From occasional breakouts in the teenage years to chronic, ongoing battles that last clear into adulthood, acne is one of the most common -- if not the most frustrating -- of all skin conditions.
And while there have always been a variety of treatment options available, more recently some have been a cause for concern.
Indeed, the popular treatment Accutane was always linked to an increased risk of birth defects. And it has also received media attention when researchers began debating whether it might also increase the risk of suicide in young users.
Antibiotics and Topicals
Long-term oral antibiotic treatments -- once a mainstay of acne care -- also hit the headlines, implicated in everything from encouraging drug resistance to escalating the risk of breast cancer to increasing respiratory infections in teens.
Topicals had their share of problems, as patients continued to report that otherwise effective treatments like Retin A (retinoic acid) were causing skin inflammation, in many instances as bad or worse than the acne itself. And while certain oral contraceptives helped many women clear their skin, some became concerned about side effects, including an increased risk of blood clots, particularly in smokers.
"The treatments that we had, worked. And most worked well. But many patients began looking for options that were either safer or more convenient to use," says David Goldberg, MD, director of Skin and Laser Surgery Specialists of New York and New Jersey. He is also director of the Laser Research and Mohs Surgery Center at The Mount Sinai School of Medicine in New York City.
Fortunately, some new options have come on board. But are they any better -- or any safer -- than what we had in the past? WebMD asked experts to help us investigate.
What Causes Acne
According to the American Academy of Dermatology, acne develops when hormonal shifts (like the kind that occur during puberty, and in women, before a menstrual cycle and sometimes prior to menopause) cause an overproduction of oil and cells inside a skin follicle. Together, they form a kind of biological traffic jam that plugs the opening of the pore and causes the follicle beneath to swell.
This allows for the overgrowth of bacteria found normally on skin -- Propionibacterium acnes (P. acnes) -- producing irritating chemical substances, which further fuel the inflammation. The end result is acne.
"It can be characterized by anything from whiteheads and blackheads, to tiny hard pimples you barely see, to pus-filled nodules, even fluid-filled cysts with roots deep in the skin," says Sumayah Jamal, MD, PhD, an assistant professor of dermatology and microbiology at the NYU Medical Center in New York City.
'Gold Standard' vs. New Treatments
For decades, doctors have said the "gold standard" for treating mild to moderate acne has been a combination of a deep pore cleanser like benzoyl peroxide (it attacks excess oil) and a topical antibiotic or sulphur drug to combat the bacteria. For some patients, treatment also included the topical prescription medication Retin A to help speed clearing. And it's a combination that is still in use today.
"If a patient has mild to moderate acne, this is still frequently my first recommended treatment. It's the easiest and the most economical, and it works very well for many people," says Jamal.
But while it works well, it can dry and irritate skin. And it was this very complaint that became the impetus for developing one of the first "boutique" acne treatments -- an over-the-counter product known as ProActiv Solution.
Blanketing the nation with celebrity-packed infomercials, product inserts, and direct mail ads, it fast became one of the most popular private-label acne treatments around. But what's in it -- and does it really work?
"It contains a much lower percentage of benzoyl peroxide, in a vehicle that isn't as drying as most prescription medications. And that frequently makes compliance better; so in that respect, yes, it can work better for some people," says Jamal.
Patients' Views
That said, Jamal tells WebMD that pretty much every patient she sees has either used ProActiv, or is currently using it, and is dissatisfied with results.
"I think the problem is that it works initially, but then stops working. At least that's what most of my patients report," says Jamal.
Goldberg agrees. He reports that most of his patients have also tried and failed on ProActiv.
"I think there's a point where it stops working. But to be fair, I think there are probably millions of people for whom the level of effectiveness it achieves is more than enough, just as there are some for whom it's not enough and professional treatment is needed," he says.
The High Price of Treatment
The cost of ProActiv is about $40 for the three-piece starter supply -- about 30 to 60 days worth of treatments, depending on the condition of your skin.
If you aren't overly sensitive to benzyl peroxide, other over-the-counter preparations like Oxy Balance (a 5% solution) and Oxy Maximum (a stronger 10% solution) sell for about $5 for a 30- to 60-day supply. Alternately, Neutrogena's On The Spot Acne Treatment contains the milder 2.5% benzoyl peroxide solution in a preparation closer to ProActiv, and it sells for about $6 for a 30- to 60-day supply.
