DIY Dermatology: Over-the-Counter Acne Treatment
As a Dermatology Physician Associate,
It’s not uncommon to open my phone and receive impromptu pictures of obscure body parts
from friends, or friends of friends -in my inbox. Mind you, I’m a mother of three, so when I’m off the clock, I’m usually driving the kiddos somewhere or out in public. I’d like to believe that this is why other parents are hesitant to get to know me (just kidding). In all seriousness, I find myself giving what we call “curbside consults” so often, that I felt the need to write this post.
So here we are, you, me, and your grandmother’s sister’s best friend’s son’s cousin’s daughter’s skin - and you’d like to know what non prescriptive products they should try out before paying a copayment at their local Dermatologist. I am so glad you asked for this help, because oftentimes, acne breakouts can be reduced by following a simple, reasonably priced, and accessible regimen with easy to find products.
The problem with writing a blog article like this lies in the fact that there are so many skin types, so many combinations of variables - that there is no cookbook recipe - no one size fits all, so if you’d like to schedule a 15-30 minute customized skin consult session, you can book here. Otherwise, I encourage you to read on, as I try to describe my initial simplistic approach to acne.
It’s important to first understand that there are four main causes of acne.
1.Excess oil (sebum) production.
this contributes to what I call 'non-exfoliative acne', which will be the main focus of this discussion. quite simply, when we produce too much oil, especially in the more oily skin types, our skin cells get gunked up and stick together. Skin cells are supposed to slough off and shed regularly, a healthy process called 'cellular turnover'. normal cellular turnover reveals smooth and bright skin. when skin cells clump together and do not exfoliate properly, they get stuck, and skin can look dull and even greasy. as a result of the backup, pores get clogged and acne lesions begin to develop.2. Hair follicles clogged by oil and dead skin cells
This also fits under my umbrella of 'non-exfoliative acne'. I consider this one in the same with cause #1 because oil glands are directly connected to the follicles. however, when follicles are involved (and we all have varying degrees of fine, vellus hair on our faces), well defined pustules are more likely to form. This can also contribute to the development of folliculitis which is a term that describes the condition of inflamed follicles. These look like white heads, though, if there's a white head present, it's not necessarily related to the follicle. But it certainly does provide your dermatologist with a context clue. On a related note, when I see what looks like 'non-exfoliative acne' on an area such as the forehead, near a hair line, I specifically ask my patients if they use any hair products such as gels, sprays, or conditioners. These products, as well as certain makeup and beauty product ingredients can also clog follicles and mimic the process of excess sebum production. This causes the skin cells to stick together. Regarding the hariline and forehead, we tend to sweat alot in this area, which is why individuals who wear headgear for sports, or hats to reduce sun exposure, more often than not do not know to routinely wash or wipe down their gear to reduce the next factor which contributes to acne:3. Bacteria
Propionibacterium acnes (P. acnes) thrives off of sebaceous matter. to put it simply, if your skin tends to be more on the oily side, this bacteria is a poster child for the microbiome's version of the keto diet. the more constant supply of food (oil and lipid byproducts) you have to P.Acnes, the more they will colonize the effected skin and make themselves right at home, irritating the lining of the follicle or pore, producing redness, as well as the final, and what I believe to be the most important factor:4. Inflammation
the other umbrella of acne that i delineate when customizing a treatment plan is "inflammatory acne." This is kind of a misnomer because i do feel that (after 13 years of dealing with all kinds of skin in clinic), inflammation is the common denominator in all kinds of acne. in an upcoming article, I will describe how you can have acne without the presence of excess sebum production, blocked pores or bacteria. inflammation - alone - is enough to cause acne.(1) the inflammation can be systemic, though more often, and in the case of non-exfoliative acne, it tends to be localized to the effected skin. The way this works is that inflammation damages the sebum. This lowers the oxygen concentration of the oil gland, which is ideal for p.Acnes, as it is an anaerobic (think non-oxygen breathing and metabolizing) bacteria. In other words, P.Acnes doesn't like o2. you can then make out the self-sustaining cycle of inflammation feeding the bacteria and the bacteria creating more inflammation - which becomes a merry-go-round. until...You Break The Cycle…
Without Breaking The Bank.
This is where some handy tools are needed in your skincare toolbox. Allow me to introduce my old friends, Salicylic Acid (Sally) , Benzoyl Peroxide (Benny), Adapalene (Ada), and the AHAs (an 80s pop band whose two main vocalists are Glycolic and Lactic acids).
