been associated with premature epiphyseal closure, leading to shorter stature (this is not been confirmed in the low dose used for the treatment of acne but is a risk to be considered)
NO need to delay lasers (except fully ablative ones or medium/deep peels) whilst on isotretinoin
Tetracyclines (including doxycycline, minocycline): these could increase the risk of headaches and blurred vision due to raised intracranial pressure so they should not be taken together.
If you have significant liver or kidney disease, high blood fats, diabetes and depression you may be advised not to take isotretinoin or to be on a lower dose than usual and to have regular follow-up visits.
Requires blood monitoring before and during treatment
Females must ensure that are on appropriate contraception if sexually active.
Possible Side effects:
Acne flare-up at the beginning
Dry lips, cheilitis (sore, cracked or scaly lips)- very common; dry nose, nose bleeds (less common)
Dry skin, fragile skin, flare of eczema/dermatitis (itchy, red patches of skin)
Dry, watery or irritable eyes (especially in contact lens wearers), conjunctivitis, keratitis
Facial redness during treatment that decreases after
Increased sweating
Lowered sunburn threshold
Temporary hair loss
Other less common but important side effects that are dose related:Headache, Myalgia (muscle aches) and arthralgia (joint aches), especially after exercise.Tiredness (lethargy and drowsiness).Disturbed night vision and slow adaptation to the dark. Drivers may experience increased glare from car headlights at night. Hypertriglyceridaemia (high levels of triglyceride in the blood), usually of no clinical relevance.Irregular or heavy menstrual periods.
Mood changes and depression. Note: depression is more often related to the skin condition being treated or other health or psychosocial problems. Antidepressant medications may be helpful. This is a controversial topic and requires a longer discussion.
Sexual dysfunction (eg, erectile dysfunction and decreased libido) (rare)
Other rare side effects: Corneal opacities and cataracts, High-tone deafness.Accelerated diffuse interstitial skeletal hyperostosis (bony change).Abnormal liver function tests or symptomatic hepatitis.Diarrhoea or bleeding from the bowel.Pancreatitis.
Hormonal Treatments for Women
Combined Oral Contraceptive Pill (OCP): Effective for hormonal acne, usually showing improvement by the third cycle.
Spironolactone: Reduces androgens that contribute to acne, with a typical dosage range of 50-100mg.
The Combined Oral Contraceptive Pill
Acne usually improves by 40-50% by the third cycle and by 80-90% by the ninth cycle Combination of various doses of levonorgestrel (oestrogen) with various progesterones
Studies show it can help all women with acne, with benefit not limited to those with hormonal flares only
If combined with other treatments it will accelerate results.
Gestodene (Minulet) and Desogestrel (Marvelon 28, Madeline) have greater specificity for progesterone receptors than older progesterones.
There are various kinds of progesterone, which may be androgenic in nature and thus unsuitable for those androgen-mediated skin conditions (particularly levonorgesterol and norgestrel)
Drospirenone (eg Yaz, Yasmin, Isabelle) is a antiandrogen analogue and has a mild diuretic effect so reduces fluid retention
Cyproterone has antiandrogen effects (Brenda, Carolyn, Diane, Estelle 25ED, Juliet, Laila, Jene) would choose these over others or drospirenone (Valette) in patients with hirsuitism or androgen XS
Need at least 30mg oestrogen and a good progesterone (very very low dose oestrogen pills may flare acne)
The pill may be unsuitable for those who have had: a previous blood clot (thrombosis, embolism or ‘DVT’), high blood pressure (hypertension) or heart disease, Smoke, Obese, recently had surgery, travelling long distance or have a family member with blood clots or high blood pressure.
Oral contraceptives can sometimes aggravate migraine and are inadvisable in those with significant liver disease. They may occasionally increase the risk of certain uncommon forms of breast cancer. They must not be taken in pregnancy.
The pill reduces the risk of ovarian and endometrial cancer, benign breast disease, ectopic pregnancy, painful periods, iron deficiency anaemia and pelvic inflammatory disease.
Anti Androgens
Topical clascoterone cream 1% applied twice daily for the treatment of acne vulgaris in patients aged 12 years and older.
Spironolactone: range 50-100mg usually (can go up to 200mg but side effects increase)
SE: breast tenderness/enlargement, headache, dizziness as has diuretic effect (important to remain hydrated on this medication), Nausea, diarrhoea, gastrointestinal bleeding, at high dosages menstrual cycle irregularities including increased frequency of menstruation, bleeding in the middle of the month or stopping periods altogether (amenorrhoea),Breast pain.
4 mths to achieve 75% improvement
No need to monitor blood pressure or bloods if <45 yo
Need a wash out period prior to pregnancy as can cause feminisation of a male fetus.
1726nm AviClear Laser
Usage: Targets the sebaceous gland for long-term results, typically requiring three treatments spaced 4-6 weeks apart.
Benefits: Safe with no downtime, though initial flare-ups may occur.
A new one of a kind medical laser cleared by the Therapeutics Goods Administration that targets the sebaceous gland leading to long term results. Has been available in America for 4 years.
Only treats the affected area and is not associated with systemic side effects.
Resets the sebaceous gland so that it can start behaving normally again. Three treatments are performed 4- 6 wks apart and there is ongoing improvement up to 12 months post-treatment. The studies have shown good long term clearance . But this is a new technology so studies are only up to 2 years post treatment but are promising and comparable to isotretinoin in terms of nodule and inflammatory lesion reduction in studies.
It may be used intercurrently with other meds (like all acne treatments) so as to minimise purge & to get your skin better while we wait for the long term results to kick in.
This tailored approach aims to address your specific needs and provide long-term acne control and skin health.
