Over the Counter and Alternative Treatments for Acne

by

Michael H. Berkson, M.D.

Milder forms of acne can sometimes be effectively managed with over the counter (OTC)  and/or alternative treatments.  In some cases, more moderate and even severe forms of acne can also benefit from the use of OTC and alternative treatments in combination with prescription medications.

The three most useful types of OTC treatments are products containing salicylic acid, benzoyl peroxide, and the retinoid, adapalene ( Differin Gel).

Salicylic acid 2% ( SA) is in a variety of acne washes and other types of topical preparations that are available OTC.  It is derived from salicin, a compound found in the bark of the willow tree.  SA is comedolytic, meaning that it can help clear existing comedones( whiteheads and blackheads), and to some extent reduce the formation of new comedones.  It also has some mild anti-inflammatory properties and can thus be beneficial in those with lesser degrees of inflammatory acne.

SA can be used once or twice daily on the areas affected by acne to speed the resolution of existing breakouts and also help reduce the intensity of future acne flares..  The higher 20% and 30% concentrations of salicylic acid are available in chemical peels which are administered by skin care professionals in medical offices and medispas.

Benzoyl peroxide (BPO) is in many acne products. It’s function  in acne treatment  is mainly as an antimicrobial agent.  Specifically it reduces the P. acnes bacteria in the sebaceous follicle.  Unlike the case with antibiotics,  P. acnes resistance to benzoyl peroxide has never been demonstrated, and is unlikely to become a problem in the future.  In fact, BPO may have a role in helping to prevent the emergence of P. acnes bacteria that are resistant to antibiotics when it is used concurrently with those same antibiotics.  For this reason, whenever antibiotics ( topical or oral) are part of an acne treatment program, it is recommended that benzoyl peroxide be a part of the regimen.

Like salicylic acid, BPO can help reduce and prevent comedones and is also mildly anti-inflammatory.  It can be formulated as a gel, cream, lotion, or wash. BPO comes in strengths ranging from 2.5%-10%. The difference in efficacy between the lower and higher concentrations is probably small. However the higher concentrations can be more irritating.

Typically, BPO is used once or twice daily.  It can be applied to the entire acne prone area to help clear existing breakouts and also help reduce or prevent future flare ups. It can take a month or two of consistent daily use to realize the preventive benefits of BPO.  BPO can also be used as a spot treatment to quickly resolve isolated inflammatory lesions. The main side effect of BPO is that it can bleach colored fabrics such as towels, clothing, and linens.  Minor irritaion, dryness, and peeling sometimes occurs during the first week or two of treatment, but usually subsides with continued use.  Allergic reactions to BPO can occur, but are uncommon.

Adapalene 0.1%, a topical retinoid previously available by prescription only, is now available OTC as Differin Gel.  Differin helps resolve existing comedones, helps prevent the formation of new comedones, and has anti-inflammatory properties. It can also help to speed the resolution of the dark blemishes ( post inflammatory hyperpigmentation) that are often left after the inflammatory lesions of acne resolve.  It can work by itself in mild acne or can be combined with benzoyl peroxide in more moderate acne.

Differin is best applied as a thin layer, once daily, to the entire acne prone area.  Differin can take several months to show results, as measured by clearing of existing acne and reduced frequency and severity of future breakouts.  Unlike BPO, Differin is not very effective as a spot treatment. The most common side effect of Differin is mild retinoid dermatitis during the first few weeks of treatment.  Retinoid dermatitis usually presents as mild redness, peeling, and stinging.  It usually resolves on it’s own or with a temporay reduction in frequency of application of the gel.  Differin and other topical retinoids can also make the skin slightly more fragile and should not be used for several days in advance of procedures such as facial waxing.

There are also OTC acne products that contain sulfur which has a drying and mild antibacterial effect. Glycolic acid, which is derived from sugar cane, is another ingredient that is found in some OTC formulations and may be mildly beneficial  for acne..  It is more commonly found in products that can be obtained from medical offices and medispas.  Glycolic acid containing chemical peels are sometimes used as an adjunctive treatment for acne, although less commonly than salicylic acid peels.

There are several alternative treatments that have been proposed for the treatment of acne.  With the exception of the role of diet in acne, evidence for the efficacy of any of these alternative treatments is very limited and based on the results of small trials.

Tea tree oil is derived from the melaleuca tree. It has antibacterial properties.  It can be diluted and used as a spot treatment to help resolve individual acne lesions. It also comes as a wash. Tea tree oil is probably less effective than benzoyl peroxide, but has little downside risk other than the small chance of an allergic rash (contact dermatitis).

Niacinamide ( nicotinamide) is a vitamin B derivative that has an anti-inflammatory effect.  It has been studied in both oral and topical forms and might offer some benefit in the treatment of acne.  Oral niacinamide is available OTC as well as by prescription (Nicazel).

Oral zinc has also been evaluated in a small study for it’s potential role in acne treatment.  Is is available by prescription only.

There are several small studies suggesting  beneficial effects of probiotics on acne when used either alone or in combination with the oral antibiotic minocycline.  The mechanism of action is unclear but it has been hypothesized by some that alterations in the intestinal bacteria (microbiome) might be linked to the inflammatory component of acne. Probiotics work by normalizing the gut microbiome thus possibly attenuating the inflammatory response in the skin.

Finally, lifestyle modifications should not be overlooked as an alternative treatment for acne. There is some evidence that in some people dietary modification can improve acne control. Foods that contain large amounts of simple carbohydrates (sugars) can aggravate acne in sensitive individuals via the hormone insulin like growth factor (IGF) which can promote comedogenesis and inflammation.  Dairy products, milk in particular, can also be an aggravating factor in some individuals probably in part as a result of hormones contained in the milk as well as a possible effect of dairy on sebum. It is highly unlikely that avoidance of excessive sugar and dairy is going to resolve one’s acne, but in certain individuals reduction in one or both of these dietary components might make their acne more manageable.  For more information on the possible role of diet in acne, please see the article on this website titled Diet and Acne: A Possible Connection, authored by Dr. Sheila Krishna.

In some people stress seems to worsen their acne.  This makes sense as it is known that stress can alter the internal neurohormonal environment which in turn can affect inflammation and even comedogenesis.  By extension one could reason that stress management, although not a panacea, might be helpful as an additional method to help manage acne.

The final article in this series discusses some common myths, facts, and tips related to acne and it’s treatment.

References:

Over-the-counter treatments for acne and rosacea.  Rosamilia LL.  Semin Cutan Med Surg. 2016 Jun;35(2):87-95.