Acne knows no boundaries, and while treatments continue to advance, some classic solutions remain a fundamental part of the skin-clearing equation. Still, innovation spearheads treatment protocols, and today, dermatologists are turning more to combination and second-generation therapies than ever before.
Here, we unpack which standard acne medications are getting makeovers, what dermatologists will always rely on, and the latest advancements that are paving the way to blemish-free skin once and for all.
Long-Time Acne Heavy Hitters
Typically, the first line of defense for treating acne starts with topical prescription creams and gels, and antibiotics. But, Santa Monica, CA dermatologist Ava Shamban, MD says that protocol isn’t always an effective mode of treatment. “Antibiotics are often difficult to use for long periods of time, and while some topical treatments may help in the short-term, they can irritate or dry the skin.”
To better address the root causes of acne, many doctors, including New York dermatologist Marina Peredo, MD, are now treating acne as a multifactorial problem. “This approach allows us to improve active acne, and even acne scars. We can modify a patient’s diet and skin-care regimen, utilize over-the-counter and prescription acne medications depending on the severity of the acne, and also add in-office treatments.”
A New Take on Oral Acne Medications + Antibiotics
According to Miami dermatologist Anna Chacon, MD, oral antibiotics are sometimes necessary to reduce bacteria when moderate-to- severe acne persists. “Tetracycline (minocycline or doxycycline) or macrolide (erythromycin and azithromycin) are common options.” Other newer oral antibiotics, such as Seysara, are also being prescribed. Omaha, NE dermatologist Joel Schlessinger, MD says Seysara is a new form of tetracycline that helps improve inflammatory acne, particularly on the chest and back.
However, not all acne-improving pills showing promise are antibiotics. Case in point: metformin, an anti- hyperglycemic drug. Dr. Chacon says the medication, which is frequently used to treat Type 2 diabetes, reduces acne in females with Polycystic Ovary Syndrome (PCOS) and males with altered metabolic profiles. “Metformin lowers ovarian hyperandrogenism, which improves acne clinically so that it may be a reliable off-label supplementary medication.”
Although oral medications have long been a go-to for improving acne, Dr. Shamban says new topical versions offer better delivery systems and tolerability. Until recently, the popular blemish-reducing antibiotic minocycline was only available as a pill and posed side effects like photosensitivity. Now, a 4-percent topical minocycline foam called Amzeeq is available, and the topical iteration signifies the first major minocycline breakthrough in nearly 50 years.
“Topical minocycline is easy to use and gentle on the skin because it contains naturally moisturizing soybean and coconut oils,” Dr. Peredo adds.
Dr. Shamban likes topical minocycline for its anti-inflammatory effects and ability to reduce bacterial count. “The foam vehicle and high lipid content allow medicine movement through sebum and into the affected area to improve inflammatory and non- inflammatory lesions,” she explains. “Plus, using minocycline topically reduces the need to combine it with other anti-acne ingredients, such as benzoyl peroxide, to reduce irritation.”
Spironolactone Is Having a Moment in Acne, Again
Dermatologists have long been prescribing spironolactone off-label because of the blood pressure and anti-androgen medication’s ability to regulate androgen hormones, suppressing sebaceous gland activity. In the past, dermatologists had to monitor potassium levels via blood work. Even though that’s no longer required, spironolactone can cause issues like elevated potassium levels, dry kidneys, hair loss, tender breasts, and concerns for women who become pregnant.
“Spironolactone is helpful for many patients, but it’s not a total home run,” Dr. Schlessinger says. “It halts acne in many women, but not everyone who takes it will see clearer skin, so I often use antibiotics alongside or in lieu of spironolactone. Additionally, spironolactone is teratogenic to the forming fetus, so I generally avoid it in women of childbearing age unless they are on oral contraceptives or a form of birth control.”
Dr. Shamban says it can also disrupt women’s hormones. But, all that is changing with Winlevi (clascoterone), a new FDA-approved anti-androgen cream drug that treats acne. “This topical version of spironolactone is a significant advancement in managing acne,” Dr. Chacon explains. “It’s an androgen receptor inhibitor with highly localized activity that prevents androgen hormones from impacting the glands that secrete oil to reduce sebum production and lessen inflammatory activity within the skin.”
Retinoids are frequently part of a well-rounded anti-acne routine. But, some skin types can’t tolerate the ingredient’s side effects, like redness, drying, peeling, and sensitivity. Newer retinoids like Altreno (tretinoin) and Arazlo (tazarotene) offer less irritation and dryness.
“There’s also AKLIEF (trifarotene), which is more tolerable than tretinoin for sensitive skin,” Dr. Peredo says. “It’s the first retinoid approved for treating truncal—chest, back and shoulder—acne.” The main ingredient in AKLIEF targets retinoic acid receptors to reduce inflammation and other factors that cause acne, but exactly how it improves the skin condition is unknown.
Retinoids are also being combined with other tried-and-true prescription acne medications, which is evident with Twyneo, a tretinoin-meets- benzoyl-peroxide formulation that gradually releases both medicines into the skin. The stabilized mix relies on a unique encapsulation, which makes the formula more tolerable and less drying. Additionally, a triple- packed combination of clindamycin, benzoyl peroxide and adapalene is currently in clinical trials and expected to make its way to the market soon.
Increased Bioavailability for Isotretinoin
An oral prescription medication that controls sebaceous gland activity, isotretinoin has been deemed by many dermatologists as the holy grail for acne when nothing else works. It too has experienced changes with a newer iteration, Absorica. According to Dr. Schlessinger, who participated in the clinical trials for Absorica, there’s no need to take it with a fatty meal or drink, which is recommended for the generic forms of Accutane as they aren’t absorbed as well without fat intake at the same time.
“Accutane is not easily absorbed if there isn’t fat in the stomach, and it may lag if you don’t eat a lot of fat,” he explains. “Absorica is great for vegetarians, vegans and anyone on a strict diet without much fat. The medicine may have 20 to 25-percent higher bioavailability.”
The Laser Lowdown
Coupling lasers with prescription medications can be the one-two punch some skin types need. The newest acne-clearing laser is AviClear, which Dr. Chacon says “uses a specific wavelength of laser light to target and repress sebaceous glands, eradicating acne at its source in a few sessions. Unlike other laser acne treatments, which are only effective on patients with certain skin tones, AviClear targets oil glands rather than melanin.”
FDA-cleared Accure is another downtime-free laser targeting oil production to diminish breakouts through a series of treatments. Like AviClear, it works on inflammatory acne across the board. It also features proprietary technology to precisely control thermal gradient depth.
The Botox + Breakout Connection
While neurotoxins (Botox Cosmetic, Dysport, etc.) are heralded for their wrinkle-reducing benefits, they can offer acne benefits, too. Dr. Peredo explains that neurotoxin injections treat acne by decreasing oil production. “Excess sebum is a common cause of acne breakouts, and reducing sebum is the primary mechanism behind a neurotoxin.”
However, neurotoxins shouldn’t be used as a standalone acne treatment because they cannot impact recurring breakouts alone. Dr. Peredo says, “They are better for those who struggle with breakouts in a particular area of the face, such as along the jawline, or an oily area like the forehead.”