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Module:3

Identifying Medications

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This module is all about different medications and treatments that are used to fight acne. In the first

section, you’ll learn about oral medications, with a particular focus on isotrenoin, oral antibiotics, and

birth control. Following on from that, we’ll explore topical medications and treatments, with sections on

creams, gels and oils, chemical peels, and other types of therapy. Next, you’ll learn about alternatives,

such as vitamins and other supplements. In the final section, you’ll discover the side effects of all the

treatments covered throughout the module, so you can weight the risks against the benefits of each

treatment.

3.1 Oral

3.2 Topical

3.3 Alternatives

3.4 Side effects

3.1 Oral

Many people who suffer from acne choose to take medication and treatment in an oral form. In this

section, we give you an overview of the oral medications available, and their features. You will learn

about any side effects in section 3.4.

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3.1.1 Isotretinoin

This drug was widely known by the name Accutane or Roaccutane which is a brand name, but is now

available as ‘isotretinoin’, though it is the same product. Isotretinoin contains a strong dosage of a

vitamin A derivative, which is taken for 15-20 weeks in pill form.

This treatment is most often prescribed for those who suffer from ‘severe nodular acne’, and will not be

prescribed until various other measures have been tried, such as oral antibiotics and topical creams.

Nodules are generally 5mm in diameter, and severely inflamed.

You will remember from Module 1 that acne occurs when excess sebum is produced by the oil

glands in the skin. The sebum mixes with dead skin and blocks the follicle, preventing oil from

flowing out, instead allowing the sebum to accumulate under the skin. Acne-related bacteria feed on

the sebum, and release fatty acids and waste products that irritate the oil glands and inflaming the

area under the skin. Isotretinoin reduces the size of the oil glands by 35-58%m and decreases the

activity of the oil glands, so that 80% less sebum is produced. This prevents the glands from

becoming blocked, and prevents bacteria from thriving. This leads to less inflammation in the skin.

When people begin to take isotretinoin, many find that their acne gets worse. This usually improves

after a week to 10 days of continuing the treatment. A single course of isotretinoin may be enough to

completely clear the skin of acne and prevent it reoccurring, with 95% of people seeing a strong

improvement in their acne. Up to 33% of patients will relapse, however. Repeat courses are not usually

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recommended, and should be started at least eight weeks after the first treatment. Overall, this drug has

a cure rate of 66%.

Taking isotretinoin varies from person to person, as the dose prescribed and how often it is to be taken

can be altered by a doctor. It is important to follow the instructions issued by the doctor. Isotretinoin

pills should be swallowed whole or on a full stomach.

Isotretinoin has serious side effects, particularly in pregnancy, and these are discussed in more detail in

section 3.4.

3.1.2 Oral antibiotics

There are a number of oral antibiotics on the market, which doctors might choose to prescribe to

someone suffering from acne. These include:

Cotrimoxazole, under the brand names of Deprim and Trisul

Erythromycin, under the brand names of E-mycin and ERA

Tetracyclines, under the brand names of Doxine, Doxy, Tetralysal, Mino-tabs and Minomycin

Trimethroprim, under the brand name of TMP

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Oral antibiotics work by helping to halt the growth of acne bacteria known as P. Acnes, and producing

an anti-inflammatory effect. About 50% of patients respond to antibiotics to some degree, though it is

rare that their acne is totally clear. Antibiotics seem to work better on mild to moderate cases of

acne.

These are in pill form, and usually taken once a day. They should only be taken for six months or

less.

3.1.3 Birth control

Birth control is another method often advised for women who want to clear their acne. Clinical trials

have illustrated that taking combination (estrogen and progesterone) pills, can result in less severe

acne, 30-60% fewer lesions, less inflammation, and fewer flare ups.

When high levels of androgens are produced by a woman’s ovaries and adrenal glands, this can

lead to too much sebum, which leads to acne. Birth control pills that contain both progesterone and

estrogen can lower the androgen levels in the body, thereby lessening sebum and acne.

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The FDA has approved three birth control pills for the treatment of moderate acne, for women who are

age 14-15 or above, need contraception, and have started menstruating. These are:

Estrostep

Ortho Tri-Cyclen

YAZ (though the FDA has advised that the form of progestin used, drospirenone, increases the risk

of blood clots. Other brands that include drospirenone include Zarah, Safyral, Syeda, Loryna,

Yasmin, Gianvi, Beyaz and Ocella.

In practice, doctors will prescribe a wider range of birth control products that have been shown to

improve acne, such Alesse and Yasmin, and will do so for mild to severe acne.

