Over the counter acne medications: has anything changed?



There are two ingredients that you have probably seen listed as active ingredients of acne products at your local pharmacy are: benzoyl peroxide and salicylic acid. These two ingredients have dominated the market for years– here’s how they work:

  • Benzoyl Peroxide: Benzoyl peroxide unclogs skin pores by stopping bacteria from growing and causing an acne pimple. It acts as an antiseptic against Propionibacterium acnes, the bacteria that causes acne. In addition to killing bacteria, benzoyl peroxide makes some prescription antibiotics more effective in their fight against acne causing bacteria. Furthermore, benzoyl peroxide can prevent resistance from developing to antibiotics. Benzoyl peroxide is available in many forms: soap, lotion, cream, gel, liquid, pad and foam. Although it is available in strengths ranging from 2.5% to 10%, more is not always better!  Once you get above 5%, the benzoyl peroxide doesn’t work any better to kill bacteria, it just will make your skin more dry.  One caution with using benzoyl peroxide as it can bleach your towels or clothes so apply with caution!

  • Salicylic Acid: Salicylic acid has the ability to break down sebum that clogs pores. Because salicylic acid can unclog pores, it can help reduce blackheads and whiteheads. Salicylic acid does not reduce the acne causing bacteria. It is also available in many different forms and strengths over the counter. There are also chemical peels available to treat acne that contain salicylic acid.

Both benzoyl peroxide and salicylic acid are tried and true ingredients that can help clear acne. Recently, a new acne-fighter has been introduced to the pharmacy: Differin. Up until a few months ago, Differin was a prescription-only medication. It has recently been approved for over the counter use and has kept its original strength of 0.1%. This is a different mode of treating acne than benzoyl peroxide and salicylic acid, as it is a retinoid product. Retinoids are a form of vitamin A. They also reduce acne outbreaks by preventing dead skin cells from clogging pores. Talk to your dermatologist about which topical may be right for you.

Isotretinoin (Accutane®)

Isotretinoin, formerly known as Accutane, is the most effective medication for the treatment of severe acne. Other medications may or may not help severe acne or moderate versions that can be unresponsive, but isotretinoin is known to clear up most people’s acne. Around 80% of those who use isotretinoin are cured of their acne. Isotretinoin pills remain the most efficacious treatment for severe acne as well as many cases of more moderate acne that are unresponsive to other treatments.  Some other conditions such as rosacea and folliculitis may also be treated with isotretinoin.

Isotretinoin is a version of high dose vitamin A that blocks processes in the body that lead to acne, such as shrinking the skin’s oil glands, reducing acne-causing bacteria on the skin, and changing the way that you shed skin cells. One course of treatment takes about 5-7 months on average; the course of treatment can take less time or a bit more depending on the individual, as dermatologists tailor the treatment to each patient. It is a medication that is usually given after other acne medicines or oral antibiotics have been tried without successful treatment of breakouts. This is a medication that requires monitoring so monthly check ups with your dermatologist are required while on this medication.

What is Mohs surgery?

Mohs surgery is a specialized treatment for skincancer treatment on delicate skin areas or “high real estate areas” of the body like the face. Mohs surgeons are dermatologists who have performed additional fellowship training to become experts in Mohs micrographic surgery. Fellowship-trained Mohs surgeons are highly skilled in all aspects of this technique, including surgical removal of the tumor, pathologic examination of the tissue, and advanced reconstruction techniques of the skin.

It is a very precise, highly detailed method whereby the skin cancer is excised and then stained and examined under the microscope immediately. Repeated saucer-shaped layers of tissue are removed and examined until no more skin cancer can be microscopically visualized in the sample.

Mohs is scheduled with the understanding that the patient may be spending the entire day in the office depending on the number of levels necessary to clear the tumor. General anesthesia is not required for Mohs micrographic surgery. Most of these procedures are performed with the patient in the waiting room awaiting the verdict from the Mohs surgeon. The procedure uses frozen sections of skin that are then stained with special dyes. The dyed frozen pieces of skin are examined under the microscope and a tumor map showing the sites of any residual cancer cells is drawn by the Mohs surgeon. The process permits an examination of the entire tumor’s margins simultaneously while the patient is waiting in the office. If more cancer cells are seen under the microscope, tissue is removed at the site of involvement. Each skin layer that is removed is called a “level”. If no more cancer cells are seen at a particular level, then it is deemed “clear” (no more tumor) and the surgeon can begin on closing the excised area. Some tumors that appear small on clinical exam may have extensive invasion underneath normal appearing skin, resulting in a larger surgical defect than would be expected. It is therefore impossible to predict a final size until all surgery is complete. Cure rates typically exceed 99% for new cancers, and 95% for recurrent cancers.

By removing only tissue where cancer is known to be present, the technique combines a very high cure rate with excellent preservation of normal skin. Once the cancer has been fully removed, the surgeon will determine the type of repair for the best cosmetic result. The surgeon may refer patients to another physician for wound closure, may close the wound immediately, or may let the wound heal on its own.

Parabens in products

Parabens are used in pharmaceuticals and skin care products as antifungal agents. In fact, parabens are the most widely used preservatives in the cosmetics industry. They’re often used in makeup, hair care products, moisturizers and shaving products. There are several types of parabens, the most common being methylparaben, probylparaben and butylparaben. They are used to maintain the integrity of the product, as they protect against the growth of fungus and bacteria, and have been used in products since the 1950’s. Yet while they do lower the chance of you developing a skin infection from a compromised product, they can still be irritating to some people’s skin.

The controversy comes from when in the 1990s, parabens were found to be xenoestrogens ― agents that can mimic the body’s natural estrogen. Additional sources of exogenous estrogen has been linked to organ system toxicity, reproductive and fertility problems, birth and developmental defects, and hormone disruption. As a result, experts in many countries have recommended limits on paraben levels in cosmetic products. What’s more, watchdog organizations worry that if parabens can be stored in the body, over time they could have a cumulative effect and pose a health risk.

This remains controversial, as other studies have shown parabens to have a very weak estrogenic effect and it is unknown if cumulative effects could pose a health risk. Currently the USDA and WHO consider the chemicals safe at low levels, as the amount of parabens in any product is typically quite small.

There’s reason to be mindful, but no reason to have an all-consuming concern about these chemicals. If it helps you rest easy, use a paraben-free body lotion. Today there are a number of formulas available from paraben-free brands. Epionce® is a botanical based brand created by a board-certified dermatologist that is completely paraben free.