Acne vulgaris treatment

What treatment has to fix

Acne vulgaris is the medical name for common acne. NIAMS describes how it forms: oil (sebum) and dead skin cells plug the hair follicle, bacteria that normally live on the skin grow in the plug, and the result is inflammation with swelling, redness and pain. The American Academy of Dermatology sets three goals for treatment: clear the acne you have, stop new breakouts and prevent scars.

Each ingredient works on a different part of that chain. A retinoid such as adapalene keeps pores from plugging. Benzoyl peroxide reduces the bacteria. Salicylic acid opens clogged pores. Azelaic acid unclogs pores, works on bacteria and calms inflammation. Hormonal treatments act on oil made under the influence of androgens. That is why most acne vulgaris treatment plans combine two or more of them.

Acne vulgaris treatment by acne type

Blackheads and whiteheads

Small plugs with no redness. An open pore with a dark top is a blackhead; a closed, skin-colored bump is a whitehead. Doctors call both comedones.Start with: adapalene, sold without a prescription, or salicylic acid.

Red pimples

Raised, tender bumps (papules), some with a white or yellow top (pustules). This is inflammation at work.Start with: benzoyl peroxide, beginning with a 2.5% product, as the AAD advises for adults. Adding adapalene helps if blackheads come along with them.

Deep nodules and cysts

Large, painful lumps that sit deep under the skin and can leave scars. Store products rarely reach them.Start with: a dermatologist. Options include isotretinoin for nodular acne that has not responded to other treatment and a corticosteroid shot to calm one big, painful lump.

Hormonal flares

Stubborn breakouts on the lower face, chin and jawline, or breakouts that come predictably with a period.Start with: the same skin treatments, then ask a doctor about spironolactone or a combined birth control pill (women only), or clascoterone cream, approved for people 12 and older.

Dark spots after acne

Flat red, pink, brown or gray marks where pimples used to be. They are leftover color, not active acne.Start with: daily sunscreen and azelaic acid or a retinoid, and keep treating the breakouts so new marks stop forming.

Acne vulgaris treatment by severity

Mild to moderate

Treatment you apply to the skin. NICE lists a fixed combination of adapalene with benzoyl peroxide, or tretinoin with clindamycin, as first-line options for any severity, and benzoyl peroxide with clindamycin for mild to moderate acne. When a topical antibiotic is part of the plan, the AAD says it is used together with benzoyl peroxide to lower the risk of antibiotic resistance.

Moderate to severe

The same topical base plus a pill for a limited time. NICE pairs adapalene with benzoyl peroxide, or azelaic acid, with an oral antibiotic such as doxycycline. The AAD says dermatologists prescribe an antibiotic for the shortest time needed, usually several months, together with benzoyl peroxide.

Severe nodular acne

Isotretinoin, which dermatologists prescribe for nodular acne that has not responded to other treatment. It must not be taken in pregnancy, and in the US it comes with a safety program and a follow-up visit every 30 days.

How to tell which type you have

Look in daylight and use your fingertips. Flat dots with no redness point to blackheads and whiteheads. Raised red bumps that feel sore point to inflamed pimples. A lump you feel more than see, that hurts when you press it, points to a nodule or cyst. Then think about timing: if flares line up with your cycle, a hormonal pattern is likely.

Most people have a mix, so treat the type you see most. If you can't tell which one dominates, an acne face scan from a clear photo is one way to get a first read before you buy anything, and a dermatologist can confirm it in person.

Some rashes only look like acne. The AAD names hidradenitis suppurativa, perioral dermatitis around the mouth and a skin infection called folliculitis as conditions that are often mistaken for acne and need different treatment.

How long acne vulgaris treatment takes

For an over-the-counter product, the AAD advises using it for 6 to 8 weeks before judging it, and expects fewer breakouts in 4 to 8 weeks and clearing at about 16 weeks. NICE reviews a first-line plan after a 12-week course. Spironolactone can reduce breakouts and oiliness within a few weeks, while the pill takes 2 to 3 months, according to the AAD.

Once skin is clear, NICE says ongoing treatment is not always needed, but it is worth considering if your acne has come back often after treatment in the past.

Starting the right treatment

1. Use one product first. Spread a thin layer over the whole area, not just the spots you can see.
2. Wait long enough. Give it 6 to 8 weeks before you decide it isn't working.
3. Add a second active only if needed. If you use benzoyl peroxide, the second product should contain a different acne-fighting ingredient.
4. See a dermatologist for cysts or nodules, for acne that hasn't cleared with products you can buy without a prescription, or for acne that is leaving marks.
5. Pregnant or trying? Talk to your doctor before you start, since several acne medicines, including isotretinoin and spironolactone, aren't safe in pregnancy.

Still unsure where your breakouts fit? Check your acne type from a photo, or go back to the full treatment comparison.