Women taking birth control pills for acne treatment may experience a flare up at the beginning of

treatment, and it may take a few months before the skin begins to clear.

As birth control pills only decrease sebum, other acne fighting treatments might be prescribed alongside

them. These can include topical medications and antibiotics. It is important to note that some antibiotics

can interfere with the oral contraceptive’s effectiveness, and could lead to pregnancy. For example,

antibiotic tetracycline can affect the effectiveness of some types of oral contraceptive.

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3.2 Topical

Topical treatments are for use on the skin. They may come in cream, gel or oil form. Other treatments

used on the skin include chemical peels, and various types of light and laser therapy. In this section,

you’ll learn about the features of various topical treatments.

3.2.1 Creams, gels and oils

Differin gel – This gel prevents skin cells shedding too fast inside the follicle, preventing pores from

becoming blocked. It also has an anti-inflammatory effect.

Azelex – This cream contains 20% active ingredient azelaic acid. This is a naturally occurring acid, found

in animal products and wholegrain cereals. It prevents the build up of cells that block pores. It also kills

acne bacteria, and has an anti-inflammatory effect.

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Benzoyl peroxide – This is available in cream, gel and wash form, both over-the-counter and by

prescription. Its main function is to bring oxygen under the surface of the skin. Bacteria cannot

survive in oxygen, and when benzoyl peroxide is used in the proper dosage, it eliminates 99.9% of

bacteria. Using benzoyl peroxide also has a mild peeling and drying effect, minimizing oil on the skin

and helping to prevent breakouts. It has anti-inflammatory effects.

Clindamycin – This is available in lotion, foam, solution or gel, and is a topical antibiotic. Applied

twice daily, it kills acne bacteria.

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Dapsone – This is a topical gel with 5% concentration, which is sold under the brand name Aczone. It

has anti-inflammatory, antioxidant and antibacterial properties. It has been found to reduce acne lesions

by 30-45%, and has been found as more effective in women.

Erythromycin – This comes in solutions, gels, ointments and packets. Often combined with products of

benzoyl peroxide, this is usually applied twice a day. It is an antibiotic which kills acne bacteria. It is

important to talk to a doctor about using this in conjunction with other medicines, or products such as

make up, perfumes or cleansers, as it may cause irritation.

Sodium sulfacetamide – This is an antibacterial product, used on the skin to stop the growth of acne

bacteria.

Tazarotene – This is a retinoid gel containing a derivative of vitamin A. This is applied to the skin

once per day, and is used for both acne and psoriasis. It reduces inflammation and prevents pores

from becoming clogged. It is effective, with a 50% reduction in lesions after 12 weeks.

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3.2.2 Chemical peels

Chemical peels are acids, applied to the skin around once every 14 days. This is done to exfoliate the skin

at its top layers. This signals for the cells inside the skin to produce more rapidly. This prevents pores

from becoming clogged, as it increases skin turnover.

A chemical peel can be administered by a doctor, or by an esthetician in a salon or spa. Doctors are

allowed to administer chemical peels with up to 70% strength, while estheticians can administer up to

30%.

Chemical peels are reasonably effective. Studies show that after four to six peels, acne lesions can be

reduced by 45-50% on average. These results last for one to two months.

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Laser therapy – Laser therapy is recommended for papules and pustules, rather than cysts, nodules,

whiteheads or blackheads. Doctors offer laser treatments, and often recommend three treatments at one

month intervals.

There are a variety of laser types doctors might use, including vacuum lasers, fractional lasers, diode

lasers, infrared lasers and pulsed dye lasers. These lasers are meant to excite compounds that live inside

acne bacteria, which are called porphyrins. When the lasers excite them, they damage the wall of the

bacteria, which kills the bacteria. This should reduce acne.

Though this has not been widely studied, results are promising, with an improvement between 36 to

83%. However, these results do not last long because the acne bacteria do not take long to grow back.

3.3 Alternatives

Many people also consider using alternatives, such as vitamins and supplements, to help them clear

their acne and get clear skin.

In this section, we’ll examine some of the common choices.

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3.3.1 Vitamins

Vitamin A – Retinoids, which are forms of retinol also known as preformed vitamin A, help release dead

skin, reduce the oil produced by the oil glands, suppress the production of androgen, and protect fats

from oxidation, which helps avoid inflammation. Retinoids are found in eggs, dairy products, liver and

animal foods, while carotenoids, another form of vitamin A are found in carrots, sweet potatoes, dark

green vegetables and orange and yellow fruits and vegetables. Unfortunately, the body absorbs vitamin

A from carotenoids at a low rate, so it is not enough to get vitamin A from vegetables.