Salicylic Acid
A first line, helper, “Sally” loosens up dead skin cells and works to gently exfoliate the skin. She breaks up oils and sebum byproducts and unclogs blocked pores. Salicylic acid also has a calming effect, reducing redness and inflammation. This is the same mechanism for the anti-inflammatory properties of aspirin. We can begin to picture how this becomes helpful with “non-exfoliative acne.”
Favorite OTC Products:
La Roche-Posay Effaclar Medicated Gel Cleanser, La Roche-Posay Effaclar Purifying Foaming Gel Cleanser for Oily Skin, and Murad Clarifying Cleanser.
Benzoyl Peroxide
The other first line acne fighter, Benny, possesses a “very particular set of skills”, making him the Liam Neeson of pimple fighting. These skills include the ability to disrupt the lifecycle and reproduction of acne by oxidizing and destroying vital bacterial cell components.(2) In other words, Benny (street name BPO) is a bactericidal ninja. He doesn’t stop there. BPO is dually effective as a sebum suppressor and a “pore unclogger,” reducing oil production and helping to exfoliate the skin. You can find him in different strengths, ranging from 2.5%, 5% and 10%, most commonly. I like to reserve BPO 10% for acne on the chest and back, or acne on the face that hasn’t responded to the weaker strength formulations. Richer complexions and darker skin types (Fitzpatrick Skin Types 3-6) should always start with the weaker formulations as these skin types are at an increased risk of hyperpigmentation (dark spots or patches). This occurs when the skin becomes inflamed from dryness and irritation.
Moreover, it’s important to be aware that BPO does bleach linens, clothing, and towels. This means, if you're washing your body with BPO in the shower, use a white towel or a towel which you do not care for when it’s time to dry off. BPO gels and creams can also bleach clothing and pillow cases, so put your clothes over your head before applying your skin care regimen, and choose a light colored pillowcase to avoid to the bleach tie-dye effect, unless that’s what you’re going for.
Favorite OTC Products:
Replenix Acne Wash + Aloe Vera, Replenix Benzoyl Peroxide Acne Gel Spot Treatment, and for more sensitive skin, PanOxyl Acne Creamy Wash, 4% and La Roche-Posay Effaclar Duo Acne Treatment
Ada (adapalene) and AHA are also helpful ingredients in any acne fighting regimen; however, I consider these second line, with the exception of
Alpha Hydroxy Acids
AHA, specifically Glycolic Acid which gets bumped to first place for my patients who want to combat acne and aging skin, simultaneously. Glycolic and Lactic Acids are known to gently exfoliate dead skin cells, revealing the renewed, fresh complexion beneath. While we tend to think of acids as irritants, when compounded in a ceramide rich moisturizer such as Glow & Show by Skin Mantra, alpha hydroxy acids actually promote hydration by breaking through the stratum corneum to nourish and hydrate the cells below. AHAs visibly improve skin texture, reduce visible signs of aging, and even skin tone, making them a favorite for individuals who cannot tolerate BPO or other topicals.
Favorite AHA Products:
Glow & Show by Skin Mantra, Replenix Gly-Sal 5-2 Pads, and Clear & Balance Wash by Skin Mantra
Adapalene
Lastly, if you’re looking for a retinol somewhere in this list, you’re not going to find one. Ask any effective Dermatologist. Retinols simply do not make the cut as worthwhile zit busting (or anti-aging for that matter) compounds. Retinoids, however, are a different story. I often liken retinols to the annoying little sister of retinoids. In part, this is because retinols ARE retinoids, just much weaker. The marketing claims tout retinol as supportive of skin cell proliferation, collagen boosting, and complexion transforming; however, in practice, it’s just not that impressive. Sorry, not sorry. I want results in a functional time frame. When I see it, I’ll believe it. And I’ve been waiting to see it for over 13 years and tens of thousands of faces. My opinion: retinol is just not worth the hype. However, when retinol grows up and turns into a retinoid, the over-exaggerated claims become more apparent in a reasonable time frame from a clinical perspective. The good news is that you no longer need a prescription to obtain a retinoid. While products like Retin-A, tazorac, Accutane, and tretinoin require clinical evaluation and prescriptions, adapalene, commonly known as ‘Differin’, is available over the counter. Adapalene is certainly a weak retinoid, but it’s a great starting point, especially for individuals with “non-exfoliative acne,” as it primarily increases cellular turnover and natural skin exfoliation and smoothing.
The rule of thumb with all retinoids is to start low and go slow. As much as we want to get results, we can position ourselves for a disappointing setback if we move too quickly. Adapalene comes in two strengths, 0.1% and 0.3%. The latter concentration is only available via prescription. In practice, I counsel retinoid virgin patients to apply their cream in a pea sized amount split among the five quadrants of the face. Initially, you’ll want to do this every other other night. I also recommend mixing with an oil free, non comedogenic moisturizer, to dilute the strength for the first couple weeks. Once you’ve done this for a few weeks and your skin isn’t giving you the “red light” (ie - redness, burning, itching, or flaking), you can increase the frequency of your regimen to every other night. Give your skin a few weeks to adjust, and then make adapalene part of your nightly routine.
