Most people had tried topical treatments for their acne – these are medicines applied to and left on spots (whereas face washes are quickly rinsed off).
Active ingredients include: benzoyl peroxide, retinoids (such as adapalene), salicylic acid and topical antibiotics. Topical treatments with a combination of active ingredients are generally more effective. Some topical treatments can be bought from shops, including products recommended by pharmacists, and others prescribed by doctors. Most people had tried shop-bought topical treatments before going to the GP for the first time.
Eli heard about a topical treatment for acne online and went shopping to find it with her friend.
Eli heard about a topical treatment for acne online and went shopping to find it with her friend.
Age at interview: 13
Sex: Female
Age at diagnosis: 11
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Can you remember where you read about that or where you heard about it?
I just watched a YouTube video about it.
Could you tell me a bit more about the YouTube video?
Well it was this lady which was about 20 years old and she had spots like all her life and she was just saying about how she lost them and well yeah, with getting creams and stuff.
One of my closest friends because we were looking at videos together on the Internet about how to remove them. And one day we went shopping together and we got this cream but this was like some months ago. So yeah.
Can you remember anything about what the video was saying about ways to remove acne?
It was saying the same thing of different creams and stuff. That’s why me and my friend went shopping but we couldn’t find the exact like the cream the video was saying but, yeah.
Topical medicines were usually the first treatment prescribed to young people with acne by GPs. Doctors can prescribe topical medicines with different ingredients, forms and strengths. Most people had used a prescribed topical medicine with benzoyl peroxide as the main active ingredient. This usually came in cream or gel form in a tube. Some people had tried others topical treatment forms, such as Abbie who had used a ‘dabber’ topical solution (like a stick that you press on to the skin to apply the medicine).
Abbie’s treatment history for acne started off with topical medicines.
Abbie’s treatment history for acne started off with topical medicines.
Age at interview: 17
Sex: Female
Age at diagnosis: 13
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So when I was about 13 I started getting like spots on my face. And it wasn’t that, like that bad at first. So I didn’t really mind. But then it started getting really bad. It was mostly on my forehead and like I get the T-zone bit. And I started to get like more self-conscious about it. So we went to the GP and he gave me, it was like a dabber like with some, it was more like an alcohol kind of thing that you’d put on your face like twice a day. And then it, it started to work really quickly. So I was like really happy. And, but then it stopped working and it got worse. So then I, I went back again and I got some different cream that I had to put on. Which was different cos it was more like a, like a gel rather than a scrubby kind of thing. And then that didn’t work. So then we went back and then he gave me like a stronger alcohol thing. And then that didn’t work. And in the end I was just getting really like agitated that it wasn’t going away. And it w-, I’d had it for about two or three years and it was just not good [laugh]. So we decided to go to a dermatologist. And my grandad kindly paid for me to go to a private one rather than the NHS one. And so we got like really quickly to go and see him. And he prescribed me another cream thing that only dermatologists can prescribe. But that didn’t work. And then in the end he gave me Roaccutane (isotretinoin).
Harriet talks about her experiences with topical treatments.
Harriet talks about her experiences with topical treatments.
Age at interview: 21
Sex: Female
Age at diagnosis: 12
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I think the first one he gave me, I’m not sure what it’s called, but it was like a little pot and you get it and it’s got a powder in. And then you’ve got another one with a liquid in. And you sort of pour one into the other and you’ve got, then you shake it and then you like sort of like spread it. It’s kind of like a Pritt Stick, you just sort of spread it over your face at night. And that, it burns but, you’re like, “Oh, it burns, so it must be working.” [laughs]. And I know one of my friends, she uses that now and it, it works for her. And then there was, I, there was something else that was sort of a, a similar sort of liquidy type one. But then I had some creams that were, I can’t, I can’t think. Benzoyl peroxide I think is one and it’s basically like bleach, so you just sort of spread it on your skin. And that’s actually quite helpful. I still, when I’m getting spots now I tend to use that. It does have a tendency, all my towels have just got like bleach streaks all over them. But it’s fine. My mum didn’t mind. So I find that, and I remember reading somewhere, because I read on the sheet, it was like “Spread it on thinly.” And it sort of, it kind of worked but it didn’t work that well. Then I read online, there was someone saying like, did a testimony to it and they were like, “I absolutely swear by those who just put loads on and it works beautifully.” So I tried that and I put quite a lot on and it does, it does help, but it does dry your skin out really badly. So now, I still, yeah, I still sometimes use acne creams now. But I’ve also got, it’s so ridiculous, I’ve got like hydrating cream, like medical hydrating creams that you use for kind of eczema and things, combined with stuff to dry out your skin. So I’ll put the, sort of moisturise my skin and then I’ll put the one to dry it off, dry it out. Then I’ll go to bed, wake up, like lather myself up for rehydrating and, yeah. It, it just about works though, yeah.
