Acne Medication: Complete Guide to Treatments

What Topical Acne Medications Should I Try First?

Most people with mild or moderate acne should start with topical treatments applied directly to the skin. These include benzoyl peroxide (available over-the-counter), prescription retinoids like adapalene or tretinoin, azelaic acid, and topical antibiotics like clindamycin. The best choice depends on your specific type of acne and skin sensitivity.

Topical treatments are the first-line approach for acne because they work directly where the problem occurs – in the hair follicles and sebaceous glands of the skin. These medications target the key factors that cause acne: excess oil production, abnormal skin cell shedding, bacterial overgrowth, and inflammation. For most people with mild to moderate acne, topical treatments alone can provide excellent results when used consistently over several weeks.

The choice of topical medication depends on several factors including the severity of your acne, whether you have primarily comedonal acne (blackheads and whiteheads) or inflammatory acne (red, painful pimples), your skin type, and your tolerance for potential side effects like dryness and irritation. Many dermatologists recommend starting with a combination approach, using different products that work through complementary mechanisms for maximum effectiveness.

Understanding how each medication works can help you use them more effectively and manage any side effects. All topical acne treatments require patience – most take at least 4-8 weeks of consistent use before you'll see significant improvement. During the first few weeks, you may even experience a temporary worsening of acne, known as "purging," which occurs as the medication brings underlying pimples to the surface faster.

First-Line Topical Treatments

The most commonly recommended topical acne medications include benzoyl peroxide for its antibacterial properties, retinoids for normalizing skin cell turnover, and combination products that target multiple acne-causing factors simultaneously. Your healthcare provider may recommend starting with one product and adding others if needed, or beginning with a combination approach for faster results.

• Benzoyl peroxide: Kills acne-causing bacteria, available over-the-counter in 2.5%, 5%, and 10% strengths
• Adapalene: A retinoid that normalizes skin cell turnover and reduces inflammation
• Azelaic acid: Antibacterial and anti-inflammatory, good for sensitive skin
• Clindamycin: Topical antibiotic that reduces bacterial populations
• Tretinoin: Prescription retinoid that's more potent than adapalene

How Does Benzoyl Peroxide Treat Acne?

Benzoyl peroxide works by killing Cutibacterium acnes bacteria and breaking down comedones (clogged pores). It's available without prescription in gel form at most pharmacies and is effective for mild acne. It works relatively quickly but can cause dryness, irritation, and bleaching of fabrics.

Benzoyl peroxide is one of the most widely used and effective over-the-counter acne treatments available today. It works through two primary mechanisms: first, it has powerful antibacterial properties that kill the Cutibacterium acnes (formerly called Propionibacterium acnes) bacteria that contribute to inflammatory acne. Second, it has comedolytic properties, meaning it helps break down and prevent the formation of comedones – the clogged pores that form blackheads and whiteheads.

Unlike topical antibiotics, bacteria cannot develop resistance to benzoyl peroxide because it works through oxidation rather than targeting specific bacterial processes. This makes it an excellent long-term treatment option and an ideal combination partner for topical antibiotics, where it helps prevent antibiotic resistance from developing. Studies show that combining benzoyl peroxide with topical antibiotics is significantly more effective than using either treatment alone.

When starting benzoyl peroxide, it's important to begin with the lowest strength (2.5%) and gradually work up if needed. Research has shown that 2.5% benzoyl peroxide is often just as effective as higher concentrations but causes less irritation. The medication should be applied as a thin layer to the entire affected area, not just individual pimples, to prevent new breakouts from forming.

Start with the Lowest Strength

Benzoyl peroxide comes in different concentrations ranging from 2.5% to 10%. Clinical studies have demonstrated that lower concentrations are often equally effective while causing significantly less skin irritation. Most dermatologists recommend starting with 2.5% or 5% strength to minimize side effects while still achieving good results. It typically takes several weeks of consistent use before you notice significant improvement in your acne.

The medication can be used once or twice daily, depending on your skin's tolerance. If you experience excessive dryness, peeling, or irritation, try reducing the frequency of application or switching to a lower concentration. Using a non-comedogenic moisturizer after the benzoyl peroxide has absorbed can help manage dryness without clogging pores.

