You may have tried some over-the-counter products, flirted with various diets, or experimented with cosmetics, facials, and soaps. Maybe you’ve even watched a few TV infomercials and tried those products with unsatisfactory results. Well, it sounds like you’re ready for a different approach.

The good news is that doctors have a treasure trove of excellent topical tools they can use to treat any type of acne. In fact, for many people, topical preparations are the only treatment necessary.

I'll tell you all you need to know about the topical preparations available through a healthcare provider to treat your acne and how to use them effectively. Before starting out on our acne treatment journey, there are three important points that you as an acne patient should be aware of:

• Six to eight weeks of treatment may be required before you see any significant improvement.

• Lesions on the back, chest, and shoulders respond more slowly to topical and oral treatment than do those on the face.

• Every patient is an individual, and as such your doctor is in the best position to tailor treatments to your needs. Always follow your doctor’s recommendations.

Taking the Topical Route

The use of topicals offers many advantages over oral therapy (taking medications by mouth). The most obvious advantage is that your skin gets the direct application of medications and very few serious complications can result, whereas the oral route may lead to more severe side effects.

In topical therapy, a vehicle (an inactive medium) “delivers” the active ingredient (the drug itself) to its intended target. The vehicle may be a cream, ointment, gel, lotion, or solution (an oil-free liquid, that’s usually composed of water or alcohol).

The solutions, gels, and lotions that contain active ingredients can also hitch a ride on convenient travel-friendly delivery systems, such as the pledget or swab. These are small absorbent pads, used to medicate the skin, that are made from cotton or wool.

Just put them in your bag, backpack, or pocket, and away you go. In the treatment of acne, the vehicle may be as important as the drug or drugs that it transports. A vehicle gives a product its texture and substance and can sometimes determine its strength and influence how effectively a drug gets absorbed.

Different topical treatments for different forms of acne are determined by many factors, such as:

• Your skin type: dry, oily, combination, or normal
• The types of lesions you have: blackheads and whiteheads, papules and pustules, or both
• How long your lesions have been present
• Your past response to acne treatments and side effects that you’ve encountered
• Your tendency to develop scarring or disfiguring acne spots
• How much a treatment costs you and whether you can afford it

The best product is one that works best for you. Topical treatment frequently involves a trial-and-error approach, beginning with those products that are known to be most effective, least expensive, and have the fewest side effects.

As you find things that don’t work, you and your doctor team up to remove them from your regimen and add different (and hopefully better-for-you) products. That’s why it’s important for you to have a continuing dialog with your dermatologist in order to come up with the right product or combination of products for you to apply.

Sometimes your dermatologist may choose to combine a drying product (most acne products are), together with a moisturizing product in order to make the drying product less irritating.

Topical Acne Therapy

Topical acne therapy aims to counter several of the major factors that cause acne:

• Blocked hair follicles
• Growth of the acne causing bacteria, P. acnes
• Inflammation

Oral therapy is required to tackle the other important acne causing factors, such as:

• Increased hormone production
• Excess sebum (oil) production

Topical treatment is sufficient for most people who have acne, but oral reinforcements are generally a must if you have more extensive, deep, or scarring acne with nodules and cysts.

The following sections offer a wide range of topical treatments for your acne. Keep in mind that one size doesn’t fit all and fitting the proper medication to your skin sometimes takes trying different ones for a while.

Most dermatologists agree that the combination therapy — the use of topical retinoids and topical or oral antibiotics or antibacterials such as benzoyl peroxide — reduces both inflammatory and noninflammatory lesions more rapidly and to a greater degree than can be effected with any of these agents alone.

Reviewing topical retinoids

Most dermatologists consider topical retinoids to be the mainstay of acne therapy. They’re often the first-line prescription treatment for acne and they’re also utilized as long-term maintenance for almost every acne patient.

Retinoids are, far and above, the drugs of choice in people who have comedonal (blackhead and whitehead) acne, but they’re also effective at fighting inflammatory lesions, so chances are that your dermatologist will start you off with one of these.

Retinoids are medications that are derived from vitamin A. Retinoids are comedolytic, which means that they work by making the skin shed more easily so that follicular plugs don’t build up and form blackheads and whiteheads. In addition to helping you shed your skin, retinoids:

• Indirectly limit the formation of inflammatory lesions by preventing comedones. After all, if comedones don’t ever form, they can’t become big, inflamed pustules and papules.