The first topical medicine worked well for some people and they didn’t need any further treatment for acne. Others tried a topical medicine but found it wasn’t effective or the improvements only lasted a short time. Some people talked about concerns that their acne would become resistant to topical creams that contain antibiotics. Usually the person went back to the doctor’s and was recommended another topical treatment to try, meaning repeat visits to see medical professionals). Abbie and Chris stressed that you have to be patient and wait a few weeks to see if an acne treatment is working. Sarah thinks she had unrealistic expectations that topical treatments would have quick results. It could be frustrating trying lots of different topical medicines though – Chris described having “one cream after another” with no major improvements.
Devan has tried a mix of treatments at once, including a topical treatment alongside a prescribed antibacterial face wash.
Devan has tried a mix of treatments at once, including a topical treatment alongside a prescribed antibacterial face wash.
Age at interview: 18
Sex: Male
Age at diagnosis: 13
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Well, I were just sort of trying whatever they had available because I just wanted to get rid of it really.
So they, doctors prescribed, they started me off on, I think it was just the creams. Then we moved to just medications and different variations of medications. And then they decided to put the cream and the medication together. And as a very last resort they decided to use the HiBiScrub, which has a bit, bit of an impact. I think it might have been because of the alcohol content that it’s got in it.
And we were, I was using them with a mixture of off-the-shelf products as well at the same time.
Could you tell me a bit about the HiBiScrub?
Yeah it was just sort of the hand wash version that you, or the, the one that you could use for the skin and it was really, really sort of easy to use, you just put it on with cotton wool pad and put it round everywhere that had the acne and it just sort of worked, it sort of cleared it up so it wasn’t visible on my face but obviously you couldn’t, I couldn’t reach to put it on my back.
Using topical treatments
Topical treatments are applied to the skin to allow the main ingredients to sink in. For example, benzoyl peroxide topical treatments work by drying up the spot and killing off any bacteria around it. Most acne treatments aim to prevent new spots from developing and so are often applied to all spot-prone areas, rather than only visible spots. For this reason, it can take a few weeks to have an obvious impact. It was usual for the people we interviewed to put on the topical treatment once a day, such as before going to bed and often they kept the topical treatment on for a long time (e.g. overnight). Will’s mum encouraged him to be sparing with his topical treatments though and only occasionally put it on the parts of his skin that were badly affected by acne.
Rachael had a topical medicine that she got used to by increasing the number of hours she kept it on for.
Rachael had a topical medicine that she got used to by increasing the number of hours she kept it on for.
Age at interview: 18
Sex: Female
Age at diagnosis: 16
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And when you were using the topical treatments you sort of said that it changed, the amount of hours that you'd leave it on?
Yeh
What was your sort of routine with that?
So with that I'd have to put a bit on, like a few hours before I went to bed at first. So, then I could wash it off before bed and then, and that was a bit annoying sometimes, but then the next night I'd then have to wear it for longer hours but still, I'd have to make sure I washed it off before bed. So, I'd have to put it on like earlier, like five or something; wear it till like ten and then take it off and then eventually wore it for the whole night so, just about getting into a routine.
So did that routine have sort of any impact on the things you could do in the evenings or?
I think I could still do stuff while wearing it but it was just quite annoying and I'd keep forgetting to put it on sometimes and that was a bit frustrating cos it is an added like commitment and it's not one that you feel you always need to do cos it's not like your school work and stuff but, you do feel bad if you don’t do it and… but also doing it is quite uncomfortable as well.
