Common Oral Treatments for Acne
Oral treatments are usually considered when acne is moderate to severe, there is acne scarring, significant psychosocial impact, or failure to respond to topical therapies. Systemic therapy should ideally be combined with topical therapy for maximum efficacy. Commonly used oral medications include antibiotics, hormonal therapy, as well as oral isotretinoin.
A mixture of oral and topical treatments can be deployed in conjunction with on-going in-clinic treatments such as chemical peels and lasers.
What types of oral medication are there for acne?
The most commonly used form of oral treatments are:
- Oral Antibiotics – such as Doxycycline / Minocycline
- Androdrogen receptor blockers such as Spironolactone
- Oral Contraceptives such has Diane 35 / Estelle 35 / Yasmin (for women)
- Oral Isotretinoin such as Roaccutane / Oratane / Accutane
Oral antibiotics are the initial choice for the management of moderate to severe inflammatory acne by reducing inflammation. Commonly used antibiotics include:
Acne is not a classical bacterial infection, and antibiotics used for acne treatment act largely through effects independent of their antibacterial actions.
Hormonal therapy is typically given as a component of a therapeutic regimen that combines other acne therapies with a hormonal agent.
Androgens are an important contributing factor to the formation of acne. They promote excess sebum production from the sebaceous glands. The accumulation of sebum and keratinous material in the pilosebaceous follicles leads to obstruction, resulting in comedone formation. Sebum also acts as a growth medium for C. acnes bacterium which contribute to the inflammatory acne. The goal of hormonal therapy is thus to minimize acne via the reduction of androgen action on the pilosebaceous unit.
Oral contraceptives can help female patients who have acne. Oestrogens in the pill supress sebaceous gland activity and decrease formation of ovarian and adrenal androgens. They may also be combined with an androgen blocker cyproterone ( e.g. Dianette 35/ Estelle 35).
Spironolactone can be used for acne treatment in female patients. The drug competitively inhibits binding of androgens to androgen receptors. This medication is often given in conjunction with an oral contraceptives, as Spironolactone may cause irregular menstrual periods.
Both hormonal therapies may take up to 3 months of continuous treatment before benefits are seen. Hormonal therapies are unsuitable for male patients as their mainstay of action is mostly anti-androgenic ( male hormones including testosterone).
Isotretinoin is a synthetic vitamin A analogue that is a powerful highly effective treatment for acne. It is usually recommended when one has:
- Nodulocystic acne
- Moderate to severe recalcitrant acne
- Severe scarring
- Psychosocial distress due to acne
It is the only treatment that has effect on all major pathogenic factors involved in acne. Isotretinoin decreases the size and secretion of sebaceous glands, normalises follicular keratinization which in turn prevents comedone formation, inhibits C. acnes growth, and has anti-inflammatory effects.
A course of isotretinoin is calculated based on body weight. The course duration depends on the maximum tolerated daily dose and can last from 4 months up to 2 years. You may experience an early flare of acne within the first month of starting isotretinoin, but this usually improves with continued treatment. Due to its potential effect on serum cholesterol and liver enzymes, most patients should have a pre-treatment blood test as well as one 6-8 weeks after treatment for monitoring. Heavy alcohol intake should also be avoided when on treatment.
It should be emphasised that many patients have benefitted from the effectiveness of isotretinoin for acne treatment without serious side effects.