• Appear to discourage P. acnes (the bacterial invaders associated with acne) growth.

• Promote the shedding of skin, which enhances the penetration of other topical anti-acne agents.

• Help to “plump up” the skin and make enlarged pores (follicular prominence, in dermatologist speak) less obvious.

Several brand-name topical retinoids, as well as generic preparations, are on the market (check out Table 1 for information on which brand-name retinoids contain which active ingredient).

Brand Name	Generic Name	Delivery	Strengths
Retin-A* (Branded generic)	Tretinoin	Cream, solution	0.025% 0.05% 0.1% 0.5%
Retin-A* (Branded generic)	Tretinoin	Gel	0.01% 0.025%
Retin-A Micro	Tretinoin	Microsphere gel	0.1%
Avita*	Tretinoin	Cream, gel	0.025%
Differin	Adapalene	Cream, gel, solution, and pledgets	0.1%
Tazorac	Tazarotene	Cream, gel	0.05% 0.1%

*Apply only at bedtime

Many studies have been performed on the topical retinoids and the results don’t clearly favor the use of one preparation over another. Individuals vary in their response to these agents and possible side effects, so you and your doctor will work together to find the best prescription for you.

Because of the known teratogenic effects (anything which produces nonheritable birth defects) of oral vitamin A, the use of topical retinoids in pregnancy has been an issue of concern. Although no studies have shown them to cause any birth defects, it is recommended that these drugs should not be used during pregnancy or breastfeeding.

Applying retinoids

Topical retinoids are applied in small, thin, pea-sized amounts to clean, dry skin once a day in the morning or at bedtime. They should be applied to all affected areas as well as to places that are acne-prone. Retin-A (not Retin-A Micro) and Avita, which tend to degrade in sunlight, should be applied only at bedtime.

Talk with your doctor about the best time to apply Retin-A Micro, Differin, and Tazorac. Dermatologists often start treatments with a lower strength preparation; in time, your doctor may prescribe higher concentrations of the active ingredient, if necessary, depending on your ability to tolerate them.

Within six to eight weeks, you should notice improvement if you have been using your product continuously. Maximal improvement most often occurs by three to four months.

Despite the common misconception, acne does not flare in the first few weeks of treatment; rather, the “flare” is due to irritation from the retinoid or from the natural progression of your acne, so try to “ride it through” unless the irritation is really severe — at which point you should call your dermatologist or healthcare provider.

It’s not uncommon for retinoids to be used improperly and discarded before they have a real chance to work. Make sure you get both verbal and written directions from your doctor to make sure that you use your products correctly.

Dealing with side effects

All retinoids can cause some skin irritation during the first few weeks of use. You may have some discomfort, such as stinging or burning, and sometimes may experience mild redness and scaling of your skin. These reactions are to be expected, and they’re an indication that the retinoid is working.

After several weeks, your skin generally gets used to the medication and the discomfort eases. A common belief is that retinoids dry the skin. But they’re actually sloughing off dead skin cells. If you have a sensitivity to the retinoid you were prescribed, you can take a number of steps to help ease the irritation:

• Build up a tolerance: Start off by using the retinoid every other day, or even less frequently, until you get used to it. If you have extremely sensitive skin, try applying the retinoid for short periods of time, such as leaving it on for a few minutes and then washing it off.

You can put it on for as little as two to five minutes. This tends to make it more tolerable and the medicine still has positive effects as long as you stick with it.

As your skin becomes accustomed to the retinoid, you can gradually increase the frequency of application and how long you leave it on. Eventually you may be able to apply it every day and leave it on all day or overnight.

• Avoid irritating OTC products: Make sure that you’re not also using an over-the-counter product that contains salicylic acid, retinols, or other possible irritants.

• Ask your doctor to prescribe a cream or a weaker concentration of the medicine. Creams are the least irritating delivery vehicle. The concentration of the agent affects the degree of irritation.

• Use a moisturizer: If you get dry and scaly, apply a moisturizer generously in the morning. The moisturizer should be applied over any medication you apply at night or in the morning. (If you also use a sunscreen, apply it over the moisturizer.)

Effective moisturizers include Oil of Olay, Nivea Ultra Moisturizing Creme, and Eucerin creams. Use only emollient, non-irritating cleansers to wash your face when you’re using a topical retinoid.