Applying and washing off topical treatments can take time and alter daily routines. For some, the process was time-consuming. Deborah’s thick topical medicine was “impractical” because it took a long time to absorb into the skin. Some didn’t use topical treatments in the morning because it was visible or flaky, preferring to apply them at night before going to bed. Others, like Fatima and Ollie, said they didn’t find the time taken up by using topical treatments too bad.
It can be difficult remembering to put on the topical medicines. Tom found it a chore having to get out of bed to put on the treatment at night when he remembered. Some people found it okay to remember though and added it to their skin care routines. Nina said her routine with topical treatments and skin care was very important to her. Harriet described her skin care practices as “regimented”. Sharing bathrooms could be an added concern for some.
Marga sometimes has to wait for other family members before she can do her skin care routine, including applying topical treatments.
Marga sometimes has to wait for other family members before she can do her skin care routine, including applying topical treatments.
Age at interview: 24
Sex: Female
Age at diagnosis: 18
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So, living here I have a sink in my room so that’s absolutely fine. I do go home quite a lot, and I share a bathroom with my mum and my brother. And sometimes I guess me and my mum probably get ready for bed generally around the same time so I'll have to -, we either share the bathroom-, because there's only one sink and I often like, like the whole sink to myself partly because I like [gestures splashing face with water] probably make a bit of a mess around the sink [laughs] and have to clean it up. Then I'll probably come back if she's in there or something, or she'll come back or whatever. So I guess, you know, and sometimes, “Ah, you’re in the bathroom again,” or whatever to my mum or something. So, I wouldn’t say it's a massive problem but I guess when you're sharing you have to compromise a lot more than obviously if you have your own sink so.
Those with spots on their back and chest sometimes found it more difficult though. Devan can’t easily reach the spots on his back but he also doesn’t want anyone to do it for him. Ollie found it easier to target spots on his face with the topical treatments, whereas this was trickier with the acne on his shoulders.
Another practical issue with topical medicines was where to store them. This was especially the case for those people who had tried lots of different treatments. Will, Ish and Deborah said they had cupboards full of topical treatments – some of which they had tried and not found effective, but they didn’t want to throw out. Tom’s friends have seen his topical treatments when visiting his house and asked questions about the products. Abbie once had a topical treatment which she had to keep in the fridge. Rachael found it annoying having to remember to take the topical treatment with you on holiday and when staying at friends.
Downsides and side effects with topical medicines
Not everyone had side effects from topical treatments, but some did. These included:
• dry and flaking skin, making the skin feel tight or itchy
• stinging, burning or soreness when applied
• allergic reactions
• sunlight sensitivity, as for Ish and Abbie
• stickiness on the skin, as for Deborah and Rachael
• bleaching fabrics
One of the ways that topical treatments help fight acne is by drying up the skin. For this reason, many topical treatments cause skin dryness and irritation. Whilst this can shrink spots and make skin less greasy, having dry skin which peels and flakes can be unpleasant. This was especially a concern for people who also had eczema. Some people were shocked at how dry their skin became whilst using topical treatments. Marga couldn’t put make-up on because her skin was so dry. Deborah’s skin sometimes felt tight and itchy after using topicals.
Topical treatments made Ish’s skin dry, adding to his image worries.
Topical treatments made Ish’s skin dry, adding to his image worries.
Age at interview: 22
Sex: Male
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It was embarrassing having acne, I’m guessing during that age. And then just, I don’t know, it was just really bad as you always had it in the most awkward place that you could think of, like in the middle of your forehead, or like, you know, somewhere where people can actually really notice it. So that made things worse. And just like, I don’t even know, it as just like that phase was like, you’re going to go to the doctor, you’re going to get something and if it’s something that dries your skin out you’re not only going to have face your acne problems, you’re going to have to face other problems now because your whole skin is turning red or like is drying out and you’re like, you know, you just put your hand next to it and like a bunch of dead skin just falls off.