Be Careful in the Sun

Benzoyl peroxide can make your skin thinner and more sensitive to sunlight. While using this medication, you should limit sun exposure and always apply a broad-spectrum SPF 30+ sunscreen when going outdoors. If you're planning significant sun exposure, such as a beach vacation, you may want to discuss with your doctor whether to temporarily pause treatment. Continue protecting treated areas with sunscreen or protective clothing.

Don't Combine with Adapalene at the Same Time

Benzoyl peroxide and adapalene should not be applied at the same moment as they can interact and reduce each other's effectiveness. Additionally, both medications have drying and potentially irritating effects on the skin, which can be compounded when used together. However, many dermatologists recommend using both products by separating their application times – for example, benzoyl peroxide in the morning and adapalene in the evening. Some combination products are specifically formulated to allow these ingredients to work together effectively.

Benzoyl Peroxide Bleaches Fabrics

Be aware that benzoyl peroxide can bleach or discolor fabrics, including clothing, towels, pillowcases, and bedsheets. Use white or old towels and linens during treatment, and allow the medication to fully dry before contact with fabrics. Wearing white or light-colored clothing to bed can prevent staining of your favorite items.

Side Effects of Benzoyl Peroxide

Common side effects include temporary warmth or mild stinging immediately after application, which typically subsides quickly. Some people experience redness, dryness, peeling, or itching, especially during the first few days of use. These effects usually diminish as your skin adapts to the medication. If severe irritation, blistering, or allergic reactions occur, discontinue use and consult a healthcare provider.

How Does Adapalene Work for Acne?

Adapalene is a topical retinoid that reduces inflammation and affects skin cells around sebaceous glands, preventing pore blockage. It works well for mild to moderate acne and is available as a prescription gel or cream. Noticeable improvement typically appears after about one month of consistent use.

Adapalene belongs to a class of medications called retinoids, which are derived from vitamin A. As a third-generation retinoid, adapalene was specifically developed for acne treatment and offers several advantages over older retinoids like tretinoin. It works by binding to specific receptors in skin cells, which normalizes the way these cells develop and shed. This prevents the abnormal clumping of dead skin cells that clogs pores and forms comedones – the primary lesions of acne.

Beyond its effects on skin cell turnover, adapalene has significant anti-inflammatory properties that help reduce the redness and swelling associated with inflammatory acne lesions. This dual mechanism makes it particularly effective for treating both comedonal and inflammatory acne. Clinical studies have demonstrated that adapalene reduces the formation of new comedones, decreases the size of existing lesions, and helps prevent acne scarring when used consistently.

One of adapalene's advantages is its stability when exposed to light and air, unlike some other retinoids that degrade quickly. This stability makes it easier to formulate and use effectively. In many countries, low-strength adapalene (0.1%) has been approved for over-the-counter sale under brand names like Differin, making retinoid therapy more accessible to patients without requiring a prescription.

Be Careful in the Sun

Adapalene makes your skin thinner and significantly more sensitive to ultraviolet light. During treatment, you should minimize sun exposure and always protect treated areas with broad-spectrum sunscreen (SPF 30 or higher) and protective clothing. Sun damage is not only uncomfortable but can also cause post-inflammatory hyperpigmentation that may be worse than the original acne. Plan outdoor activities for early morning or late afternoon when the sun is less intense.

Don't Combine with Benzoyl Peroxide Simultaneously

While adapalene and benzoyl peroxide are both excellent acne treatments, applying them at the same time can reduce the effectiveness of both medications and increase skin irritation. If your dermatologist recommends using both, apply one in the morning and the other in the evening. Alternatively, specially formulated combination products like Epiduo contain both ingredients with additional compounds that allow them to work together without interfering with each other.

Side Effects of Adapalene

Initial side effects are common and usually improve over time as your skin adjusts. Many people experience itching, burning, or stinging when first applying the medication. Redness, dryness, peeling, and increased sun sensitivity are also common, particularly during the first month of treatment. Starting with every-other-day application and gradually increasing to daily use can help minimize these effects. Using a gentle, non-comedogenic moisturizer after the adapalene has absorbed can help manage dryness.

What Is Azelaic Acid and How Does It Help Acne?

Azelaic acid is a naturally occurring substance that reduces comedones and inhibits bacterial growth. It works slowly initially and can be combined with other medications. Available as a prescription gel or cream, it typically takes about four weeks before noticeable improvement occurs.

