Acne

Acne Treatment

Acne is a chronic inflammatory disease of the pilosebaceous unit (the hair follicle and its sebaceous gland) characterised by comedones, papules, pustules, and, in more severe cases, nodules or cysts. These are collectively referred to as acne lesions. It most commonly affects the face and upper trunk and more than 80% of people experience it at some point in life.

Early, guideline-based medical treatment for acne matters because persistent inflammation increases the risk of dyspigmentation and permanent scarring [1]–[4].

What causes acne?

Acne isn't just "dirty skin." It develops from four processes that interact with each other:

1. 1. Oil glands make more sebum [skin oil] under the influence of androgens (hormones). This fills hair follicles with oil and lowers oxygen, which sets the stage for acne [2]–[4],[15]–[17].

   2. The lining cells inside the pore don't shed smoothly. Instead, they stick together and form a tiny plug (a "microcomedone") made up of dead skin cells and oil, which leads to plugged hair follicles that block the pore and trap oil and debris [2]–[4],[15]–[17].

   3. In these blocked pores, the skin's bacteria shift toward more inflammatory strains of Cutibacterium acnes and form biofilms (sticky bacterial layers). This change encourages irritation and swelling [2]–[4],[15]–[17].

   4. The immune system ramps up. Pattern-sensing pathways (like TLR2), early "priming" signals (IL-1), and an inflammation switch (the NLRP3 inflammasome) drive Th1/Th17 immune responses. If the pore wall breaks, the trapped material leaks into the skin and creates tender red bumps, whiteheads, pustules, and deeper nodules or cysts [2]–[4],[15]–[17].

Stress can worsen acne, so managing stress through sleep and relaxation techniques is beneficial.

Your baseline risk can be higher if acne runs in the family or you have a polygenic (many-gene) predisposition, and day-to-day factors like cosmetics, tight clothing or helmets (occlusion), certain medications and climate can worsen or improve how much acne you see and how severe it is. Understanding these drivers is key to choosing the right treatment for acne and to effectively treat acne [3],[13]–[16].

Why severe acne is worse in some people

Severe acne is the sum of biology and exposure. Higher baseline sebum output, a stronger tendency to follicular hyperkeratinisation, the presence of inflammatory C. acnes phylotypes, and a more reactive immune milieu all push disease toward greater inflammation and scarring risk. Acne severity is often graded on a scale from mild, through to moderate and severe acne forms. Genetics contribute substantially (heritability estimates around 70–80% are typical) and truncal involvement, earlier onset, and nodulocystic lesions predict a more persistent, relapse-prone course of persistent acne [2]–[4],[13]–[16],[18]–[20].

Why does acne continue after puberty?

Acne frequently persists into adulthood, particularly in women, either as persistent disease from adolescence or as late-onset acne, commonly referred to as adult acne. Fluctuating androgens, occlusive or comedogenic skincare and makeup, occupations or sports involving friction and sweat, and an individual's immunologic set-point sustain low-grade but chronic inflammation. Adult female acne commonly concentrates along the lower face and jawline; topical retinoids and benzoyl peroxide (BPO) remain foundational, and carefully selected hormonal therapies can help where androgen signalling and oiliness drive flares. This type of acne, known as hormonal acne, often requires tailored treatments that address underlying hormonal imbalances. For women, options such as the contraceptive pill and spironolactone are commonly prescribed to treat hormonal acne, especially when topical treatments alone are insufficient [3],[4],[6].

How acne treatment targets the four drivers

The fastest, most durable improvements happen when treatment covers each of the four core processes rather than chasing lesion types. We build plans around a nightly retinoid backbone to normalise keratinisation and dampen inflammation, then add agents to address dysbiosis and, where relevant, sebum control. This approach is known as combination therapy, using different acne treatments tailored to individual needs. These prescription medicines may include various acne products such as topical retinoids, selected based on their effectiveness for specific skin types and severity levels. Oral antibiotics are commonly prescribed for moderate to severe inflammatory acne. Oral antibiotics like doxycycline and minocycline are prescribed for moderate to severe inflammatory acne to kill bacteria and reduce inflammation. Common side effects of oral antibiotics include gastrointestinal upset and photosensitivity. When antibiotics are needed, they are time-limited and always paired with BPO to minimise resistance, and escalation to oral isotretinoin treatment is considered early where nodules, truncal burden or scarring risk are present [4]–[7],[9],[18]–[20]. Patients using isotretinoin must participate in a risk management program due to potential severe side effects.