Acne is an inflammatory condition, and the liver releases vitamin A to help rebalance the inflammation,

which can lead to vitamin A deficiency. People who suffer from acne may choose to take a vitamin A

supplement of between 5,000 IU per day (recommended on U.S. nutritional labels) and 10,000 IU per

day (though if vitamins D3 and K2 levels are low in the body, vitamin A toxicity is a potential problem

with this dosage).

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Getting vitamin A from food sources, such as livers of beef, lamb, chicken, goat, pork and fish, is

advised. A ¼ to ½ pound of animal liver once per week is sufficient, as vitamin A stores within the

body for when it is needed. An alternative source of retinol is fermented cod liver oil.

Alternatively, you might choose to take vitamin A supplements of 5000 IU.0

Vitamin E – Studies have shown that vitamin E supplements taken in oral form can help to relieve acne.

A study in 2006 of 100 acne sufferers found those with the worst acne had low levels of both vitamins A

and E. Supplementations of both these vitamins improved the acne by removing their deficiency.

15mg per day is the recommended amount, though this may vary according to age and gender. Women

who are pregnant and/or breastfeeding may require a different dosage.

In addition, make sure you get vitamin E through your diet. Foods rich in this vitamin include asparagus,

green leafy vegetables, and nuts, wheat germ, and seeds. Vegetable oils, olives and olive oil are also good

sources of vitamin E.

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3.3.2 Other supplements

Zinc– Zinc is known to decrease oil production in the oil glands, and also has antibacterial and anti-

inflammatory properties. The RDA for adults is a dose of 8-10mg. Some evidence says that 30mg is

a relatively safe dose and can assist in the treatment of acne.

Milk thistle – Milk contains two medicinal active ingredients, silymarin and silbinin. In 2012, a study

found that a group taking 210mg of silymarin from milk thistle had a decrease of 50% in acne lesions. It

is so effective because it boosts the natural antioxidant glutathione by 35-270%. This antioxidant

detoxifies the liver and can help with acne. However, milk thistle does have side effects, which are

explored in section 3.4.

Selenium – A study found that taking 200mcg of selenium per day could decrease acne lesions by 40%.

Selenium deficiency is common in acne sufferers, so taking a supplement can help boost selenium back

to optimal levels and prevent acne breakouts. Selenium also improves the efficiency of zinc, so they are

often taken together. Some people choose to take supplements, while others consume brazil nuts, which

contain high levels of selenium. It is important not to overdose on selenium, and we cover this in section

3.4.

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3.4 Side effects

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3.4.1 Side effects of isotrenoin

Upwards of 80% of patients on isotretinoin experience side effects. There are a huge range of side

effects that can be experienced when using this drug, ranging from mild to severe. Some of the most

common include:

Dry lips – 92% of users

Dry skin – 57% of users

Muscle pain – 15-50% of users

Joint pain – 15-30% of users

Lower back pain – 30% of users

Nosebleed – 30% of users

Neurological symptoms, such as dizziness, insomnia, lethargy, nervousness, tingling, numbness,

seizures, weakness – 16-29% of users

Headaches – 10-28% of users

Elevated liver enzymes – 15% of users

Overgrowth of bone – 10% of users

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Some rare, but more serious, side effects of isotretinoin include:

Acute, long lasting arthritis

Anemia

Life threatening blood disease

Depression

Long term hearing impairment

Low white blood cell count

Respiratory symptoms

Rapid breakdown of muscle tissue

Reduced blood flow to the brain

Severe allergy

Ulcerative collitis

It is important to remember that isotretinoin is the drug that causes the most birth defects in the USA.

If a woman is already pregnant, or if she gets pregnant while taking isotretinoin, there is an

extremely high risk that the infant will be deformed. It causes a developing fetus to suffer from

serious malformations as it grows. This is true even if she only takes a small amount of the drug for

a short time.

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To prevent this happening, there are strict rules, known as the Pregnancy Prevention Program, for

women who want to take isotretinoin:

One, or preferably two, methods of contraception must be used at all times to prevent pregnancy. This

contraception must be started at least four weeks before treatment begins, be used throughout

treatment, and until four weeks afterward.

Doctors are not allowed to prescribe the drug until this contraception has been used for at least a month

and a pregnancy test is taken, which must come back negative.

Doctors can only prescribe isotretinoin for 30 days.

Women must return to the doctor for a follow up visit every 30 days, and will be required to take

another pregnancy test before prescription can be continued.

While using the medicine, neither men nor women should donate blood.

Five weeks after treatment is finished, another pregnancy test must be taken.

All unused medicine must be returned to the pharmacist when treatment is finished.