Retinoids may produce sun sensitivity. A common misconception is that tretinoin shouldn’t be used during the summertime, during sunny weather, or in tropical climates.

Retinoids can make you somewhat more susceptible to sunburn, however, this problem eases after the drug has been used for a month or two. Retinoids can be applied at any time of year in any geographic region.

If you’re using a retinoid in sunny conditions, particularly if you have fair skin, just take simple sun-protective measures, such as avoiding the midday sun, applying a broad-spectrum sunscreen or sunblock (over the medication), and wearing a protective cap or hat. Applying them at bedtime is added insurance against your having problems with sun exposure the next day.

Enhancing retinoid treatment

Removal of comedones can also help to treat your acne and speed up improvement. Your dermatologist may perform acne surgery with a comedo extractor, a small instrument that mechanically removes comedones.

Comedo removal can be a useful adjunct to topical therapy when your blackheads and whiteheads are somewhat resistant to topical retinoids. Acne surgery is a noninvasive surgery, meaning that the blackheads and whiteheads are simply popped or squeezed out with the extractor.

The extractor is a special instrument that minimizes skin injury. A round loop extractor is used to apply uniform smooth pressure to dislodge the material. Lesions that offer resistance are loosened by inserting a pointed instrument to carefully expose the contents.

Pretreatment with a topical retinoid for four to six weeks often facilitates the procedure because it helps open up your pores. Comedo extraction is performed less commonly nowadays since the arrival of topical retinoids. Comedo extraction is often performed successfully by aestheticians as part of a facial.

An experienced technician may remove your blackheads and whiteheads with tissue paper or with another instrument. An improperly trained technician may also try to squeeze out your red papules which can result in persistent redness and even scarring.

Turning to topical antibiotics

Because retinoids may be more difficult for you to tolerate and can take a long time to work, your dermatologist may elect to treat your inflammatory lesions (papules and pustules) first with oral or topical antibiotics. They work much faster than the retinoids.

So if you’re in a hurry to look better, the quicker response can be a helpful incentive for you to continue therapy. Clindamycin and erythromycin are the two most commonly used topical antibiotics for the management of inflammatory acne.

Dermatologists consider them to be equally effective. They can be used alone or in combination with benzoyl peroxide and/or oral antibiotics to treat acne as well as rosacea, perioral dermatitis, shaving bumps, and other acnelike conditions. Topical antibiotics directly kill P. acnes.

In addition to their antibacterial action, these drugs have an anti-inflammatory action that helps to clear inflammatory acne lesions. Through their bacterial killing ability, they also appear to have a mild indirect blocking effect on the formation of blackheads and whiteheads (known by the fancy medical name of comedogenesis).

Topical antibiotics are available in creams, ointments, gels, solutions, and lotions. This variety allows your dermatologist or healthcare provider to prescribe according to your skin type or preference. Many prescription topical antibiotics are available, as you can see in Table 2.

Brand Name	Generic Name	Delivery	Strengths
(Branded generics)*	Erythromycin	Solution, gel, lotion, swabs	2%
A/T/S	Erythromycin	Solution, gel	2%
Theramycin Z**	Erythromycin	Solution	2%
Akne-Mycin	Erythromycin	Ointment	2%
Erycette	Erythromycin	Pledgets	2%
Staticin	Erythromycin	Solution	1.5 %
(Branded generics)*	Clindamycin	Solution, gel, lotion, pledgets	1%
Cleocin T	Clindamycin	Solution, gel, lotion, pledgets	1%
ClindaMax	Clindamycin	Gel, lotion	1%
Clindets	Clindamycin	Pledgets	1%

* There are numerous branded generics of these agents
**Contains zinc

Some erythromycin and clindamycin products have become available as generics, while other have become branded generics.

Applying antibiotics for the best results

Topical antibiotics are applied once or twice daily, in a thin layer on all of the acne-prone areas to clean, dry skin. In four to six weeks, you should see a decrease in the size of inflammatory acne lesions. The therapeutic response tends to be more effective when the topical antibiotic is combined with benzoyl peroxide.

Topical antibiotics may promote the appearance of resistant strains of P. acnes. Resistance is diminished by combining them with or using them in conjunction with benzoyl peroxide.