Sebum overproduction (androgen-driven)

Excess sebum enriches a low-oxygen niche that fuels congestion and bacterial lipase activity. Oral isotretinoin directly shrinks sebaceous glands and normalises sebum quality and quantity, producing prolonged remissions in severe, scarring or refractory acne; relapse risk is influenced by sex, age, total cumulative dose and whether a maintenance retinoid or hormonal regimen is used [2],[4],[18]–[19]. In adult females, combined oral contraceptives and spironolactone reduce androgen signalling and sebum-driven flares when chosen appropriately and monitored carefully [4],[6]. Topical retinoids are not anti-androgens, but by preventing microcomedones they mitigate the congestion that sebum excess otherwise sustains [4],[7],[20].

Abnormal follicular keratinisation (retention hyperkeratosis)

Microcomedones are the "seed" of every acne lesion. Topical retinoids (adapalene or tretinoin) are therefore first-line for almost all patients because they treat acne by normalising desquamation, opening existing microcomedones and preventing new ones. Mild irritation is a common side effect during the initial phase of treatment with topical retinoids, but this is typically manageable with proper application. This comedolytic effect underpins both active treatment and long-term maintenance once clear. Topical retinoids also exert direct anti-inflammatory effects, which improves clinical response beyond decongestion alone [4],[7],[20]. When topical retinoids are contraindicated, poorly tolerated, or during pregnancy, azelaic acid (15–20%) offers a comedolytic and anti-inflammatory alternative to treat acne. Azelaic acid has the added advantage of improving hyperpigmentation [4],[8]. Glycolic acid is another topical option that promotes exfoliation and helps manage abnormal keratinisation in acne-prone skin.

Cutibacterium acnes bacteria

Shifts in C. acnes bacteria on the skin promote inflammatory cascades in obstructed follicles. Benzoyl peroxide is rapidly antibactericidal and also provides an anti-inflammatory effect, making it the essential partner whenever topical antibiotics or systemic antibiotics are used. Topical therapies play a key role in acne treatment by targeting skin bacteria and are often combined with benzoyl peroxide to enhance efficacy and reduce the risk of resistance. Systemic antibiotics (for example doxycycline) are reserved for moderate to severe inflammatory or truncal disease, prescribed for the shortest effective course (typically ≤12 weeks), and always combined with a topical retinoid ± BPO to sustain control and reduce resistance selection pressure [4]–[6],[9]. Azelaic acid can help with reducing inflammation. Everyday product choices matter too: non-comedogenic sunscreens and moisturisers, and avoiding heavy occlusive cosmetics, help keep the follicular environment unfavourable to dysbiosis [15]–[17].

Inflammation (TLR2, IL-1, NLRP3; Th1/Th17)

Skin surface inflammation is present from the earliest microcomedone stage and intensifies with follicular rupture. Retinoids and azelaic acid reduce inflammatory signalling while also correcting keratinisation. BPO combined with a topical antibiotic reduces inflammatory lesions more effectively than an antibiotic alone and curbs resistance; antibiotic monotherapy should be avoided. When the inflammatory burden is high or there is extensive truncal disease, short courses of oral antibiotics can be useful, but topical agents must continue during and after the course, applied to affected skin, to prevent rebound. For nodulocystic or scarring-risk acne, or for disease that fails to respond to appropriate combinations, oral isotretinoin offers comprehensive disease modification across sebum, keratinisation and inflammation [2],[4]–[9],[18]–[19].

Physical treatments, such as dermatological procedures, are generally less suitable for active, inflamed acne.

Non-pharmaceutical acne treatments

Non-pharmaceutical acne treatments offer valuable options for managing acne, whether used alone or alongside topical treatments and oral medications. For those with mild acne, blue light therapy is a gentle, non-invasive approach that targets Cutibacterium acnes, the bacteria involved in acne development. By reducing bacterial load on the skin, blue light therapy can help decrease inflammatory lesions and is often paired with topical treatments such as salicylic acid or benzoyl peroxide for enhanced results.

Photodynamic therapy (PDT) is another advanced option, particularly suited to severe or treatment-resistant acne. PDT involves applying a photosensitising agent to the skin, which is then activated by a specific wavelength of light. This process targets overactive sebaceous glands, reducing excess oil production, a key factor in acne formation. PDT can be especially helpful for individuals with severe inflammatory acne characterised by persistent or deep lesions.

