6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases
medicine or combining oral and topical medicines.

Treatment for Blackheads, Whiteheads, and Mild Inflammatory Acne

Doctors usually recommend an OTC or prescription topical medicine for people with mild signs of acne.
Topical medicine is applied directly to the acne lesions or to the entire area of affected skin.

There are several OTC topical medicines used for mild acne. Each works a little differently. Following
are the most common ones:

¢ Benzoyl peroxide—destroys P. acnes, and may also reduce oil production

¢ Resorcinol—can help break down blackheads and whiteheads

¢ Salicylic acid—helps break down blackheads and whiteheads. Also helps cut down the shedding
of cells lining the hair follicles

¢ Sulfur—helps break down blackheads and whiteheads.

Topical OTC medicines are available in many forms, such as gels, lotions, creams, soaps, or pads. In
some people, OTC acne medicines may cause side effects such as skin irritation, burning, or redness,
which often get better or go away with continued use of the medicine. If you experience severe or
prolonged side effects, you should report them to your doctor.

OTC topical medicines are somewhat effective in treating acne when used regularly; however, it may
take up to 8 weeks before you see noticeable improvement.

Treatment for Moderate-to-Severe Inflammatory Acne

People with moderate-to-severe inflammatory acne may be treated with prescription topical or oral
medicines, alone or in combination.

Prescription Topical Medicines

Several types of prescription topical medicines are used to treat acne. They include:

¢ Antibiotics—help stop or slow the growth of bacteria and reduce inflammation

¢ Vitamin A derivatives (retinoids)—unplug existing comedones (plural of comedo), allowing
other topical medicines, such as antibiotics, to enter the follicles. Some may also help decrease the
formation of comedones. These drugs contain an altered form of vitamin A. Some examples are
tretinoin, adapalene, and tazarotene

¢ Others—may destroy P. acnes and reduce oil production or help stop or slow the growth of
bacteria and reduce inflammation. Some examples are prescription strength benzoyl peroxide,
sodium sulfacetamide/sulfur-containing products, or azelaic acid.

Like OTC topical medicines, prescription topical medicines come as creams, lotions, solutions, gels, or
pads. Your doctor will consider your skin type when prescribing a product. Creams and lotions provide
moisture and tend to be good choices for people with sensitive skin. If you have very oily skin or live ina
hot, humid climate, you may prefer an alcohol-based gel or solution, which tends to dry the skin. Your
doctor will tell you how to apply the medicine and how often to use it.

For some people, prescription topical medicines cause minor side effects, including stinging, burning,
redness, peeling, scaling, or discoloration of the skin. With some medicines, such as tretinoin, these side

http/web.archive.orgweb/20120214145400/http:www.niams.nih.gov/health_info/acne/ 5/10


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

For Your Information

This publication contains information about medications used to treat the health condition discussed here.
When this publication was developed, we included the most up-to-date (accurate) information available.
Occasionally, new information on medication is released.

For updates and for any questions about any medications you are taking, please contact

U.S. Food and Drug Administration
Toll Free: 888-INFO-FDA (888-463-6332)
Website: http://www. fda.gov/

For updates and questions about statistics, please contact

Centers for Disease Control and Prevention's National Center for Health Statistics

Web site: http://www.cde.gov/nchs

This publication is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as
needed.

Additional copies of this publication are available from:

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-3675

Phone: 301-495-4484

Toll Free: 877-22-NIAMS (877-226-4267)
TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov
Website: http://www.niams.nih,.gov

NIH Publication No. 06-4998
Many of our publications are available in print. Would you like to order publications on skin disorders to

be mailed to you? Visit our online order form.

NIH... Turning Discovery into Health

http:/web.archive.orgweb/20120214145400/http:;www.niams.nih.govihealth_infolacnel 10/10


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

as loss of appetite, loss of interest in once-loved activities, or trouble concentrating, it's important to
consult your doctor.

Other possible side effects of isotretinoin include:

¢ dry eyes, mouth, lips, nose, or skin (very common)

¢ itching

¢ nosebleeds

muscle aches

sensitivity to the sun

poor night vision

changes in the blood, such as an increase in fats in the blood (triglycerides and cholesterol)
change in liver function.