Favorite OTC products:
La Roche-Posay Effaclar Adapalene Gel 0.1%, and Differin Acne Treatment Gel
It’s important to understand that effectively treating acne is all about BALANCE. The key, here, is that we never want to overdry the skin, because a vulnerable and irritated skin barrier is one that is susceptible to acne inciter #1: Inflammation. Remember that guy? Yeah, he sucks. To ensure he doesn’t come around, we have to refrain from scrubbing and burning the heck out of our skin (you think you’re going to kill the bacteria that way? Think again, now they’re just pissed and ready to feast.). Instead, we need to know when to pull back, and we need to keep products within reach to offset dryness and prevent us from stripping our skin of it’s natural protective and balanced barrier.
This is why I recommend Cetaphil Gentle Wash for nearly all skin conditions which have even the slightest component of inflammation. It’s a favorite for my Rosacea, Irritant Dermatitis, and Perioral Dermatitis patients as well. I like to incorporate this into the PM skincare routine for acne patients, particularly women who wear makeup, as this cleanser can be used as an effective makeup remover. It’s important to appreciate that you don’t need a lather or foam to get a deep clean. This product is so effective, you don’t even need to wash it off with water, though my personal preference is to do so, myself.
If skin is still dry and irritated, a moisturizing lotion / humectant is invaluable. Individuals with acne, in particular, need to become expert label readers. That is, we have to know how the ingredients we are putting on our skin function. To do this, we have to know the hidden comedogenic (pore blocking / skin cell sticking) offenders in skincare products. Most commonly these are variations of oils, emulsifiers, silicones, gums, and lipids. Without having to earn a PhD in Chemistry, you can begin by making sure the label says “oil free, non-comedogenic.” If it doesn’t and you’re still truly sold on a particular product, maybe your friend (who is not you and not wearing your skin… unless they’re Buffalo Bill… in which case, you might have bigger problems than acne), read the ingredient list and google the “comedogen rating” for each ingredient that sounds suspect. If that sounds like too much work, you can find my own skin soothing, acne-friendly moisturizer by Skin Mantra, here. Patients love it because it’s packed with nourishing, skin balancing antioxidants, and it’s lightweight, luxurious feel.
Now for the fun part… putting your tools to use.
Sample Regimen: AM:
1) Wash face with Salicylic Acid or Benzoyl Peroxide Wash
2) Spot treat with topical Benzoyl Peroxide, only applying to oily areas such as the T-Zone, or where pimples are present or commonly arise.
3) Finish with a Non-Comedogenic Sunscreen
PM:
1) Wash face with a Glycolic Wash, or if skin is getting irritated or sensitive, Cetaphil Gentle Wash
2) Treat the T-zone or active breakout with adapalene or glycolic moisturizer
3) If skin is showing signs of dryness or irritation, apply an oil-free, non comedogenic moisturizer
As you graduate from “Acne 101", I leave you with these final words of profound clinical wisdom:
To make your products work, you have to use them. As I tell all my patients, “If you don’t use your products, they’re not going to work.” You’d be surprised how many people believe that getting the pieces of the puzzle but not actually putting them together, not following a regimen is enough to earn them clear skin. Those #skingoals are something we all have to work for; however, armed with your newfound knowledge from this crash course, you can work smarter and not harder. The truth is, acne doesn’t have to make us feel so helpless. You really don’t need to text me impromptu pictures of your teacher’s friend’s veterinarian’s teenager’s skin. In fact, there’s a good chance you probably don’t need my help at all by now. If you’ve read this much, the power is in your hands. May this breakdown help you to build your understanding of the accessible and effective methods to get your skin back under control.
1) Tanghetti EA. The role of inflammation in the pathology of acne. J Clin Aesthet Dermatol. 2013 Sep;6(9):27-35. PMID: 24062871; PMCID: PMC3780801.
2) Boonchaya P, Rojhirunsakool S, Kamanamool N, Khunkhet S, Yooyongsatit S, Udompataikul M, Taweechotipatr M. Minimum Contact Time of 1.25%, 2.5%, 5%, and 10% Benzoyl Peroxide for a Bactericidal Effect Against Cutibacterium acnes. Clin Cosmet Investig Dermatol. 2022 Mar 10;15:403-409. doi: 10.2147/CCID.S359055. PMID: 35300432; PMCID: PMC8922035.
