To treat the four major causes of breakouts—clogged pores, proliferating P. acnes bacteria, inflammation, and oil—New York–based dermatologist Arielle Kauvar, MD, suggests starting with tried and true OTC topicals that "gently exfoliate and reduce inflammation," such as a cell-renewing glycolic acid cleanser, an allover retinol lotion for brightening, and an antibacterial benzoyl peroxide spot treatment.
When drugstore options don't do the trick, New York–based derm Jennifer MacGregor, MD, prescribes antibacterial standby Aczone, a topical anti-inflammatory that "modulates the immune system by blocking an enzyme in white blood cells that would normally lead to inflammation and tissue damage."
If spots are concentrated around the chin, elevated testosterone levels (which can cause oil production to spike) may be the culprit. New York–based derm Barney Kenet, MD, recommends birth control pills such as Ortho Tri-Cyclen and Yaz, or he prescribes Spironolactone, an antiandrogen medication that balances hormones. And while Kenet notes that "the single most effective agent in stopping acne" is still 33-year-old Accutane, he warns that it can cause "quite significant side effects, [including] birth defects if you get pregnant while using it."
An arsenal of in-office acne procedures are all designed to target the same thing: oil glands. In addition to surefire sebum-reducing treatments such as the Isolaz laser, which utilizes intense pulsed light (IPL), Beverly Hills–based derm Michael Lin, MD, blasts spots with photodynamic therapy (PDT), originally used to treat some types of skin cancer and later FDA-approved for acne. During PDT, aminolevulinic acid (ALA)—a photosensitizing chemical that becomes a potent antimicrobial when triggered by specific wavelengths of light—is applied to the skin, then activated by blue light. "It incubates for 30 minutes to an hour, killing bacteria and injuring the sebaceous glands," Lin says. A single session of PDT can improve the complexion for up to 12 weeks.
For severe cases, Kauvar switches to red light, which "penetrates more deeply." She also leaves the ALA solution on skin for three hours (it's usually on for an hour or less), a variation that can incur a week of intense swelling. The discomfort is worth it for some patients: After multiple sessions spaced eight weeks apart, the combo can diminish acne for up to a year.
Alternatively, radio-frequency treatments, such as Aluma or Thermage, can shrink sebaceous glands via heat. In a 2003 study published in the journal Dermatologic Surgery, radio frequency significantly reduced 82 percent of participants' acne in one to two sessions, spaced up to eight months apart.
When you need a spot gone in a flash, the gold standard is a quick shot of the anti-inflammatory steroid cortisol, which can shrink a blemish in under 24 hours. Post injection, Kenet suggests dabbing on the drugstore astringent Domeboro, typically used to quell rashes, "to dry out the pimple."