Hester found some topical acne treatments were too strong to put on spots near sensitive facial features.
Hester found some topical acne treatments were too strong to put on spots near sensitive facial features.
Age at interview: 21
Sex: Female
Age at diagnosis: 15
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With the creams it was just - I think they're very aggressive. And different ones would be worse than others. So I think with a lot of the gel or the lotion, they dry my skin out really badly and I'd have like sort of cracked skin around my mouth. And obviously you couldn't really get them like near sensitive areas but if you accidentally did, and I'd have like kind of almost eczema-like sort of bits on the sensitive eye areas and around the mouth in particular. And that, and so that's not that pleasant. But then I think my doctor did eventually give me one that was a bit more moisturising. And I also learnt to use like slightly less [laugh]. I think there's always a temptation and most of it is that you use a lot of the product, when actually the recommendation is to use like a pea-sized amount and I was probably using like a handful [laughs]. So it was probably exacerbated by that.
Moisturising was seen as especially important because of the drying side effect of topical treatments. This could be difficult as some people needed to find moisturisers and lip balms which didn’t irritate their skin or make it greasy.
Tom wasn’t sure about the instructions for his topical cream, including about when to moisturise.
Tom wasn’t sure about the instructions for his topical cream, including about when to moisturise.
Age at interview: 15
Sex: Male
Age at diagnosis: 15
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And so what about the cream that you said there was quite a lot of complicated instructions for?
Oh, that’s, there’s, that’s most of the creams that I’ve used. There’s always stuff like, so like, I don’t know, the branded ones will always be like, “Put it in your hand, rub it, a thin layer round your face, wash it off with hot water and then pat dry.” Which is really stressful. And then the other one was sort of like, “Rub it in until it disappears.” But the problem with those ones is I don’t know whether I’m supposed to moisturise before or after, or whether I’m supposed to wash my face at all before that. I probably am but like, whether I’m supposed to wash my face before or after in case it comes off. So like you kind of have to work out. So like I stopped using moisturiser when I used the one that you just rub in, because I figured that you wouldn’t like, and [sister’s name] was like, “You probably shouldn’t do both.” But then again that didn’t help because I wasn’t moisturising. So that left like dry skin and stuff. So it was kinda, it wasn’t very well explained on the back basically.
So were some of the instructions more complicated than they needed to be?
Yeah.
But also missed off stuff –
Yeah.
- that you needed to know?
Yeah.
Okay.
It would be nice if they were like, “Put it on your face, wash it off, apply moisturiser afterwards.” Because then at least it’s just all there and then you know what you need to do and you don’t have to worry about, “Should I be doing this? Should I be doing that?” Which is quite annoying. Because it’s already stressful enough having spots without having to worry about what sort of treatment you have to do and how you have to do the treatment.
Rebecca went back to her GP to be prescribed a moisturiser to help with the dry skin caused by the topical cream for acne.
Rebecca went back to her GP to be prescribed a moisturiser to help with the dry skin caused by the topical cream for acne.
Age at interview: 18
Sex: Female
Age at diagnosis: 12
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It was like a cream that I would put on my face to basically dry out like the spots and stuff. And then because it obviously dries your skin out, it did dry my skin out too much. So I did need to go back to the doctor’s to basically get some sort of oil-free moisturiser. Because if I was to use oil moisturiser, it would just make things worse again. So then I was prescribed some moisturiser to help with the dry skin.
And is that the sort of combination of things that then cleared up your acne with a bit of time, or-?
Yeah.
Yeah. How long do you think that the treatment maybe lasted for?
It lasted for about two years and then I stopped for a while. I don’t use the dry, the stuff that dries the skin out any more. I use-, I still use the moisturiser though because my skin’s still really dry. So-
Did your doctor suggest any different kinds of treatments that you might have tried for acne?
They did suggest a type of tablet. But I weren’t too keen on that because I would prefer to just do something externally rather than internally.
Yeah.
So-
Yeah, that’s interesting. Could you say maybe a bit more about why you prefer external treatment over an internal tablet?
