OTCs
Mary Warner
cne vulgaris is a common inflammatory skin condition that occurs when hair follicles become plugged with skin cells and sebum. This mixture of sebum and cells can allow Cutibacterium acnes bacteria that live on the skin to grow in the plugged follicles, causing swelling, redness, pain, and the pimples most teenagers know well. Fortunately, several OTC medications are available to heal existing lesions, minimize new lesions, and prevent scarring.
Acne is most common in teens and young adults, although patients of all ages can develop acne. Interestingly, acne in teens is more common in males, while acne that continues into adulthood is more common in females. The increase in androgens during puberty causes the sebaceous glands to enlarge and produce more sebum, contributing to development of acne. Hormonal changes during pregnancy may also cause acne, as can some medications that contain hormones, corticosteroids, phenytoin, vitamin B12, or lithium. Research has also shown that genetics can contribute to acne prevalence; that is, if a patient’s parents had acne, their children are more likely to develop acne.
Acne treatment
Acne usually appears on the face, forehead, chest, upper back, and shoulders. Patients may develop one or more of the 6 common types of acne lesions in any of these areas.
- Whiteheads: White bumps under the skin caused by plugged hair follicles
- Blackheads: Open plugged follicles on the surface of the skin; they appear black because air discolors the sebum
- Papules: Small, inflamed pink lesions on the skin
- Pustules or pimples: Lesions filled with white or yellow pus
- Nodules: Large, painful solid lesions deep within the skin
- Severe nodular acne (cystic acne): Deep, painful, pus-filled lesions
For minor cases of acne consisting of whiteheads, blackheads, papules, and/or pimples, OTC medications are generally effective. Some products remove excess oil and dead skin cells, while others kill acne-causing bacteria. The most common active ingredients include benzoyl peroxide, salicylic acid, azelaic acid, adapalene, and α-hydroxy acids.
Benzoyl peroxide, which is available in OTC strengths of 2.5–10%, removes excess oil and dead skin cells and kills bacteria on the skin. Because it can cause dry skin, scaling, irritation, burning, and stinging, it’s best to start with a low-concentration form.
Salicylic acid products are available without a prescription in strengths of 0.5–2% strengths as leave-on and wash-off products. These products can clear both blackheads and whiteheads and also reduce the shedding of skin cells within the hair follicles. Possible adverse effects include mild stinging, skin discoloration, and minor skin irritation.
Azelaic acid products prevent pores from becoming clogged and are available in strengths up to 10%. These products can also minimize dark spots that can remain after acne clears (postinflammatory hyperpigmentation). Glycolic acid and lactic acid are the most common α-hydroxy acids used to treat acne by removing dead skin cells and calming inflamed skin while improving the appearance of acne scars.
The newest OTC treatment for acne is adapalene, a retinoid previously approved only for prescription use in patients 12 years or older. Approved by FDA in 2016, it treats acne by regulating the proliferation and differentiation of epidermal cells to keep pores from clogging. According to FDA, adapalene gel is for external use only and should be applied once daily in a thin layer on the affected skin. It should not be used on skin with cuts, abrasions, eczema, or sunburn, and patients should avoid contact with the eyes, lips, or mouth. Slight stinging is common upon application, and other adverse effects include dry or inflamed skin and scaling. As with all retinoid products, adapalene may take a few weeks to work, and patients should limit sunlight exposure and use sunscreen regularly.
More severe cases of acne, such as those that include nodules or cystic acne, may require prescription medications (e.g., tretinoin and isotretinoin). In 2020, FDA approved clascoterone, a first-in-class topical androgen receptor inhibitor for the topical treatment of acne in patients 12 years and older.
What to tell your patients
Advise patients to start treatment with the lowest strength topical treatment and to be sure to clean skin thoroughly at least twice a day. Avoiding environmental irritants, such as pollution and high humidity, can minimize breakouts. Patients should avoid rubbing or touching blemishes, which can cause scars or dark splotches to develop. Some studies show that diets high in carbohydrates, milk, saturated fats, and trans-fatty acids may contribute to development of acne, as can stress. Finally, advise patients to limit sun exposure and always use sunscreen. ■