As if exam pressure, changing hormones, frenemies, relationship troubles and social networking nastiness isn't enough for a teen to deal with, many are also struggling with the age-old burden of teenage acne. Then there's the adults!

Acne isn't just a cosmetic disease; it can affect self-esteem and social interactions too. Ask anyone who suffered through acne-ridden teen years and they'll probably tell you there are no perks to being a wallflower. Successful treatment can improve a person's quality of life and their overall wellbeing.

But there are thousands of products that claim to fix acne, and just as many stories of failed treatments. CHOICE gives you a rundown of the different types of products available, how they work, which ones are most likely to work best, and how to look after acne-prone skin.

What is acne?

Everyone's skin produces sebum, an oily substance made by the sebaceous glands. Sebum moisturises your skin, and helps maintain a healthy bacterial population on the skin's surface.

During your teenage years, surges of the male hormone androgen (which girls have too) cause the skin to produce more sebum than usual, and the cells of the sebaceous follicles seem to get stickier. The sticky cells then block the skin's pores and the sebum can't get out.

If the blockage stays below the skin you get a whitehead. But when the sebum reaches the air, it turns dark and becomes a blackhead. The dark colouring isn't dirt, it's just the pigment in the sebum. Whiteheads and blackheads are called comedonal acne.

Sometimes bacteria, called Propionibacterium, get into the surrounding tissue, causing it to become inflamed. Inflammatory acne can be small red bumps (papules), white or yellow pus-filled pimples (pustules) or large red bumps (inflamed nodules).

What causes acne?

Around 90% of teenage boys and 80% of girls get acne to varying degrees. It typically starts just before puberty and mainly affects the face, upper back and chest. Acne usually becomes less of a problem after the age of 25.

Hormones aren't the only problem. Acne can also be caused or aggravated by oil-based cosmetics and some medications (for example steroids). And harsh cleansing or vigorous scrubbing won't help — in fact, if you wash and scrub too vigorously or use abrasive products, you'll irritate the skin and make the acne worse. There also seems to be a genetic link.

Despite the myths, acne isn't caused by junk food. Studies have found no connection between acne and chocolate, chips or pizza. However, researchers are currently investigating whether there's a link between acne and high glycaemic index (GI) foods, such as white bread and potatoes.

How to look after your skin

  • Wash your face twice a day with water and a mild soap or cleanser, and pat it dry.
  • Use oil-free or 'non-comedogenic' skin-care products and make-up.
  • Apply acne treatments all over the affected area, not just on the spots.
  • If you have acne on your back or chest, wear loose clothing.
  • Don't squeeze pimples or blackheads with your fingers.

The blackhead removal tool

Don't squeeze or pop pimples — it can damage the skin and cause infection and scarring when sebum, bacteria and shed skin cells are pushed into the surrounding tissue. Blackheads and pimples can be dealt with using a blackhead removal tool available from the pharmacy. Usually made from medical-grade stainless steel, the tool should feature a needle on one end and a thin loop of metal on the other. Follow the directions included with the device to ensure proper use.

Acne treatment

Many acne treatments contain an antibacterial agent called triclosan. Although it's good at killing surface bacteria (you'll also find it in some toothpastes and soaps), it won't reach the bacteria in your pores. In fact, a recent review of medical research found no evidence that triclosan's an effective acne treatment. That's bad news for anyone who's spent a lot of money on such products. 

The good news is that whether you suffer from occasional blackheads, troublesome pimples or severe inflammatory acne, there are plenty of products that will help.

Over-the-counter acne treatment

Anything you buy from a chemist or over the counter without a prescription will likely be a topical treatment that you apply directly to the affected area. Topical acne treatments come as creams, gels, ointments and washes.

  • One of the most effective ingredients is benzoyl peroxide. It's safe for use by adults and children and can be used during pregnancy. However, it can dry and irritate the skin. Products vary in concentration and accompanying ingredients, so you might need to experiment to find one that suits you.
  • Sulphur, salicylic acid, resorcinol and azelaic acid help unblock pores. Salicylic acid may dry the skin, but azelaic acid and resorcinol have no notable side effects. Sulphur, an old-fashioned remedy, can be unpleasant to use at higher, more effective concentrations.
  • Topical vitamin A, tea tree oil and zinc supplements may help relieve acne. There's no strong evidence that other claimed alternative remedies — such as echinacea, acupuncture, calendula or yoga — have any benefit.
  • Triclosan and cetrimide are antiseptics found in some acne treatments (especially washes) but there's no evidence that they work either.

There are a few things to consider when buying and using acne treatments:

  • Acne treatments won't get rid of existing pimples — rather, they help prevent new ones. This means it pays to continue using the treatment even when your skin's looking good, and spread it over the entire affected area, not just on existing spots.
  • Give it time. Acne treatments usually take a while to kick in (anything up to six to eight weeks), so if you give up too soon you won't know if they work.
  • What works for your friends may not work for you — and vice versa.
  • Your acne may have cleared up of its own accord, not because of the product you're using (especially if it miraculously clears up the next day). Obviously, if the treatment continues to be effective, that's a different story.
  • If you have a reaction to a particular product, it could be an allergy to one of the ingredients (such as the preservative used), an interaction with something else you're using or a result of overusing the product.

Prescribed acne treatment

If moderate or severe acne doesn't improve, it's worth seeing a doctor or a dermatologist. There's a range of effective oral and topical treatments they can prescribe — sometimes a combination of both may work best.
  • Topical creams and gels: The first choice for many will be topical retinoids, which includes tretinoin, isotretinoin and adapalene. These are widely regarded as the best external medication available to treat whiteheads and blackheads and prevent the formation of new ones. They're based on vitamin A and cause the skin to peel, unblocking your pores. They may not be safe for pregnant women.

