Will my acne return after I stop my acne medication?

One very common question we get in our daily practice is, does acne come back after oral medication?

We understand that this can be a worrying thought to some patients, especially as they think about how they have to battle acne all over again after having come so far to having it well-controlled with oral medication. Much research and scientific studies have been conducted in an attempt to answer this question, especially with regard to oral isotretinoin medication.

The relapse rates quoted in patients with acne after treatment with oral isotretinoin vary between 10% and 60%; this is highly dependent on the dosage regimen used during the acute phase of treatment, the duration of the acute phase of treatment, the length of follow-up, and the characteristics of the study population, such as severity of acne to begin with. 1 In general, an adequate cumulative dose of oral isotretinoin would be at least 120 mg/kg, the acute phase of treatment should on average be 6-9 months long, and the length of follow-up of around 2 years of completion of isotretinoin medication.

There have been a few factors that are suggested to be associated with a higher rate of acne relapse after completion of oral isotretinoin treatment. These include: male gender, young patients below 16 years of age or conversely females above 25 years old, a low cumulative dose of isotretinoin, excessive sebum production, truncal acne, conditions such as polycystic ovarian syndrome, smoking and the absence of a maintenance treatment regime after the completion of oral medication therapy. 2 Notably, most of the above factors cannot be controlled by the individual, except for smoking and the use of a maintenance treatment regime!

This brings us to the next point of the importance of a maintenance regime. Most studies suggest that a maintenance regime or protocol should be initiated after oral isotretinoin is stopped and continued for at least 1 year. Studies on oral antibiotics have also found a maintenance regime to be beneficial to prevent relapses. 3

Topical retinoids such as adapalene and topical benzoyl peroxide, used in combination, are some of the maintenance regimes that have been shown in studies to prevent relapses of acne, and may even help to continuously improve the skin over the next 6 months after discontinuation of isotretinoin. In one study, relapse occurred in only 3% of patients who were on a maintenance regime of topical retinoid and benzoyl peroxide gel.

In conclusion, do speak to your doctor regarding possible steps you can take to prevent an acne relapse after stopping your oral medication, including the use of a suitable maintenance regime. This will help you stay acne-free!

1 (Truchuelo et al. Acne Relapses and Maintenance Therapy: an Update on Definition and Prevention. Scientific Journal of Clinical Research in Dermatology 2017.)

2 (Morales-Cardona et al. Acne relapse rate and predictors of relapse following treatment with oral isotretinoin. Actas Dermosifiliogr 2013.)
3 (Poulin et al. A 6-month maintenance therapy with adapalene-benzoyl peroxide gel prevents relapse and continuously improves efficacy among patients with severe acne vulgaris: results of a randomized controlled trial. British Journal of Dermatology, 2011.)

Does my diet or dairy cause breakouts?

The current evidence regarding food affecting acne breakouts it still controversial. It is very difficult to study to the role of diet in acne.

Some studies, have found possible associations with low-glycemic, low-protein, low-fat and low-dairy diets with improvements in acne. These benefits are thought to be related to the diet’s effects on lowering insulin and insulin-like growth factor-1 (IFG 1). Insulin induces male hormones (androgens), glucocorticoids and growth factors. These can worsen acne by increasing keratinisation and sebum production. Most of these studies have been criticised for their quality, and their association is subject to many confounding factors.

Other studies have found weak associations with cow’s milk increased acne. This is hypothesised to be due to androgens, oestrogen, progesterone, and glucocorticoids in milk. These factors can also provoke keratinisation and increased sebum production. However, there is no strong evidence that milk, high-fat foods, or chocolate increases the risk of acne.

It is a good idea to have a healthy balanced diet with consumption of whole grains, fresh fruits, vegetables, fish, less red meat, and to moderate alcohol intake. Limiting consumption of high glycemic index foods such as sugar, biscuits, cakes, ice creams, and sugary drinks is also prudent. However, changing your diet does not always help with acne.

Always seek medical help early if you are concerned about your skin.

 

1Yosipovitch G et al. Study of Psychological Stress, Sebum Production and Acne Vulgaris in Adolescents Acta Derm Venereol 2007; 87: 135–139

What can I do during a sudden acne outbreak?

Sometimes, despite our best efforts, we may wake up to sudden red, angry-looking acne breakouts on our skin. The whole pathogenesis of acne is a complex interplay of factors as mentioned earlier, but here are some of the most common triggers of an acne breakout, and what to do during a sudden acne breakout.

Common acne triggers

Hormonal Acne

Acne by its very nature can be considered a hormonal disease. Hormones, particularly androgens, play a major role in acne formation. In women, acne may also be due to the fluctuation of hormones during the menstrual cycle, pregnancy or menopause. Hormones are responsible for the maturation of the oil glands in our skin and only once matured do these glands develop the capability of becoming acne lesions. This is also why children do not experience acne!

Stress

Stress affects the skin and acne through an increase in cortisol (stress hormone) and androgen production from the stress response. These are associated with a rise in sebum production and resulting formation of comedones. Sleep deprivation is also associated with higher circulating levels of stress hormones and the whole process as described above. Even those with dry skin experience this surge in oil production and hence, are not spared. Stress-related acne is a vicious cycle; when we stress about the acne, the whole cycle repeats!

On this note, it is a myth that exercise causes acne. In fact, exercise is known to reduce the levels of circulating stress hormones in the body, such as cortisol and adrenaline, and stimulate the production of endorphins (our body’s natural painkillers and mood elevators!). One just needs to take note to removal all traces of make-up before exercise, towel down with a clean towel during the work-out, and cleanse thoroughly after.

