Prescribed and Confused: Acne Edition

If you see a doctor for a skin concern, you often leave with 1-3 topical and/or oral prescriptions. Many skin conditions are chronic, so these medications may decrease the flare-ups but won’t cure the condition. If you don’t change what triggers the condition, you could end up taking these medications forever to ease the symptoms continually. Unfortunately, all medicines have side effects, so you likely don’t want to stay on them long and also understand the risks associated.

Too often, patients take prescribed medications for years without reassessing if they work for their specific ailment – or even knowing how they truly work. We asked our resident nurse practitioner, Becky, for her professional medical input on considerations to understand with these meds – i.e., to help us interpret the fine print. 

This is the Skin MPLS guide to the most common medications often prescribed for acne so you can understand what you got and why you might have been given it. Also, we want to help you understand the important finer details of the risks and side effects.

Oral Medications

Antibiotics (doxycycline, minocycline): Oral antibiotics are usually one of the first treatments given because they could be a helpful short-term fix. Antibiotics can help control both acne bacteria and inflammation. But acne bacteria is not the cause of acne; shedding too much dead skin is – so antibiotics don’t treat the root cause of acne. Luckily, severe short-term side effects are rare, but long-term use of antibiotics can cause some level of antibiotic resistance – which can lead to more significant health issues. However, antibiotics are hard on the gut and can interfere with other medications and treatments. 

The fine print: Today, antibiotics are given less frequently as more information on antibiotic resistance and the gut microbiome emerges. However, they still seem to be a bit too freely given for acne, even though they won’t fix the root issue and come with various concerning side effects including nausea, diarrhea, abdominal pain, and increased sun sensitivity. Using benzoyl peroxide topically is a better option without the side effects of ingesting antibiotics. Even if antibiotics work for you, you will struggle with skin and other issues when getting off them.

Combination Birth Control (Ortho Tri-Cyclen, etc.): Combination oral contraceptives may be prescribed for acne alone or with an antibiotic or androgen-blocker (more on that below) for acne. But if you are prescribed Isotretinoin (more on that below, too) and are female, you will be required to take birth control pills as well. Here’s our guide to birth control pills.

One of our hormones’ many functions is to trigger oil production, so your hormones directly affect acne because the formation of acne lesions requires oil (along with dead skin and bacteria). So, taking an estrogen-heavy birth control pill can help clear skin because it reduces the amount of testosterone in the body, and testosterone is one of the hormones that causes us to produce oil.

The fine print: It will usually take being on estrogen-dominant oral contraceptives over a month to see skin progress, and, for some, these pills may not affect acne. Additionally, acne can just come right back when women get off their birth control pills, and sometimes the acne may be even worse. Common side effects of birth control can include weight gain, nausea, mood swings, breast tenderness, and increased risk of cardiovascular problems, blood clots, breast cancer, and ovarian cancer. 

Spironolactone (Aldactone, Carospir): Spironolactone is used to control blood pressure, treat heart disease, and help regulate kidney disease and fluid production. It is a diuretic and prevents your body from absorbing salt. It may seem odd that a blood pressure medication is a go-to acne treatment, but this pill blocks the androgen hormone, testosterone, which can decrease oil production. Then, the hope is that you'll produce less acne if you produce less oil. However, that only removes one part of the equation required to form acne – we still have the dead skin and bacteria to address.

The fine print: This medication may save you a pimple here and there, but it alters many vital functions in your body, like blood pressure, blood sugar, hydration, and electrolyte balance. You aren’t even supposed to eat potassium-rich foods like bananas while on it because of the increased potassium it can cause you to make. Some unwanted side effects include but are not limited to, lightheadedness, hyperkalemia, painful periods, nausea, nervousness, and numbness in your hands. Dermatologists should do blood tests initially to make sure the patient doesn’t have kidney disease, and testing should be done regularly while on the medication.

Isostretanoin (Accutane): Isostretanoin is a high concentration of vitamin A taken orally that works by shutting down the oil production in your body and clearing away dead skin cells. It should be a last resort, meaning you have tried products, treatments, lifestyle changes, and sought a second and third opinion. Due to the toxicity and danger of side effects, it should be reserved for painful and disfiguring cystic lesions. This medication takes 3-5 months to begin working by drying out the skin and attempting to clear acne. However, since acne is a genetic issue, often acne just comes back once the prescription is finished.

The fine print: Lawsuits don’t stop this medication from being easily accessible. Isotretinoin’s common side effects are burning and chapped skin and lips, joint pain, eye inflammation, nose bleeds, and skin infections. Potential less common side effects can be suicidal thoughts. If you want to know the severity of this medication, just google the side effects. Monthly labs must be done to make sure the toxicity in the drug is not affecting the liver. Women must take birth control pills plus one other form of birth control because if a woman gets pregnant while on this medication, there is a 100% chance of congenital disabilities.