Dealing with side effects

Mild side effects such as redness, skin irritation, and scaling are associated with use of these drugs, but most people tolerate topical antibiotics well.

If you have a skin condition known as eczema, you may have extremely sensitive skin. Irritation and burning may be associated with applying certain topical antibiotic preparations. This may be avoided if you’re prescribed an ointment-based erythromycin such as Akne-Mycin or clindamycin in a lotion preparation.

Combining benzoyl peroxide with topical antibiotics

Benzoyl peroxide is the mainstay of over-the-counter acne treatment. In addition to using benzoyl peroxide alone to treat your mild acne, benzoyl peroxide is also often used in conjunction with topical or systemic antibiotics. This treatment option is referred to as combination therapy.

In fact, combination therapy is used to treat most cases of acne because it’s caused by a combinations of factors. Combination therapy can refer to using combination products, such as those in Benzamycin, Duac, or BenzaClin, or by using them in addition to a topical retinoid and an oral antibiotic, for example.

By using drugs that have different means and modes of activity, your acne is attacked on many fronts. Combining benzoyl peroxide with erythromycin or clindamycin has the following advantages:

• In contrast to topical antibiotics used alone, adding benzoyl peroxide to the mixture prevents P. acnes from becoming resistant to them.

• The combination also appears to have a synergistic effect (the combination works better than either agent used alone).

Table 3 tells you the names of these preparations.

Brand Name	Generic Name/Strengths	Delivery
Benzamycin* (Branded generic)	5% benzoyl peroxide 3% erythromycin	Gel
Benzamycin Pak (Foil pouches)	5% benzoyl peroxide 3% erythromycin	Gel
BenzaClin Topical Gel**	5% benzoyl peroxide 1% clindamycin	Gel
Duac Gel	5% benzoyl peroxide 1% clindamycin	Gel

* Refrigeration is necessary to maintain potency
** Sometimes these agents come unmixed and the pharmacist or you must combine the clindamycin or erythromycin powder with the benzoyl peroxide gel.

If you’re on the go — for instance traveling or camping, or you’re a teen that splits time between two homes — the Benzamycin Pak comes in foil pouches, which are easier to deal with.

If you’re looking to save some money on your combination acne treatments, talk to your doctor about using a prescription for a generic topical antibiotic such as clindamycin or erythromycin lotion along with an over-the-counter benzoyl peroxide. Use them one on top of the other.

How to apply them

Before applying medicine to affected areas, wash your skin gently, rinse with warm water, and pat dry. Apply the gels in small, pea-sized amounts once or twice a day or as directed by your doctor, in the morning or at bedtime to all of your acne-prone areas.

When used alone, the benzoyl peroxide/antibiotic combination takes about four to six weeks to show significant improvement. Once-a-day applications are usually sufficient and allow for the application of other topicals such as retinoids, if they are required, at another time of day.

If you have blackheads and whiteheads (comedones), a comedolytic agent such as a topical retinoid may be prescribed for you to apply at a different time of day. To minimize irritation, try alternating the products daily for two weeks until you adapt to using them both daily.

Side effects

You can expect the same dry skin and skin irritation that are the most common side effects for benzoyl peroxide, plus the slight chance of mild irritation from the topical antibiotics. Side effects may include dry skin, itching, peeling, redness, and possibly a contact dermatitis from the sensitivity to the benzoyl peroxide.

To combat excessive dryness, apply a moisturizer generously in the morning. If you apply medication in the morning, the moisturizer should be applied over the medicated gels so that you don’t block them from doing their job.

As with the topical retinoids, use only emollient, non-irritating cleansers to wash your face when you’re using these preparations.

If you find that the combination products are too irritating (that’s usually due to the benzoyl peroxide in them), you might try an over-the-counter water-based benzoyl peroxide preparation such as Neutrogena On-the-Spot Acne Treatment, or a benzoyl peroxide soap bar such as Fostex 10% BPO Wash.

There are also prescription benzoyl peroxide washes such as Zoderm and Triaz Cleansers. All of these products may be left on the skin for 5 minutes and then rinsed off. Afterward, a topical antibiotic preparation such as clindamycin or erythromycin can be applied. That way, you still can get the benzoyl peroxide effect and hopefully avoid the irritation.