Azelaic acid is a dicarboxylic acid that occurs naturally in grains like wheat, barley, and rye, and is also produced by the Malassezia yeast that lives on human skin. As an acne treatment, it offers multiple mechanisms of action that make it effective for various types of acne lesions. It normalizes the keratinization process in hair follicles, preventing the formation of comedones, while also having direct antibacterial effects against Cutibacterium acnes.

One of azelaic acid's unique benefits is its ability to reduce post-inflammatory hyperpigmentation – the dark marks that often remain after acne lesions heal. This makes it particularly valuable for people with darker skin tones who are more prone to these lasting marks. It works by inhibiting tyrosinase, an enzyme involved in melanin production, helping skin tone become more even over time.

Azelaic acid is generally well-tolerated and can be an excellent option for people who cannot use or tolerate retinoids. It's safe to use during pregnancy (Category B) and while breastfeeding, making it one of the few effective acne treatments available to pregnant women. It can be safely combined with many other acne treatments, including benzoyl peroxide, antibiotics, and retinoids, for enhanced effectiveness.

Side Effects of Azelaic Acid

Azelaic acid is typically well-tolerated, but some users experience mild side effects, especially initially. Common reactions include itching, tingling, stinging, or burning sensations upon application. Some people notice redness, dryness, or mild peeling. These effects are usually temporary and diminish as treatment continues. Unlike benzoyl peroxide and retinoids, azelaic acid does not significantly increase sun sensitivity.

How Do Topical Antibiotics Treat Acne?

Clindamycin is a topical antibiotic available as a solution or lotion that reduces acne-causing bacteria. After three months of treatment, effectiveness should be evaluated and a break may be needed to prevent antibiotic resistance. Do not combine topical antibiotics with oral antibiotics for acne.

Topical antibiotics work primarily by reducing the population of Cutibacterium acnes bacteria on the skin and within hair follicles. This reduction in bacterial numbers decreases the inflammatory response that causes red, swollen pimples. Clindamycin is the most commonly prescribed topical antibiotic for acne and is available in various formulations including solutions, lotions, gels, and foams to suit different skin types and preferences.

While topical antibiotics are effective at reducing inflammatory acne, they have limited effect on comedonal acne (blackheads and whiteheads) because bacteria aren't the primary cause of these lesions. For this reason, dermatologists typically recommend using topical antibiotics in combination with other treatments like benzoyl peroxide or retinoids that address the complete spectrum of acne pathophysiology.

A critical concern with topical antibiotic use is the development of bacterial resistance. Long-term use of topical antibiotics alone can lead to the emergence of antibiotic-resistant bacteria, which reduces treatment effectiveness and has broader public health implications. To minimize resistance development, topical antibiotics should be used for limited periods (typically no more than 3 months), always in combination with benzoyl peroxide, and never with oral antibiotics simultaneously.

Combine with Benzoyl Peroxide

Combining topical clindamycin with benzoyl peroxide significantly improves treatment outcomes and helps prevent antibiotic resistance. Benzoyl peroxide kills bacteria through oxidation, a mechanism that bacteria cannot develop resistance to. When used together, these medications provide superior acne control while protecting the long-term effectiveness of antibiotics. Many combination products like Duac contain both clindamycin and benzoyl peroxide for convenient application.

Avoid Combining with Oral Antibiotics

Using both topical and oral antibiotics simultaneously is generally not recommended for acne treatment. This combination increases systemic antibiotic exposure without proportionally improving outcomes and significantly increases the risk of developing antibiotic-resistant bacteria. If your current treatment isn't working adequately, discuss with your healthcare provider about switching to different medication classes rather than adding more antibiotics.

Side Effects of Topical Antibiotics

Topical clindamycin is generally well-tolerated. Some people experience mild skin irritation, itching, or dryness at the application site. Allergic reactions are uncommon but possible. Long-term use can disrupt the normal bacterial balance on the skin, which is another reason to limit treatment duration and use in combination with benzoyl peroxide.

How Does Tretinoin Work in Combination Products?

Some acne medications combine tretinoin (vitamin A acid) with clindamycin. Tretinoin improves superficial skin cell growth, prevents pore blockage, and reduces sebum and comedone development, while clindamycin reduces bacteria. Do not use for more than 12 weeks at a time.