To be able to determine if isotretinoin should be stopped if side effects occur, your doctor may test your
blood before you start treatment and periodically during treatment. Side effects usually go away after the
medicine is stopped.

Treatments for Hormonally Influenced Acne in Women

In some women, acne is caused by an excess of androgen (male) hormones. Clues that this may be the
case include hirsutism (excessive growth of hair on the face or body), premenstrual acne flares, irregular
menstrual cycles, and elevated blood levels of certain androgens.

The doctor may prescribe one of several drugs to treat women with this type of acne:

¢ Birth control pills—to help suppress the androgen produced by the ovaries

¢ Low-dose corticosteroid drugs, such as prednisone or dexamethasone—to help suppress the
androgen produced by the adrenal glands

¢ Antiandrogen drugs such as spironolactone—to reduce the excessive oil production.

Side effects of antiandrogen drugs may include irregular menstruation, tender breasts, headaches, and
fatigue.

Other Treatments for Acne

Doctors may use other types of procedures in addition to drug therapy to treat patients with acne. For
example, the doctor may remove the patient's comedones during office visits. Sometimes the doctor will
inject corticosteroids directly into lesions to help reduce the size and pain of inflamed cysts and nodules.

Early treatment is the best way to prevent acne scars. Once scarring has occurred, the doctor may suggest
a medical or surgical procedure to help reduce the scars. A superficial laser may be used to treat irregular
scars. Dermabrasion (or microdermabrasion), which is a form of "sanding down" scars, is sometimes
used. Another treatment option for deep scars caused by cystic acne is the transfer of fat from another
part of the body to the scar. A doctor may also inject a synthetic filling material under the scar to improve
its appearance.

How Should People With Acne Care for Their Skin?

Clean Skin Gently

http:/web.archive.orgweb/20120214145400/http:;www.niams.nih.govihealth_infolacnel 7H0


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

effects usually decrease or go away after the medicine is used for a period of time. If side effects are
severe or don't go away, notify your doctor.

As with OTC medicines, the benefits of prescription topical medicines are not immediate. Your skin may
seem worse before it gets better. It may take from 4 to 8 weeks to notice improvement.

Prescription Oral Medicines

For patients with moderate-to-severe acne, doctors often prescribe oral antibiotics. Oral antibiotics are
thought to help control acne by curbing the growth of bacteria and reducing inflammation. Prescription
oral and topical medicines may be combined. Common antibiotics used to treat acne are tetracycline,
minocycline, and doxycycline.

Other oral medicines less commonly used are clindamycin, erythromycin, or sulfonamides. Some people
taking these antibiotics have side effects, such as an upset stomach, dizziness or lightheadedness, changes
in skin color, and increased tendency to sunburn. Because tetracyclines may affect tooth and bone
formation in fetuses and young children, these drugs are not given to pregnant women or children under
age 14. There is some concern, although it has not been proven, that tetracycline and minocycline may
decrease the effectiveness of birth control pills. Therefore, a backup or another form of birth control may
be needed. Prolonged treatment with oral antibiotics may be necessary to achieve the desired results.

Treatment for Severe Nodular or Cystic Acne

People with nodules or cysts should be treated by a dermatologist. For patients with severe inflammatory
acne that does not improve with medicines such as those described above, a doctor may prescribe
isotretinoin, a retinoid (vitamin A derivative). Isotretinoin is an oral drug that is usually taken once or
twice a day with food for 15 to 20 weeks. It markedly reduces the size of the oil glands so that much less
oil is produced. As a result, the growth of bacteria is decreased.

Advantages of Isotretinoin

Isotretinoin is a very effective medicine that can help prevent scarring. After 15 to 20 weeks of treatment
with isotretinoin, acne completely or almost completely goes away in most patients. In those patients
where acne recurs after a course of isotretinoin, the doctor may institute another course of the same
treatment or prescribe other medicines.