More recently, another over-the-counter treatment emerged known as Nicomide-T. A topical preparation in cream or gel form, it is derived from vitamin B. In clinical trials of 1,000 patients conducted by the manufacturer it was shown to reduce redness and inflammation not only associated with acne, but also many acne treatments -- like Retin A. In other studies conducted by the manufacturer it was found to be more effective than the topical antibiotic treatment clindamycin. Independent studies found it to be equally as effective as clindamycin "without concerns over bacterial resistance," according to research published in the Journal of Dermatological Treatment.
Still, some doctors say it works best only on mild acne.
"I've used the oral form of this treatment and not had great results. It seems limited to treating mild acne," says Jamal.
Nicomide-T sells for about $40 for a 30-gram tube -- a 30- to 60-day supply.
Zapping Pimples Away
The newest over-the-counter acne treatment is not a cream or lotion, but a device -- a tiny electronic pimple "zapper" with the high-tech name of "Zeno."
Recently cleared by the FDA, Zeno resembles a tiny cell phone or a large cigarette lighter. It purportedly works by supplying a small amount of controlled heat directly to the acne lesion for two to three minutes, causing the bacteria to self-destruct and ultimately the pimple to clear.
According to the manufacturer, most zits require a single treatment and are completely gone in just hours. Others, they say, may require up to three treatments in 24 hours to see results.
It sounds impressive, but does it work?
"If the lesion is not too large -- and not too severely inflamed -- it can work. But it's not for widespread acne, or moderate to severe breakouts," says Jamal. She says it's best for the occasional pimple and perfect for zit-phobes who want to keep their skin blemish-free without having to run to the dermatologist every week.
Goldberg agrees that it can work, but recommends it only for those with mild, occasional breakouts. "This is not the treatment you want to use for moderate to severe acne," says Goldberg.
The Zeno device sells for about $215, and the company offers a free 30-day trial.
New Laser Treatments
But what if your acne is causing more than just an occasional pimple? Then you may be a candidate for one of several new laser treatments -- professional medical procedures that use laser light to heat up and destroy bacteria, as well as shut down excess oil production.
"One type of laser works to inhibit the growth of 'bugs' -- the bacteria that cause acne; the second type shrinks the oil glands and has an 'Accutane-like' effect, but without the side effects," says Goldberg. Both lasers also have antiaging benefits including encouraging collagen production, making it an excellent treatment for midlife acne.
Although treatment is pretty much painless, it is expensive, costing between $500 and $800 per session, with at least five to seven treatments necessary to see results. Moreover, those results are frequently not permanent.
"The laser that works on the bugs, usually requires five or six treatments, which may need to be repeated in about two months; the lasers that work on the oil glands have a longer-lasting effect, but flare-ups do generally occur again within six months to a year," Goldberg tells WebMD.
He also adds that laser treatments frequently work better after microdermabrasion -- a treatment that helps loosen skin cells and open pores.
Jamal says because they are so costly, lasers should only be used when topical antibiotic preparations aren't enough.
"The lasers don't do a better job than the topical treatments, and they are more expensive. I use them only as an adjunct, when the topicals alone don't work, or to treat large areas such as the back," she says.
New Light Treatment
Shedding yet more new light on acne care is "Photo Dynamic Therapy", a treatment involving either a pulsed light source or a laser, in combination with a topical preparation known as Levulan. This therapy is approved for use in treating a precancerous skin condition associated with sun damage.
According to Bruce Katz, MD, one of the pioneers of this procedure, it has turned into a powerful one-two punch that not only clears acne lesions, but may be one of the first treatments to offer permanent results.
"So far, we are experiencing three years of clear skin. And it may be longer, but three years is the longest study we have thus far," says Katz, director of the JUVA Skin and Laser Center in New York City.
Katz tells WebMD the treatment kicks in when the light source activates properties in the Levulan that both destroy the bacteria and shrink the oil gland, returning production back to normal.
"If the long-term results studies prove to be true then this is indeed an excellent advance that may work well for patients not wishing to take Accutane," says Jamal.
Goldberg says the treatment is effective, but it can be problematic if patients do not follow the treatment with sunblock or stay out of the sun.
"Sunblock must be on for at least 24 hours after treatment and direct and indirect sun exposure must be avoided," he says.
And, yes, it too is expensive. Treatment is rendered every two weeks for up to 12 weeks -- at a cost of between $500 and $800 per session. Because skin is extremely sun-sensitive for 24 to 48 hours after each treatment, doctors recommend wearing a superstrong sunblock.
But you are getting a bit more for your money: Katz says not only are the results likely to be very long lasting, the treatment also offers antiaging benefits.