There is no evidence to indicate that men who take this medicine should not father children during

this time. There does not appear to be a connection between a father taking isotrenoin and a fetus

becoming deformed.

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3.4.2 Side effects of oral antibiotics

Some common side effects of oral antibiotics include upset to the digestive system and discoloration of

the teeth. The yellowing of the teeth is particularly prevalent with tetracycline use, along with an effect

on bone formation. For this reason, tetracycline is not recommended to be prescribed to children under

14 or to pregnant women.

The antibiotic minocycline is associated with more serious effects such as irreversible

hyperpigmentation, autoimmune liver damage and autimmune disease lupus erythematosus. In this

condition, the immune system becomes hyperactive and begins to attack healthy body tissue.

3.4.3 Side effects of birth control

Women taking oral contraceptives have a higher risk of blood clots, particularly in the leg and lungs,

heart attacks, and strokes. Other potential side effects include high blood pressure, gallbladder and

liver disease, depression, and migraine headaches. Less serious side effects include mild

headaches, breast tenderness, temporary acne flare ups and breakthrough bleeding.

Women with the following conditions or family health histories are advised against taking oral

contraceptives:

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Those with a history of heart disease

Those with a history of hypertension

A blood clotting disorder or previous blood clots in the lungs or the legs

A history of uterine, breast or liver cancer

Migraine headaches

Liver disease

Diabetes

Obesity

Smokers aged over 35

Pregnant or breastfeeding

3.4.3 Side effects of topical treatments

Topical gels, creams, oils, washes - Potential side effects of topical gels, creams and washes include

more sensitivity to sunlight, redness, drying, burning, itchiness, scaling, stinging and tingling. It is

important that people with dark complexions are careful with the use of Azelax (azelaic acid). This is

because lightening of the skin has been reported, and the treatment has not been studied enough in

people with darker complexions.

Benzoyl peroxide – Itchiness, redness and dryness is expected in the first few weeks of using the

product. This is known as the ‘hardening effect’ and is normal. However, 1-3% of people have an allergic

reaction to benzoyl peroxide, which can manifest in severe crusting or inflammation of the skin. These

people should discontinue use. Benzoyl peroxide might also have a bleaching effect on fabric and hair.

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Clindamycin – Along with skin irritation, inflammation of the colon, diarrhoea, and bloody diarrhoea

have been reported with use of this product.

Chemical peels– In the days after the first peel, most people take on a sub burnt look with redness and

peeling. This is consistent after every peel, but is less severe each time. Some people with dark

complexions have experienced skin lightening which could be permanent, while lighter skinned people

have reported their skin tone darkening. People who are prone to keloid scarring need to consult a

dermatologist before getting a chemical peel, to find out how it might affect them. After a chemical peel,

the skin is more sensitive to sunlight.

Sodium sulfacetamide – Some people can have a severe reaction to sulfonamides, which can result in

death. This is very rare.

Tazarotene – This should not be used by pregnant women, as it may cause harm to the fetus.

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Photodynamic therapy – Pain is felt during treatment, and this can be severe. A week or so after

treatment, side effects such as redness, itching, peeling, crusting and swelling might be

experienced. Many people prefer not to leave their homes for several days after receiving the

therapy. Patients are not permitted to go in the sun for two days after treatment, because the skin is

extremely sensitive to light.

Laser therapy – Pain or discomfort during laser therapy is common. Some people experience

crusting, blistering, inflammation and/or redness after treatment.

3.4.3 Side effects of alternatives

Vitamin A – If you decide to take retinol as a pill, only do so under the careful supervision of a doctor.

Vitamin A overdose can lead to toxicity, which is a very serious medical matter. Vitamin A is stored in

the liver, but when there is too much vitamin A coming in for the liver to store, some of the storage cells

burst and release vitamin A into the blood stream. This can cause birth defects and miscarriages for

pregnant women, abnormalities in the liver, and osteoporosis. If vitamin A toxicity is severe or long

term, this could lead to coma or death.

Zinc – Excessive zinc can lead to a copper deficiency. Zinc toxicity can cause vomiting, diarrhoea,

headaches, loss of appetite, abdominal cramping and nausea. In the long term, it may cause kidney

failure and urinary tract infections.

Milk thistle – Side effects of milk thistle can include loss of appetite, nausea, abdominal cramping

and bloating. Insomnia is another frequently reported side effect, as well as changes in libido.

Selenium – Overdosing on selenium (taking over 400mcg a day) can lead to discoloration of the

skin, baldness, tooth decay, mental fatigue, and weak hair, nails and skin. In addition, excessive

selenium can disrupt the healing process of acne, because it slows down the formation of collagen.