Disadvantages of Isotretinoin

Isotretinoin can cause birth defects in the developing fetus of a pregnant woman. It is important that
women of childbearing age are not pregnant and do not get pregnant while taking this medicine.
Women must use two separate effective forms of birth control at the same time for 1 month before
treatment begins, during the entire course of treatment, and for 1 full month after stopping the drug. You
should ask your doctor when it is safe to get pregnant after you have stopped taking isotretinoin.

Some people with acne become depressed by the changes in the appearance of their skin. Changes in
mood may be intensified during treatment or soon after completing a course of medicines like
isotretinoin. There have been a number of reported suicides and suicide attempts in people taking
isotretinoin; however, the connection between isotretinoin and suicide or depression is not known.
Nevertheless, if you or someone you know feels unusually sad or has other symptoms of depression, such

http/web.archive.orgweb/20120214145400/http:www.niams.nih.gov/health_info/acne/ 6/10


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

Scientists are also trying to better understand the mechanisms involved in acne so that they can develop
new treatments that work on those mechanisms. For example, one group of NIAMS-supported
researchers is studying the mechanisms that regulate the development of the sebaceous glands. Another
group is trying to understand how P. acnes activates the immune system in order to identify possible
immunologic interventions. Other areas of research involve examining the effects of isotretinoin (a
potent drug for acne) on the sebaceous glands. Moreover, a new drug called isoprenylcysteine is
currently being evaluated for the treatment of P. acnes-induced inflammation and overproduction of
sebum

Where Can People Find More Information About Acne?

¢ National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-3675

Phone: 301-495-4484

Toll Free: 877-22-NIAMS (877-226-4267)
TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov
Website: http://www.niams.nih.gov

Other Resources
e American Academy of Dermatology (AAD)

Web site: http://www.aad.org

For additional contact information, visit the NIAMS Web site or call the NIAMS Information
Clearinghouse.

Acknowledgments

NIAMS gratefully acknowledges the assistance of the preparation and review of current and previous
versions of this booklet: Laurence H. Miller, M.D., Chevy Chase, MD; Kenneth A. Katz, M.D., M.Sc.,
University of Pennsylvania School of Medicine, Philadelphia; Edward W. Cowen, M.D., National
Cancer Institute, NIH; and Alan Moshell, M.D., NIAMS, NIH

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a
part of the Department of Health and Human Services' National Institutes of Health (NIH), is to support
research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the
training of basic and clinical scientists to carry out this research; and the dissemination of information on
research progress in these diseases. The National Institute of Arthritis and Musculoskeletal and Skin
Diseases Information Clearinghouse is a public service sponsored by the NIAMS that provides health
information and information sources. Additional information can be found on the NIAMS Web site at

www.niams.nih.gov.

http/web.archive.orgweb/20120214145400/http:www.niams.nih.gov/health_info/acne/ 9/10


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

|» U.S. Department of Health and Human Services banner

Acne

Online version updated October 2010

Questions and Answers about Acne

This booklet contains general information about acne. It describes what acne is and how it develops, the
causes of acne, and the treatment options for various forms of acne. Information is also provided on
caring for the skin. If you have further questions after reading this booklet, you may wish to discuss them
with your doctor.

What Is Acne?

Acne is a disorder resulting from the action of hormones and other substances on the skin's oil glands
(sebaceous glands) and hair follicles. These factors lead to plugged pores and outbreaks of lesions
commonly called pimples or zits. Acne lesions usually occur on the face, neck, back, chest, and
shoulders. Although acne is usually not a serious health threat, it can be a source of significant emotional
distress. Severe acne can lead to permanent scarring.

How Does Acne Develop?
What Causes Acne?

Who Gets Acne?

How Is Acne Treated?

Treatment for Blackheads, Whiteheads, and Mild Inflammatory Acne
Treatment for Moderate-to-Severe Inflammatory Acne

Treatment for Severe Nodular or Cystic Acne

Treatments for Hormonally Influenced Acne in Women

Other Treatments for Acne

How Should People With Acne Care for Their Skin?

Research Highlights
Where Can People Find More Information About Acne?