Tretinoin is the original topical retinoid, first introduced for acne treatment in the 1960s. As the acid form of vitamin A, it works by binding to retinoic acid receptors in skin cells, profoundly affecting how these cells develop, function, and shed. This normalization of the keratinization process prevents the accumulation of dead skin cells that would otherwise clog pores and form comedones.

When combined with the antibiotic clindamycin in products like Acnatac, tretinoin provides a dual-action approach to acne treatment. The retinoid addresses the comedonal component of acne by preventing pore blockages, while the antibiotic reduces bacterial populations and associated inflammation. This combination can be more effective than either ingredient alone for treating acne with both comedonal and inflammatory components.

Because tretinoin is more potent than adapalene, it often produces more significant initial irritation but may also provide stronger efficacy for stubborn acne. The 12-week treatment limit for combination products containing antibiotics helps prevent the development of antibiotic resistance while still allowing time for meaningful acne improvement.

Be Careful in the Sun

Tretinoin thins the outer layer of skin and makes it significantly more sensitive to sunlight. During treatment, strict sun protection is essential – use broad-spectrum SPF 30+ sunscreen daily, wear protective clothing, and avoid peak sun hours when possible. Sun exposure during tretinoin treatment increases the risk of sunburn and can worsen the hyperpigmentation that often follows acne lesions.

Do Not Use Tretinoin if Pregnant or Planning Pregnancy

Tretinoin and all retinoids are strictly contraindicated during pregnancy due to the risk of severe birth defects. Do not use tretinoin if you are pregnant, planning to become pregnant, or could become pregnant during treatment. You should also avoid tretinoin for at least one month before attempting to conceive. Reliable contraception is essential throughout treatment and for one month afterward.

Side Effects of Tretinoin

Common side effects include dry skin, redness, peeling, itching, and increased sun sensitivity. Some people experience skin darkening or lightening at the application site. A "retinoid dermatitis" with flaking and irritation is common initially but usually improves after 2-4 weeks of continued use. Starting with lower concentrations and less frequent application can help minimize these effects.

When Should I Consider Oral Acne Medications?

If topical treatments haven't improved your acne after three months of consistent use, oral medications may be needed. Common oral acne medications include tetracycline antibiotics, hormonal treatments (for women), and isotretinoin. These are prescription medications requiring medical supervision.

Oral acne medications become necessary when topical treatments alone cannot adequately control acne, or when acne is severe enough that topical therapy would be insufficient from the start. Oral medications work systemically throughout the body, allowing them to reach acne lesions from the inside and address factors that topical treatments cannot reach effectively. They're particularly important for preventing scarring in moderate to severe acne.

The decision to start oral treatment depends on multiple factors: the severity of your acne, whether you're developing scars, how well you've responded to previous treatments, and your individual circumstances including gender, age, and other health conditions. Your healthcare provider will evaluate these factors to recommend the most appropriate oral medication for your situation.

During oral treatment, many patients continue using topical medications to enhance results and, in the case of antibiotics, to help prevent resistance development. After completing a course of oral antibiotics, topical treatments can help maintain improvement and prevent acne recurrence. The exception is isotretinoin, which should not be combined with topical acne treatments.

How Do Oral Antibiotics (Tetracyclines) Treat Acne?

Tetracycline antibiotics reduce acne-causing bacteria and have anti-inflammatory effects. They typically take 1-3 months to show full effect, with treatment courses of 3-6 months being common. Do not reduce the dose or stop treatment early without consulting your doctor.

Tetracycline-class antibiotics, including doxycycline, minocycline, and lymecycline, are among the most commonly prescribed oral medications for moderate to severe inflammatory acne. These antibiotics work through two mechanisms: they directly inhibit the growth of Cutibacterium acnes bacteria, and they have intrinsic anti-inflammatory properties that reduce the redness and swelling of acne lesions independent of their antibacterial effects.

The anti-inflammatory action of tetracyclines is particularly valuable in acne treatment. These medications inhibit various inflammatory pathways and reduce the production of inflammatory chemicals that contribute to acne pathophysiology. This dual action explains why tetracyclines often provide improvement beyond what their antibacterial effects alone would predict.