Because like when you’re taking tablets – you-, I didn’t feel at the time that it was necessary. Because I just thought like ‘it’s just on my skin. I can sort it out externally’. And I didn’t really want to take medication. So the creams were a better option for me.
Could you say a bit about the side effects? You’ve mentioned the dry skin. The side effects that you got from the cream that the doctor prescribed you.
Well, initially I would put a lot of the cream on my skin. But then I realised that it was drying my skin out too much, so I only used a little tiny bit. And then I used a lot of moisturiser. But I would space out using the moisturiser and the skin that dries your skin out. So I would use the moisturiser in the morning and the stuff to dry your skin out at night.
Lots of people said it made their skin sting when they applied topical treatments. This added to the soreness of spots for Molly. Chris says the creams burnt for the first week before his skin got used to them. Kosta puts on a topical cream before he goes to bed and finds the soreness can make it hard to get to sleep. Some people had experiences where they had come into contact with other strong chemicals whilst using a topical treatment. Harriet described swimming in pool water (with chlorine in it) as having a “searing effect”. Ish found it painful when he had put aftershave on areas where the topical cream had been.
Harriet’s acne wasn’t always painful, but it could be when she used topical creams.
Harriet’s acne wasn’t always painful, but it could be when she used topical creams.
Age at interview: 21
Sex: Female
Age at diagnosis: 12
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It wasn’t that painful usually, but then sometimes you’d get sort of the big kind of nodal acne where you’d have these big lumps under your skin and that would be painful. You’d like, they’d sort of throb during the day and if you touched them they’d be painful. So that was a kind of uncomfortable pain. But with, with the, sort of when you put certain creams on or, yeah, or oils and things and they have a bit of a burn, it’s not really, sometimes it’s a burn, sometimes it’s more of a tingle. But it’s that, it’s kind of that feeling of, like if you were cleaning the hob or something and it would just, it would kind of like sizzle away all the grime and you’d clean it. It’s sort of, that kind of burning is a sort of a feeling of cleanliness almost, yeah. I don’t know if that makes sense.
I think it does. It’s so hard to convey though, isn’t it, unless you sort of know…?
It’s when it, with the burning you feel like it’s doing something useful, cos you, you can sort of feel it almost, you can almost imagine like the acne evaporating from your skin. You’re like “Yeah”, this, and then you look in the mirror and you expect to be, you know, completely, completely clean skinned. But it does, it definitely feels like it’s working when it burns.
A few people had true allergic reactions to topical treatments. Deborah remembers one cream she had which caused her skin to swell up. Ollie had expected some problems with topical treatments irritating his skin, but was pleased not to have any allergic reactions. Tom did an allergy check when he first starting using a topical treatment, by putting a small dab of the cream behind his ear to see if it had any bad reaction.
Sarah had worried when one of her topical treatments for acne had a warning for people with ulcerative colitis.
Sarah had worried when one of her topical treatments for acne had a warning for people with ulcerative colitis.
Age at interview: 22
Sex: Female
Age at diagnosis: 16
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And with the topical cream that a GP in [university city] prescribed that was sort of, you weren’t able to use – was your GP aware of you having an additional condition?
Yes she was. I think it was just a case of not being aware that the cream might interfere with that.
Yeah.
In the event I did actually raise this with a couple of gastroenterologists and they both told me that this was ridiculous and I shouldn’t worry about it and I should just use the topical cream but, you know, when you’re kind of reading a patient information leaflet and it says, “Do not take if you have colitis” and you don’t, you don’t want a flare up of colitis. It’s not a fun experience.
Although not exactly a side effect, some topical treatments contain bleaching agents which can damage fabrics. This includes bleaching or discolouring things like clothes, towels and bedding. Devan found it a problem with his shirts when he was using topical treatments on his back. Will had a “designated towel” at home which he used, so that the other towels didn’t get bleach stains. Harriet was careful when staying over at other peoples’ houses, so as not to stain their towels when drying her face.
Ish describes some of the side effects and impracticalities of topical treatments he’s tried.
Ish describes some of the side effects and impracticalities of topical treatments he’s tried.