How Does Acne Develop?

Doctors describe acne as a disease of the pilosebaceous units (PSUs). Found over most of the body, PSUs
consist of a sebaceous gland connected to a canal, called a follicle, that contains a fine hair (see "Normal
Pilosebaceous Unit" diagram). These units are most numerous on the face, upper back, and chest. The
sebaceous glands make an oily substance called sebum that normally empties onto the skin surface
through the opening of the follicle, commonly called a pore. Cells called keratinocytes line the follicle.

Normal Pilosebaceous Unit

http:/web.archive.orgweb/20120214145400/http:;www.niams.nih.govihealth_infolacnel 10


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

If you have acne, you should gently wash your face with a mild cleanser, once in the morning and once
in the evening, as well as after heavy exercise. Wash your face from under the jaw to the hairline and be
sure to thoroughly rinse your skin.

Ask your doctor or another health professional for advice on the best type of cleanser to use.

Using strong soaps or rough scrub pads is not helpful and can actually make the problem worse.
Astringents are not recommended unless the skin is very oily, and then they should be used only on oily
spots.

It is also important to shampoo your hair regularly. If you have oily hair, you may want to wash it every
day.

Avoid Frequent Handling of the Skin

Avoid rubbing and touching skin lesions. Squeezing, pinching or picking blemishes can lead to the
development of scars or dark blotches.

Shave Carefully

Men who shave and who have acne should test both electric and safety razors to see which is more
comfortable. When using a safety razor, make sure the blade is sharp and soften your beard thoroughly
with soap and water before applying shaving cream. Shave gently and only when necessary to reduce the
tisk of nicking blemishes.

Avoid a Sunburn or Suntan

Many of the medicines used to treat acne can make you more prone to sunburn. A sunburn that reddens
the skin or suntan that darkens the skin may make blemishes less visible and make the skin feel drier.
However, these benefits are only temporary, and there are known risks of excessive sun exposure, such
as more rapid skin aging and a risk of developing skin cancer.

Choose Cosmetics Carefully

While undergoing acne treatment, you may need to change some of the cosmetics you use. All cosmetics,
such as foundation, blush, eye shadow, lubricants, and hair-care products should be oil free. Choose
products labeled noncomedogenic (meaning they don't promote the formation of closed pores). In some
people, however, even these products may make acne worse.

For the first few weeks of treatment, applying foundation evenly may be difficult because the skin may
be red or scaly, particularly with the use of topical tretinoin or benzoy! peroxide.

Research Highlights

Medical researchers are working on new drugs to treat acne, particularly topical antibiotics to replace
some of those in current use. As with many other types of bacterial infections, doctors are finding that,
over time, the bacteria that are associated with acne are becoming resistant to treatment with certain
antibiotics, though it is not clear how significant a problem this resistance represents.

http/web.archive.orgweb/20120214145400/http:www.niams.nih.gov/health_info/acne/ 8/10


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases
Factors that can cause an acne flare include:

¢ Changing hormone levels in adolescent girls and adult women 2 to 7 days before their menstrual
period starts

¢ Oil from skin products (lubricants or cosmetics) or grease encountered in the work environment

(for example, a kitchen with fry vats)

Pressure from sports helmets or equipment, backpacks, tight collars, or tight sports uniforms

Environmental irritants, such as pollution and high humidity

Squeezing or picking at blemishes

Hard scrubbing of the skin

Stress.

Myths About the Causes of Acne

There are many myths about what causes acne. Chocolate and greasy foods are often blamed, but there is
little evidence that foods have much effect on the development and course of acne in most people.
Another common myth is that dirty skin causes acne; however, blackheads and other acne lesions are not
caused by dirt. Stress doesn't cause acne, but research suggests that for people who have acne, stress can
make it worse.

Who Gets Acne?

People of all races and ages get acne. It is most common in adolescents and young adults. An estimated
80 percent of all people between the ages of 11 and 30 have acne outbreaks at some point. For most
people, acne tends to go away by the time they reach their thirties; however, some people in their forties
and fifties continue to have this skin problem.