Looking at other topicals

Newer agents, such as azelaic acid, and older preparations that contain sulfur and sodium sulfacetamide are used as alternatives or addons to retinoids, benzoyl peroxide, and benzoyl peroxide/antibiotic preparations. They’re the second line of defense when the first team isn’t doing so well or, more commonly, isn’t tolerated.

Azelaic acid

For those of you who want to go a more “natural route,” azelaic acid might be right up your alley. Azelaic acid is a naturally occurring acid found in grains like wheat, rye, and barley. Azelaic acid has been shown to possess:

• Antibacterial activity against P. acnes
• A mild anti-inflammatory effect
• A minor reduction on comedone (blackheads and whitehead) formation

Azelaic acid can be found in 20 percent creams under the brand names Azelex or Finevin. Apply it in small, pea-sized amounts once or twice a day to a clean, dry face to all acne-prone areas. Most people start to see improvement in their acne within four to six weeks.

It is tolerated fairly well; however, some people experience mild side effects such as redness and scaling. Because azelaic acid decreases pigmentation, it should be used with some caution in patients with darker complexions.

On the other hand, this side effect can be an added benefit in people of color in the treatment of dark spots that often occur when their acne heals.

Topical sulfacetamide/sulfur combinations

The combination of sulfacetamide and sulfur can be effective in the treatment of inflammatory skin lesions without the unpleasant side effects (primarily a rotten egg odor) that occur with sulfur preparations alone.

They’re less effective than retinoids, benzoyl peroxide, and benzoyl-peroxide-and-antibiotic combinations, but as with azelaic acid, they’re sometimes useful as adjunctive therapy for the inflammatory component of acne as well as for rosacea.

Sulfacetamide/sulfur combinations are available as lotions, creams, and washes. You can find a host of products that contain sodium sulfacetamide 10 percent and sulfur 5 percent, such as Rosula, Rosac, Rosanil, Nicosyn, and Novacet, to name a few. Rosac also contains a sunscreen.

In general, apply these products twice a day on clean dry skin to all acne-prone areas. Some of these preparations have color tinting in them so that they can serve as a cosmetic cover-up to hide the redness of acne. Sulfacet-R is one of them.

This medicine comes with a color blender that allows you to change the tint of the lotion to match your skin color. In my experience, these products have a marginal utility and appear to have less anti-inflammatory effect than the topical antibiotics I describe here.

If you use them, expect a slower, and less effective, response than you get with other treatments. Mild stinging and redness may occur with these products.

Going Generic

Did you know that when you have a prescription to be filled, you may have a choice between filling it with a brand-name drug or a generic drug? Generic drugs are pharmaceuticals that are essentially similar to an original product that had been on the market for years.

The active ingredients in the original product are protected by a patent for a specific period of time. When a patent expires, a generic drug company introduces a copycat version of the original drug. Because the original drug has been a proven commodity, the generic versions are expected to work just as well as the originals.

Generic medications are:

• Generally 30 to 60 percent less expensive than the equivalent brand-name product. Help control health insurance costs for yourself and everybody else by asking for generic drugs when possible. Ask your doctor to indicate on the prescription that substitution is permitted if you want a generic prescription.

When you get to the pharmacy, ask if a generic version of your drug is available and ask the pharmacist to substitute the generic for the brand-name drug unless your doctor has written on the prescription that no substitution can be made.

• Most often just as effective even though they cost less. Applicants for generic drug approval must scientifically demonstrate that their product is bioequivalent (meaning that it performs in the same manner) to the brand-name drug.

• Made of the same active ingredient or ingredients and the same strength as the brand name. Bioequivalent medications contain the same active ingredients and are subject to the same Food and Drug Administration (FDA) standards for quality, strength, safety, potency, and purity as their brand-name counterparts. They must also produce the same effect on the body as the brand-name counterpart.

The TV infomercial and Internet acne products marketed as “total acne treatment systems” are now available over the counter as generic “house brands.” They’re sitting on the shelves of many of your local stores at a great savings.

Some generics don’t have the same effectiveness as the well-known brand. If you aren’t doing well on a generic, you might want to ask for the brand-name version.

Even though generics still contain the same active ingredient as the original branded drug, their vehicles may be sub par and there may be instances when they act somewhat differently on or in your body. Talk about it with your doctor. For more information about generic drugs, you can go to the following Web site: www.fda.gov.