Age at interview: 22
Sex: Male
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I think I just only remembered the last one I had cos that one had benzoyl peroxide in it. But with that one, I remember the problem was that it tended to make my skin really dry after a while, so you had to stop the treatment. But that was the best one that was working for me. So it really wasn’t, so I did it like for a month or two and then my skin got really dry. Then I stopped for a month and then it like came back. So you’re just repeating it over and over and over again. You’re not really getting a definite cure. So that’s, yeah, that’s annoying.
It bleaches fabrics. So I mean I had a white pillow so it didn’t really affect that part. But my clothes here, over here all the way on the collar here it bleached it. And also makes your skin very sensitive to sunlight and where I’m from it’s like the tanning beds are everything. So if you’re tanning or going to the beach or something like that, basically your face is going to burn and it’s going to make it worse. So that was a little bit downer.
Do you remember any other side effects from any other treatments for acne?
I remember one of them made my skin itch and one of them gave me rashes. So, it just made it a little bit worse, yeah.
The cost of topical treatments was a concern for some people. This includes topical treatments which are shop-bought as well as those that pay for prescribed treatments. Fatima plans to look online to find a cheaper product with the same ingredient. Chris felt that the topical medicine he had was okay value as it had lasted him a long time.
Outcomes of using topical medicines
Whilst topical treatments alone cleared up some people’s acne, others didn’t find these helpful. Devan says topical medicines “didn’t really touch the sides” of his acne, and he moved on to other treatments (including isotretinoin). Naomi had been excited when she got her first topical medicine but disappointed when it didn’t clear up her acne. Chris and Ollie found topical treatments helped their acne ‘level out’ for a bit, but didn’t fully clear up.
The side effects, impracticalities and expense played a big part for some people in deciding whether to keep going with topical treatments. Devan stopped using his because it bleached his clothes. Tom had a shop-bought topical treatment which, once he had used up the whole bottle, he decided not to buy again.
Some people found they didn’t get along with using topical medicines and preferred a different form of acne treatment – often comparing topical creams with tablets. Rebecca, Molly and Fatima felt more comfortable putting creams on their skin than taking tablets (e.g. antibiotics or isotretinoin tablets). Others found tablets quicker and easier to take than applying a topical treatment.
Tom chose antibiotic tablets over a topical treatment offered by his GP.
Tom chose antibiotic tablets over a topical treatment offered by his GP.
Age at interview: 15
Sex: Male
Age at diagnosis: 15
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And then he offered me like a face, a face cream or a tablet. And I went for the tablet because I’ve tried a lot of face creams. I didn’t really like them and I didn’t really see them doing much. So I tried that. And I’ve been on, I’ve been taking that for about a month now. And it seems to be, well, my face feels a lot better and I think it looks better [laughs] Yeah.
So is that like a face wash or is it like a gel that you put on?
It was a, he described it as topical, so I guess it is a gel sort of thing. I think it’s sort of, not a wa-, it’s more of a rub it in. Kind of, I think it’s one of the ones where you have to, cos I tried one of them before where you have to like put it behind your ear to check if you’re allergic to it and stuff like that. So quite like, you know, it tingles a bit when you put it on sort of thing, yeah.
Was that first one like over the counter or was that prescription as well?
That one was over the counter. Because in the summer I’d asked mum about the doctor’s and she said, “I’ll go to the pharmacy first and ask what they recommend.” And we tried that and it did work a bit to start with. But then over time it just kind of didn’t work anymore. And I don’t know if I was using it wrong or whatever, but we just decided that it would probably be easier to go for like a tablet, because you can’t really do wrong with a tablet. You can’t like, cos the ones, on the back of the face ones it’s a lot of like, “You’ve got to do this, this and this.” It’s just like you’ve got to swallow this after breakfast. It’s quite easy.
If topical treatments didn’t seem to work or caused problems for the person, GPs might suggest antibiotic tablets or a referral to dermatology (e.g. for isotretinoin tablets). Some people, such as Emma and Naomi, had tried multiple acne treatments at once – for example, topical medicines alongside other treatments like antibiotics or hormonal contraceptives. For those who no longer had acne, they sometimes still had a topical medicine to apply on occasional spots.
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