Topical Medications

Tretinoin Cream or Gel (Altreno, Atralin, Avita, Refissa, Renova, Retin-A, Tretin-X): Tretinoin is the topical use of vitamin A, which clears out the pores and promotes cell turnover. Dead skin and oil in the pores are two major acne culprits, so tretinoin gel can help treat that. The cream should be used for sun damage and anti-aging concerns, like wrinkles. Tretinoin will cause skin and sun sensitivity and may help treat conditions but will not erase them.

Fun fact: Dr. Fulton (Vivant Skincare founder) co-developed Retin-A (the original form of Tretinoin) in 1969. It was groundbreaking acne treatment technology but was very difficult for patients to use because it was so strong. In the coming years, he worked to make a topical vitamin A formula that acne sufferers could better tolerate that was just as effective and patented it. You can find it in Derm-A-Renew, Derm-A-Gel, Exfol-A, Exfol-A Forte, Clear Body Therapy, Triple Repair Complex, and Biointensive GF.

The fine print: This form of strong topical can be difficult to combine with other active skincare products and treatments. If using Tretinoin, you will feel dry and irritated. Adding more moisture is very important, and it’s very easy to get sunburned while using Tretinoin. It’s important to use Tretinoin regularly to see results, so if it is too uncomfortable to use on the skin daily – you may want to look for a more sustainable treatment. Tretinoin creams have pore-cloggers in them, so if they have been prescribed to treat acne, they may just exacerbate the problem. Tretinoin can also lighten the skin and cause long-term or even permanent damage to deeper skin tones. 

Clindamycin Gel (Cleocin T, Clindacin ETZ, Clindacin P, Clindacin Pac, Clinda-Derm, Clindagel, ClindaMax, ClindaReach, Clindets, Evoclin, Z-Clinz): Topical Clindamycin has many forms including creams, gels, foams, pads, and lotions. It belongs to the antibiotic family. It’s most commonly used for controlling acne-causing bacteria but can be used for other skin conditions as well. It will usually be prescribed with other oral and topical medications.  

The fine print: While there aren’t many concerns with topical antibiotics, they can still cause antibiotic resistance. Additionally, they can kill the good bacteria on your skin – disrupting the balance and leading to dryness, redness, and premature aging. Antibiotics should be a short-term treatment and may not work well with other skincare and treatments. If your acne hasn’t improved after four weeks of using topical clindamycin, discontinue use and look for a better treatment. 

Erythromycin Gel (ATS, Akne-Mycin, Emcin, Emgel, Ery, Erycette, Eryderm, Erygel, Theramycin Z): Erythromycin is an antibiotic that can help control acne when used topically. In 1970, Dr. Fulton (creator of Vivant Skincare) developed the usage of topical erythromycin after seeing that oral antibiotics were minimally effective with many unwanted side effects. Dr. Fulton discovered applying these antibiotics topically to the pore gave it a better shot of reaching the skin. 

The fine print: Skin irritation is a common side effect, and by applying antibiotics topically you greatly minimize the risks. However, antibiotics are powerful and should only be used for as long as needed. Back  In 1970, Erythromycin gel improved the acne treatment field, but now in 2024, there are even more long-term ways to clear the skin.

Adapalene (Differin, Plixda): Adapalene is a retinoid, like Tretinoin, that is used specifically for clearing the pores versus concerns of aging or discoloration. Adapalene speeds up your cell turnover time, meaning less dead skin to plug the pores. Adapalene has been shown to be better tolerated than Tretinoin, making it easier to use. Also, it is now available over the counter. 

The fine print: While Adapalene might be less irritating than Tretinoin, it can still be too harsh for the skin – especially when not used correctly. Adapalene can increase the risk of sunburn. It should not be used during pregnancy.

Epiduo (Epiduo, Epiduo Forte): Epiduo combines Adapalene (see above) and benzoyl peroxide. Benzoyl peroxide is a popular and effective antibacterial and keratolytic acne treatment available over the counter and in professional skincare. Combining adapalene with benzoyl peroxide further increases cell turnover and kills acne bacteria. Common side effects are itching, burning, and skin rashes. It may take months of use to see results, and results may be minimal if you are not targeting other acne triggers.

The fine print: There are no significant side effects with Epiduo usage. It combines two strong topicals, so it can be difficult to adapt to and use regularly, which can impede results. It commonly causes warmth and irritation to the skin. While Epiduo may treat acne, it will not treat other skin conditions like dry skin, dull skin, or uneven pigmentation.

Azelaic Acid (Azelex, Finacea, Finacea Plus): Azelaic acid is used to treat mild to moderate acne by killing acne bacteria. It is not the first line of defense but is often used when a patient is pregnant as a safer option. It is found naturally in wheat but is synthetically made. It can help increase cell turnover and help with conditions like melasma and rosacea by brightening skin pigment, killing bacteria, and reducing inflammation.

The fine print: Fortunately, there are not many concerning side effects with azelaic acid, and it’s even pregnancy-safe. Unfortunately, due to its more gentle nature, patients do not always see enough desired results.