Treatment with oral antibiotics requires patience, as significant improvement typically takes 6-8 weeks to become apparent, with continued improvement over 3-4 months. Courses are usually limited to 3-6 months to minimize the risk of antibiotic resistance and side effects. During oral antibiotic treatment, continuing topical benzoyl peroxide helps prevent bacterial resistance and improves outcomes.

Skin Can Become More Sun-Sensitive

Tetracycline antibiotics can cause photosensitivity, making your skin more susceptible to sunburn. This effect is more pronounced with doxycycline than with other tetracyclines. If you'll have significant sun exposure, such as a beach vacation or outdoor work, discuss timing with your doctor – you might start treatment in autumn or take a break during summer months. Use sun protection consistently during treatment.

Avoid Certain Medications

Take tetracyclines at least three hours apart from antacids, iron supplements, calcium supplements, and magnesium-containing products. These substances can bind to tetracyclines in the digestive tract, significantly reducing absorption and effectiveness. Be aware that many multivitamins contain these minerals. Do not take tetracyclines simultaneously with isotretinoin, as this combination can cause increased intracranial pressure with symptoms like severe headache, nausea, vomiting, and visual disturbances.

Side Effects of Tetracyclines

Tetracyclines can disrupt the normal bacterial flora in the gut, leading to gastrointestinal side effects. Common complaints include nausea, stomach pain, and diarrhea. Taking the medication with food (but not dairy) can reduce stomach upset. Women may develop vaginal yeast infections during treatment. Rare but serious side effects include esophageal ulceration (prevent by taking with plenty of water and remaining upright afterward) and, with minocycline, drug-induced lupus or hyperpigmentation.

Pregnancy Considerations

Tetracyclines should not be used during the second half of pregnancy. These antibiotics can be incorporated into developing bones and teeth, potentially causing permanent tooth discoloration (yellow-brown staining) and affecting skeletal development in the fetus. Women of childbearing potential should use effective contraception during treatment.

How Does Hormonal Treatment Help Acne?

Hormonal medications combining two different hormones can reduce acne in women by blocking the effects of androgens that trigger acne during puberty. These prescription medications also function as birth control pills. Treatment typically takes 3-4 months before acne improves significantly.

Hormonal acne treatments work by addressing one of the fundamental causes of acne: androgenic hormonal stimulation of sebaceous glands. Androgens (male hormones, present in both men and women) stimulate oil production in the skin, contributing to the oily skin and clogged pores that characterize acne. In women, hormonal treatments can block androgen effects on the skin, reducing oil production and improving acne.

The most common hormonal acne treatments are combined oral contraceptives containing both estrogen and progestin. The estrogen component increases sex hormone-binding globulin (SHBG), which binds circulating androgens and reduces their biological activity. Some progestins used in these pills, such as drospirenone and cyproterone acetate, also have anti-androgenic properties that directly block androgen effects on sebaceous glands.

Hormonal treatment is particularly effective for women with acne that worsens around their menstrual period, acne that started or worsened after stopping birth control, or acne accompanied by other signs of elevated androgens like irregular periods or excess hair growth. It can be used alone or in combination with topical treatments for enhanced effectiveness.

Also Provides Contraception

While hormonal acne medications shouldn't be used solely for contraception, they do provide effective birth control protection when taken correctly. If you're using hormonal acne treatment, you don't need to use additional hormonal contraceptives simultaneously – this would provide no additional benefit and could increase side effect risks. The pregnancy prevention is equivalent to standard birth control pills.

Not for Men

Hormonal acne treatments are not appropriate for men because they work by blocking androgen effects, which would cause feminizing side effects in males. Men with severe acne have other treatment options including isotretinoin.

Side Effects of Hormonal Treatment

Initial side effects can include breakthrough bleeding, nausea, headaches, and breast tenderness. These effects are usually mild and typically resolve within 2-4 months as the body adjusts. Some women experience weight changes, mood alterations, or decreased libido. Contact your doctor if you experience heavy or prolonged bleeding between periods. Serious but rare risks include blood clots, particularly in women who smoke, are obese, or have other risk factors.

What Is Isotretinoin and When Is It Used?

Isotretinoin is related to vitamin A and is used to treat severe scarring acne or acne that hasn't responded to other treatments. It reduces sebum production and makes skin drier. Despite potential side effects, it's used because of its exceptional effectiveness for severe acne. Treatment is managed by dermatologists and typically lasts about 6 months.