Reaction to Skincare

Cosmetics and skin-care products can trigger acne by clogging up the pores; excessive/unsuitable exfoliation products and devices can worsen comedones, cause bacteria to spread, and induce more inflammation (acne cosmetic and acne mechanica, as described above). In fact, data suggests that cosmetics trigger acne in as many as 60% of women.

There is no consensus on any “safe” makeup products, but regardless of brand, try to choose sheer or light coverage varieties which specifically claim to be non-comedogenic and are fragrance-free. Go bare when you can; but if you are applying makeup, try to use it sparingly.

What to do during an acne outbreak

We understand that a sudden acne breakout can be a stressful situation. Here are some tips on what and what not to do, should that happen.

Over-the-counter treatments

Very often, a short course of topical acne medication creams are useful for sudden breakouts. Benzoyl peroxide gel as a spot treatment is one of the most effective medications to kill bacteria and lessen inflammation. In Singapore, benzoyl peroxide is available in many different formulations, of which some are over-the-counter and easily available at drugstores and pharmacies.

Benzoyl peroxide is actually the only known substance which can bring oxygen under the skin surface. Since the P. acnes bacteria cannot survive in the presence of oxygen, when used in an adequate dosage, benzoyl peroxide eradicates 99.9% of these bacteria almost immediately. It also exerts a mild drying and peeling effect, which is thought to help prevent breakouts. Benzoyl peroxide also helps lessen inflammation. Studies have found that 2.5% benzoyl peroxide is just as effective as higher concentrations, but with less side effects.1

Taking some oral zinc supplements in doses of 30-50mg a day may help the acne lesions to heal faster as zinc helps heal wounds, is an anti-inflammatory agent and an antioxidant. It has been shown in some studies to help heal acne.2

Gentle icing on inflamed acne lesions such as cysts and nodules may also calm the skin down. Ice can reduce pain, swelling and redness. and those same principles apply for pimples. You may place one ice cube in a plastic bag and press it gently to the pimple for 5 minutes.

We generally do not recommend trying any new products or home remedies when having a sudden acne breakout to avoid the risk of causing more inflammation to the skin.

Proper Skincare

An acne cleanser, moisturizer and sunscreen will still be essential even when having a sudden breakout. Check out our article on  appropriate skincare regime for acne and acne-prone skin and the types of ingredients that are beneficial for treating and preventing future acne breakouts.

However, for very inflamed skin, exfoliation and toner may be omitted while the skin is healing. Also, for such skin, we advise washing your face with bare hands and avoiding the use of washcloths, or hand-held cleansing devices as these can cause unnecessary irritation to inflamed skin.

Seek medical opinion

Aside from topical benzoyl peroxide, other topical medications that may be initiated include topical salicylic acid (an exfoliating ingredient that unclogs the pores), topical retinoids such as differin and tretinoin (slows down the accumulation of skin cells inside the follicle that plug the pores, also has anti-inflammatory effects), and topical antibiotics (to kill P. acnes bacteria). However, these medications may have certain side effects and may not be suitable for everyone and/or all types of acne breakouts, so we recommend that you consult a doctor first before starting any of these on your own.

Your doctor will also be able to assess the severity of your breakout, and identify possible causes and triggers for your current sudden breakout. It is also important that your doctor rule out some other conditions that may seem like an acne breakout but may in fact be another different condition, such as folliculitis or rosacea.

Based on your diagnosis and severity, your doctor will be able to advise more on which topical medication is most suitable for you and whether you may need a period of oral medication to help with your acne breakout. In addition, your doctor will be able to provide more information on procedures that may be beneficial and used concurrently to more effectively target your current acne breakout. Some examples of procedures include chemical peels, light therapy, photodynamic therapy, and lasers.

Just a note on this, as we have been frequently asked on the efficacy of home-use light therapy devices: The American Academy of Dermatology issued the following statement in 2011 regarding the at-home light therapy devices: “While scientific research substantiates the effectiveness of in-office light treatments, there has been little research performed on many at-home light devices…many of the home-use devices are relatively underpowered and some are not approved for the indications for which they are marketed. Since it is unclear whether these devices are relatively effective or more akin to purchasing ‘hope,’ consumers should discuss their treatment options with a doctor to ensure the best results for their individual condition.

What NOT to do

In general, one should not “pop”, squeeze, scratch or touch acne lesions, as doing so inappropriately may increase your risks of post-inflammatory hyperpigmentation (PIH) and acne scars, which can be more difficult to treat than the acne itself!

Trying to pop papules (which usually progresses into pustules) can lead to even more issues. When you push and squeeze on a papule, the pressure could send the bacteria deeper into the skin. This makes the infection larger and last longer, which is what many articles mean when they say popping a pimple can make acne worse.

Also, unlike properly popping a pimple, scratching and picking can cause irritation, and when the skin is irritated, it produces more sebum. This sebum then clogs pores and leads to more acne.

  • Blackheads and whiteheads shouldn’t be popped at home, but should be extracted by trained therapists.
  • Cysts cannot be “popped” and should be treated at a doctor’s office, either through an incision and drainage procedure or a corticosteroid injection. Incision and drainage is a more sterile and controlled procedure. Never try to pop a cyst at home as it will likely lead to scarring and could spread infection.
  • The only pimples that should ever be “popped” are pustules – meaning the reddish bumps with a yellow or white centre. If you must do it, it is important to do it safely and effectively too. Here’s a video on how to pop your pimple safely (and properly)!

Unsure, or still have questions on what to do about your acne break out? Drop us an email and let us try to help you instead.

1Journal of Drugs in Dermatology; 2010
2Journal of the American Academy of Dermatology; 2010