    Retinoids can irritate the skin and increase its sensitivity to the sun, so you're usually advised to apply them at night. A sunscreen is also recommended — at least SPF 15+ and containing a physical blocker, such as titanium dioxide — to reduce the risk of UV damage and skin cancer. Gel-based sunscreens are probably best for people with acne, as creams might aggravate it. As well, keep out of the midday sun and avoid sunlamps and tanning beds.
  • Topical antibiotics: These work by reducing bacteria on the skin and in the pores. They're useful for mild to moderate inflammatory acne but may not be so effective on blackheads. However, overuse of antibiotics in general has led to the rise of antibiotic-resistant bacteria, causing a rethink on their role in acne treatment. Topical antibiotics include clindamycin and erythromycin. They may cause dry or scaly skin and erythromycin may also give an itching, stinging or burning feeling, but there are no other notable side effects.
  • Oral antibiotics: These are becoming very popular and work well for moderate acne, especially if you have inflamed and painful pimples. However, they're not a magic bullet. You should notice a marked decline in the severity of your acne, but it may not disappear altogether. Oral antibiotics include doxycycline, tetracycline and erythromycin.

    All oral antibiotics can cause stomach upsets, and some aren't suitable for pregnant women. Doxycycline can make people more sensitive to sunlight and easily sunburnt. Minocycline is also widely used, but it can have side effects including dizziness, light-headedness and vertigo.

    Antibiotics can fail, although it may be because they've not been taken as directed, rather than because of problems with the medicine itself. You need to follow the instructions carefully and keep going to the end of the course — even if your symptoms have disappeared, or you think they're never going to disappear. There's also the problem of the rise of antibiotic-resistant bacteria.
  • Hormonal treatment: One of the more common treatments for acne in girls and young women is oral contraception. Contraceptive pills decrease the effect of male hormones, which in turn means a decrease in the production of sebum. Effective for reducing acne are Diane-35 and Brenda-35, both of which contain cyproterone acetate and oestrogen. The former has an anti-androgenic effect, and is often used to treat problems caused by androgens, such as acne, hirsutism (excess hair growth) and female-pattern baldness.

    Other so-called second and third-generation contraceptives are also effective at reducing acne - ask your doctor about them. If you use oral contraceptives to treat acne, your doctor should explain the risk of blood clots - and cyproterone acetate may increase the risk more than some other contraceptive pills.
  • Isotretinoin: An anti-acne treatment with a very high success rate is oral isotretinoin (a retinoid). It's available only on prescription under the brand names Roaccutane, Oratane, Isohexal and Accure. Isotretinoin attacks all the contributing causes of acne. It reduces the amount of sebum made by the glands in your skin, reduces bacteria and inflammation, and opens clogged pores. But it can have serious side effects, including depression and birth defects. Isotretinoin should only be prescribed for people with severe acne.
  • Sometimes a combination of treatments works best. Some studies suggest that combining a topical antiseptic like benzoyl peroxide with an oral antibiotic can give better results than either used alone. Talk to your doctor.

The Roaccutane debate

Thousands of young Australians have used oral anti-acne drugs containing the active ingredient isotretinoin, such as Roaccutane. It's an effective treatment for severe acne and treatment failure is uncommon. The effects can last long after you stop taking the drug, but there can also be severe side effects.

Birth defects

Women who take the drug during pregnancy have a very high risk (30–40%) of serious birth defects in their baby. The main effects are on the heart, brain and ears. For this reason, doctors will want to rule out any possibility of pregnancy before treatment begins. Effective contraception should be used diligently during treatment and for one month before and after. Breastfeeding is also not advised while taking this drug.

Depression

The drug's been linked to serious depression and even suicide. The US Food and Drug Authority (FDA) revealed in 2000 it was receiving a growing number of reports of psychiatric side effects, including suicides, in patients taking the drug Accutane (the US version of Roaccutane). 

However, while it does happen, reported mood change associated with isotretinoin is relatively uncommon. Current medical estimates put it at 1–2% of patients. Doctors point out that it's difficult to determine whether the drug really is the cause because people with severe acne are more prone to depression, as are teenagers.

Over-prescribed?

Generally only dermatologists can prescribe isotretinoin. Although for some people it's the only solution to a debilitating medical and psychological problem, there's concern overseas that it's too often prescribed for mild and moderate acne that could be treated some other way.

More information

Treatment summary

Some big-name acne treatments don't contain effective active ingredients and won't be much help.

To control mild to moderate outbreaks of acne, first try a product containing benzoyl peroxide. For severe acne, consult your doctor or a dermatologist. A range of effective treatments is available, and a combination of prescription and non-prescription products may be your best bet.


Topical treatments

Try first
  • Benzoyl peroxide
May help
  • Azelaic acid 
  • Resorcinol 
  • Sulphur 
  • Salicylic acid 
  • Tea tree oil 
  • Topical vitamin A 
  • Zinc supplements 
Antiseptic cleansers (no good evidence of effectiveness)
  • Triclosan
  • Cetrimide
  • Chlorhexidine gluconate
  • Phenoxyisopropanol

Prescription acne treatments (if over-the-counter products don't help)

Topical retinoids
  • Tretinoin
  • Isotretinoin
  • Adapalene
Topical antibiotics
  • Clindamycin
  • Erythromycin
Oral antibiotics
  • Doxycycline
  • Tetracycline
  • Erythromycin
  • Minocycline
Hormonal treatment
  • Contraceptive pill
As a last result (for severe acne)
  • Oral isotretinoin

Please note: this information was current as of August 2004 but is still a useful guide today.