Laser acne treatments, including fractional laser resurfacing, are increasingly used to address scarring and post-inflammatory hyperpigmentation. By creating controlled micro-injuries in the skin, these lasers stimulate collagen production and promote skin renewal. This not only helps to smooth acne scars but can also improve the absorption of topical medications, making your treatment regimen more effective.

Good skin care practices remain essential for anyone with acne-prone skin. Using a gentle cleanser, avoiding harsh exfoliants, and selecting non-comedogenic products can help prevent clogged hair follicles and reduce the risk of making acne worse. It's important to apply topical medications as directed and to be mindful that some over-the-counter treatments or cosmetic products may exacerbate breakouts.

For individuals with severe acne or persistent symptoms, consulting a dermatologist is crucial. A dermatologist can recommend a tailored combination of non-pharmaceutical treatments, topical therapies, and oral medications to address your specific skin concerns and reduce the risk of acne scarring. In cases where oral antibiotics are prescribed, combining them with topical benzoyl peroxide or retinoids is essential to prevent antibiotic resistance and maintain long-term efficacy.

Ultimately, non-pharmaceutical treatments can be a powerful adjunct to traditional acne therapy. By integrating these options with a consistent skincare routine and evidence-based topical treatments, individuals can achieve significant improvement in acne management, reduce post-inflammatory hyperpigmentation and support healthier, clearer skin over time.

What to expect from acne treatment and when

With consistent use, early reductions in tender papules and pustules usually appear within the first few weeks, particularly where BPO or a fixed retinoid/BPO combination is included; transient "purging" reflects microcomedones surfacing and generally settles with continued therapy and sensible moisturiser use. During this initial period, common side effects such as dry skin and skin redness may occur, especially with topical retinoids and other potent treatments, but these often improve as your skin adjusts. By six to twelve weeks, comedones fall, texture and tone improve, and most patients are ready to taper any oral antibiotics while maintaining their nightly retinoid. Between three and six months, control consolidates; azelaic acid can be layered to manage colour change, and isotretinoin or other acne medications (such as oral antibiotics, hormonal therapies or combination treatments) are considered earlier in the course whenever scarring risk is evident [4],[6]–[9],[18]–[20].

Lifestyle factors that affect acne treatment and acne prone skin

Diet is supportive rather than determinative. Low-glycaemic eating patterns modestly reduce lesion counts, likely via IGF-1 signalling, while evidence linking dairy to acne is observational and heterogeneous; we use shared decision-making rather than strict prohibitions. Sleep, stress management, and avoiding friction and heavy occlusion on acne-prone sites reduce triggers that otherwise complicate care [10]–[12].

Why prescription treatment for acne outperforms over-the-counter and topical treatments

Prescription care delivers therapeutic-level actives and combinations including prescription medicines and targeted acne medications such as retinoids, fixed-dose adapalene/BPO, time-limited systemic therapy, hormonal options and, when needed, isotretinoin. These are implemented within resistance-aware protocols and monitored over time. This process-first approach treats what drives acne rather than masking flares, reduces relapse, and protects against scarring. It is why prescription treatment for acne delivers clearing rates that over-the-counter products cannot match; when these initial therapies are insufficient, other treatments such as additional prescription medications, hormonal therapies, or advanced procedures may be considered under medical supervision [4]–[7],[9],[18]–[20]. Consulting a healthcare professional is advised if over-the-counter treatments do not improve acne after 12 weeks.

Start your acne treatment with Prescription Skin

Getting effective treatment for acne in Australia no longer means waiting weeks for a dermatologist appointment. Start with a quick online skin assessment and a medical review. We personalise your formulation to your skin tone, sensitivity and goals, then adjust strengths and companions over follow-ups. For example, we titrate retinoids to tolerance, choose appropriate BPO or azelaic acid strengths, and decide when to add, continue or stop systemic therapy. For adult female acne, we assess suitability for hormonal therapy, while also discussing the potential long-term risk of breast cancer with certain medications. For scarring-risk disease, we discuss isotretinoin early, coordinate care safely, and highlight the importance of monitoring for birth defects in women of childbearing age. Clear, step-by-step instructions ensure you know what to use, when to use it, and how to manage temporary irritation (such as using moisturisers and lip balm to prevent chapped lips) while results build. Some patients also consider complementary options like tea tree oil, but we recommend consulting a healthcare professional before starting any alternative therapies.

Start with a quick skin assessment →

Find out how a personalised prescription formula could work for your skin at Prescription Skin.