The Skin After Acne: Focus on Calming and Repair
Most patients will always remain acne-prone, but the right interventions can keep their skin healthy.
Adult acne is a disease of its own. Certainly some adults have acne that has lingered since adolescence, (and it seems that this is more likely in women than in men). Even in those cases, however, the disease seems to evolve. But many adult women will develop either new onset acne in adulthood or a recurrence of acne that had previously waned. Teenage acne is often manifested with comedones, new onset oil production, and inflammatory lesions in the mid-face (or “T-zone”), but adult acne is frequently more inflammatory or cystic and involves the chin and lateral jawline. In general, adult acne behaves and responds to treatments differently than teenage acne does. In a majority of adult females, the presentation of acne is stimulated by hormonal fluctuations, dietary influences, and stress.
Acne in Control
The majority of widely marketed products sold over the counter to manage acne contain salicylic acid and/or benzoyl peroxide, which tend to provide minimal efficacy for adult acne. Additionally, such products tend to be formulated for more oily adolescent skin, and therefore these products can be particularly irritating for adults. For the most part, adult skin can be more sensitive and can dry more easily than adolescent skin due to decreasing oil production and photodamage.
The Bottom Line
Emphasize anti-inflammatory and non-irritating topical formulations. Niacinamide is a calming ingredient found in many OTC products that also has some anti-aging properties and is suitable for acne-prone skin. Sunscreen is a must for all adult acne patients. Topical retinoids provide benefit for acne and skin aging. Light-based interventions similarly can affect both acne and photodamage.
I tailor both my skincare and prescription regimens for adult patients and their unique needs. I prefer to recommend both a topical prescription regimen and cosmeceutical formulations for use at home. Adjunctive in-office procedures may also be offered.
I emphasize anti-inflammatory and non-irritating formulations. Most socially active and career-focused adults won’t tolerate skin peeling and excess dryness.
Topical antimicrobials, such as benzoyl peroxide or clindamycin, may be prescribed, in appropriately formulated products for patients with classic papulopustular acne. Essential to medical acne management is a topical retinoid. The selection of a retinoid can be tailored to the patient, and therapy can be titrated, if necessary, for optimum tolerability. Beginning therapy with a lower potency retinoid, such as adapalene or over-the-counter retinol, is often necessary. Other methods that are helpful to decrease retinoid irritation include short-contact therapy, using the product less frequently (every two to three days), or applying a moisturizing cream to provide enhanced barrier function immediately before or after the retinoid.
For adult women with acne, where there is a hormonal component to the disease, adjunctive treatments, such as oral contraceptive pills or spironolactone, may be beneficial.
Niacinamide is one of my favorite ingredients in non-prescription skincare. It is a calming ingredient found in many products that also has some anti-aging properties. This additional benefit is attractive to adults, as the product is good for their skin in multiple ways. Our office dispenses Clear Skin by PCA with niacinamide 4%, which is a light formulation with only a few ingredients.
Sunscreen is a must for all adult acne patients, even though many believe that sunscreen causes acne flares. Be prepared to recommend specific formulations. Elta MD UV Clear contains niacinamide and is good for not exacerbating acne.
I am generally hesitant when it comes to botanical products, as many are more trendy than scientifically backed. I often have patients ask about using essential oils on their face. My favorite botanical ingredient is called blue tansy. It is derived from a chamomile plant and has calming, anti-inflammatory, and anti-bacterial activity. It is available in several formulations (oils, masks, toners, etc.) in over the counter cosmetic skin care products, and I do recommend it to patients interested in another skincare option.
I will treat acne scarring in patients as long as their acne is well managed. My practice is primarily cosmetic, and I see a lot of adults who want to address scars and discoloration from past acne. The first thing I do is ask patients whether they still have active acne and need to address that; usually the answer is yes.
For treatment of acne scars, I usually use laser and/or microneedling. My laser treatment of choice in someone with Type I-III skin with active inflammatory acne and primarily erythematous scars is a combination of vascular laser and Nd:Yag Genesis (Cutera). I counsel patients that laser is typically not appropriate for long-term management of acne, but can be a good starting point while waiting for the effects of prescription medications and skincare, which can take several months. Laser and light therapy is usually a good option for patients who cannot use traditional prescription therapy, such as during pregnancy. The vascular laser will address any redness in scars or acne lesions and Laser Genesis promotes gentle heating that temporarily decreases the appearance of pores and reduces inflammatory lesions relatively quickly. I will often combine laser therapy with red and/or blue light panels or light devices for home use. Ideally, the patient comes in for treatment every two to four weeks. I prefer not to use microneedling for patient with active acne, as it may induce acne flares.
Alternatively, a low-energy resurfacing laser treatment like the Clear + Brilliant (Solta Medical), which works very well on photodamage, can also be useful for acne. Acne seems to respond well to the heating from the device. This device also pairs well with a vascular laser, if needed, and/or microneedling.
We used to offer red and blue light therapy in the office. However, best results required multiple treatments, and it became challenging for people to commit to come into the office to have it done frequently enough.
Now there are home devices available for patients to use in the comfort of their home. Blue light helps with acne because it specifically targets and kills P. acnes. The red light can help reduce inflammation, swelling, and redness. Red light also has been shown to help build collagen. Virtually any patient is a good candidate for using it. There are no side effects, and I would even advise that pregnant women could use it.
Of course, adherence remains a concern. Having the device at home may increase the likelihood the patient will use it as needed. Those who do not use the device regularly will not see improvements.
Microneedling is my go-to for textured, indented, or atrophic acne scars. Platelet rich plasma (PRP) is frequently added to microneedling via injection and topical application, which adds nominally to the cost and time of treatment, but enhances the collagen-building results. The only other topical I would use during microneedling is a pure hyaluronic acid serum. I find it risky to apply other topical active ingredients during or right after microneedling because sometimes they induce irritation or an unexpected allergic reaction.
I consider acne to be a chronic skin condition and advise patients as such. Once patients are no longer developing active acne lesions, I switch to “preventative mode.” I may withdraw topical prescription therapy entirely or, more likely, withdraw antibacterials and maintain a retinoid alone. Retinoids are proven to promote texture improvement by stimulating collagen. They are good for not only acne scars but also wrinkles and texture changes associated with photodamage. Adults thinking about anti-aging goals will benefit from a retinoid. There is usually no need to go above a 0.05% concentration of tretinoin to obtain maximum benefit over time.
Some patients can be switched to an OTC retinol-based formulation in place of the prescription retinoid. For example, Sente Biocomplete Serum has a slow release retinol that is well tolerated.
Dr. Samolitis has no financial interest in the products mentioned.
Nancy Samolitis, MD is Co-founder of Facile Dermatology in West Hollywood, CA.