How Is Acne Treated?

Acne is often treated by dermatologists (doctors who specialize in skin problems). These doctors treat all
kinds of acne, particularly severe cases. Doctors who are general or family practitioners, pediatricians, or
internists may treat patients with milder cases of acne.

The goals of treatment are to heal existing lesions, stop new lesions from forming, prevent scarring, and

minimize the psychological stress and embarrassment caused by this disease. Drug treatment! is aimed at
reducing several problems that play a part in causing acne:

¢ abnormal clumping of cells in the follicles
¢ increased oil production

¢ bacteria

¢ inflammation.

| All medicines can have side effects. Some medicines and side effects are mentioned in this booklet.
Some side effects may be more severe than others. You should review the package insert that comes with
your medicine and ask your health care provider or pharmacist if you have any questions about the
possible side effects.

Depending on the extent of the problem, the doctor may recommend one of several over-the-counter
(OTC) medicines and/or prescription medicines. Some of these medicines may be topical (applied to the
skin), and others may be oral (taken by mouth). The doctor may suggest using more than one topical

http:/web.archive.orgweb/20120214145400/http:;www.niams.nih.govihealth_infolacnel 4/0


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

‘Skin surface
Skin surface Blackhead

Blockage of
follicle ¢ ‘opening Enlargement
i of follicle f
Bacteria opening —

Sebaceous
gland ——,

Follicle |

Closed Comedo (Whitehead)

Other troublesome acne lesions can develop, including the following:

¢ Papules. Inflamed lesions that usually appear as small, pink bumps on the skin and can be tender
to the touch

¢ Pustules (pimples). Papules topped by white or yellow pus-filled lesions that may be red at the
base

¢ Nodules. Large, painful, solid lesions that are lodged deep within the skin

¢ Cysts. Deep, painful, pus-filled lesions that can cause scarring.

What Causes Acne?

The exact cause of acne is unknown, but doctors believe it results from several related factors. One

important factor is an increase in hormones called androgens (male sex hormones). These increase in
both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum.
Hormonal changes related to pregnancy or starting or stopping birth control pills can also cause acne.

Another factor is heredity or genetics. Researchers believe that the tendency to develop acne can be
inherited from parents. For example, studies have shown that many school-age boys with acne have a

family history of the disorder. Certain drugs, including androgens and lithium, are known to cause acne.
Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug.

Factors That Can Make Acne Worse

http:/web.archive.orgweb/20120214145400/http:;www.niams.nih.govihealth_infolacnel ano


6/8/2015 National Institute of Arthritis and Musculoskeletal and Skin Diseases

\s

Aa
Skin surface = = 3

Sebum

Follicle

Sebaceous_—““ E

gland

The hair, sebum, and keratinocytes that fill the narrow follicle may produce a plug, which is an early sign
of acne. The plug prevents sebum from reaching the surface of the skin through a pore. The mixture of
oil and cells allows bacteria Propionibacterium acnes (P. acnes) that normally live on the skin to grow in
the plugged follicles. These bacteria produce chemicals and enzymes and attract white blood cells that
cause inflammation. (Inflammation is a characteristic reaction of tissues to disease or injury and is
marked by four signs: swelling, redness, heat, and pain.) When the wall of the plugged follicle breaks
down, it spills everything into the nearby skin—sebum, shed skin cells, and bacteria—leading to lesions
or pimples.

People with acne frequently have a variety of lesions, some of which are shown in the diagrams below.
The basic acne lesion, called the comedo (KOM-e-do), is simply an enlarged and plugged hair follicle. If
the plugged follicle, or comedo, stays beneath the skin, it is called a closed comedo and produces a white
bump called a whitehead. A comedo that reaches the surface of the skin and opens up is called an open
comedo or blackhead because it looks black on the skin's surface. This black discoloration is due to
changes in sebum as it is exposed to air. It is not due to dirt. Both whiteheads and blackheads may stay in
the skin for a long time.

Types of Lesions

http:/web.archive.orgweb/20120214145400/http:;www.niams.nih.govihealth_infolacnel 20