Isotretinoin (formerly sold under the brand name Accutane) is the most effective medication available for treating severe acne. It's a retinoid that works by dramatically reducing sebum production, normalizing skin cell development within hair follicles, reducing inflammation, and possibly affecting bacterial populations indirectly. These combined effects address all the major factors that cause acne, which explains isotretinoin's remarkable effectiveness.

The medication is typically reserved for severe nodular or cystic acne that risks scarring, or for acne that has failed to respond adequately to other treatments including oral antibiotics. Its effectiveness is striking: approximately 85% of patients experience long-term remission after a single course of treatment, meaning their acne doesn't return or is easily controlled with simple topical treatments afterward.

Because of its potential for serious side effects, isotretinoin is prescribed only by dermatologists or physicians with special experience in its use. Treatment requires regular monitoring with blood tests to check liver function and lipid levels, and strict pregnancy prevention measures are mandatory for women of childbearing potential due to the medication's teratogenic effects.

Avoid Certain Medications

Do not take isotretinoin simultaneously with tetracycline antibiotics. This combination can cause a dangerous condition called pseudotumor cerebri (increased intracranial pressure), with symptoms including severe headache, nausea, vomiting, and visual disturbances. Do not use any topical acne medications while taking isotretinoin, as they can worsen skin irritation without providing additional benefit.

Side Effects of Isotretinoin

Virtually all patients experience dry lips – keeping lip balm on hand is essential. Dry skin, dry eyes, and dry nasal passages are also very common. Some patients experience temporary worsening of acne during the first few weeks before improvement begins. Less common side effects include muscle and joint aches, mild hair thinning, and increased sensitivity to sunlight.

More serious but less common side effects can include changes in mood (though research is conflicting on whether isotretinoin causes depression), elevated blood lipids (cholesterol and triglycerides), and changes in liver function tests. Regular blood monitoring during treatment helps detect these changes early. Some patients experience night vision problems, which usually resolve after stopping the medication.

Do Not Use Isotretinoin if Pregnant or Could Become Pregnant

Isotretinoin causes severe birth defects affecting the brain, heart, and face when taken during pregnancy. There is no safe dose during pregnancy. Women who could become pregnant must use two forms of effective contraception beginning one month before starting isotretinoin, throughout treatment, and for one month after stopping. Pregnancy tests are required before starting treatment and monthly during treatment. In some countries, patients must register with monitoring programs (like iPLEDGE in the USA) that track compliance with these requirements.

When Should You See a Dermatologist for Acne?

See a dermatologist if your acne is severe with painful nodules or cysts, if over-the-counter treatments haven't worked after 6-8 weeks, if you're developing acne scars, if acne is significantly affecting your quality of life or mental health, or if you want to discuss prescription options like isotretinoin.

While mild acne often responds well to over-the-counter treatments and consistent skin care, there are several situations where professional dermatological care becomes important. Seeking treatment early for more severe acne can prevent permanent scarring and achieve faster, more effective results than self-treatment alone.

Dermatologists have access to the full range of acne treatments, including prescription-strength topical medications, oral antibiotics, hormonal treatments, and isotretinoin. They can also properly assess your acne type and severity, identify any underlying conditions that might be contributing to your acne, and develop a personalized treatment plan based on your specific situation and preferences.

Beyond prescribing medications, dermatologists can perform procedures that help with acne and acne scarring. These include comedone extraction, corticosteroid injections for large cysts, chemical peels, and various laser and light treatments. For acne scars, dermatologists offer treatments like microneedling, laser resurfacing, fillers, and subcision that can significantly improve skin texture and appearance.

Signs You Should See a Dermatologist

• Severe acne: Large, painful nodules or cysts that are deep under the skin
• Scarring: Your acne is leaving permanent marks or indentations
• Treatment failure: Over-the-counter products haven't helped after 6-8 weeks of consistent use
• Emotional impact: Acne is significantly affecting your self-esteem, social life, or mental health
• Adult-onset acne: You're developing acne for the first time as an adult
• Associated symptoms: Acne accompanied by irregular periods, unusual hair growth, or other hormonal symptoms
• Suspected rosacea: Your condition might be rosacea rather than acne