How to treat acne and actually get clearer skin

I am the Prescriptsy editorial team, and acne is one of those conditions I could happily treat every day.

The pathophysiology is well understood, the evidence base is strong, and the results of proper treatment are visible and genuinely life-changing for the patient in the chair.

The problem is not that we lack effective treatments. The problem is that most people with acne are undertreated, mistreated, or treated too briefly before giving up.

This guide works through acne from the mildest comedonal spotting to nodulocystic disease, explains the whole NHS ladder of treatments, and is written to be read before a GP appointment so you can have the conversation that actually moves the needle.

What acne actually is

Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit. Four mechanisms drive it, all interacting:

1. Excess sebum production, driven largely by androgens.
2. Abnormal keratinocyte desquamation in the follicle, forming microcomedones.
3. Colonisation and biofilm formation by Cutibacterium acnes.
4. Inflammation, both innate and adaptive, producing papules, pustules, nodules and scarring.

Every effective treatment addresses at least one of these mechanisms. Combination therapy works because it addresses several at once.

Myths I undo first

• Diet is the main cause. It is not. High glycaemic load and whey protein supplementation have modest effects in some studies; greasy food and chocolate do not. Washing your face more often does not clear acne and can worsen it.
• Acne is a teenage problem only. Adult acne, particularly in women, is common and often hormonal in pattern.
• You should "let it dry out". No. Drying products increase inflammation and delay healing.
• Stronger equals better. Overly aggressive topical regimens cause rebound flaring and compliance collapse.

Severity grading and why it matters

The simplest NHS working grade is:

• Mild: mostly comedones, a few papules and pustules, no scarring.
• Moderate: more widespread papules and pustules, some nodules, early scarring.
• Severe: widespread nodulocystic disease, prominent scarring, psychological impact.

The NHS page on acne describes these categories in accessible language, and NICE NG198 formalises the same framework for prescribers.

The treatment ladder

NICE recommends a twelve-week course of first-line combination therapy, reviewed, then escalated. The sequence looks like this.

Step 1: fixed-combination topicals

First-line in 2026 is a fixed-combination topical product. The preferred options in UK practice are:

• Epiduo gel (adapalene 0.1% plus benzoyl peroxide 2.5%). My usual first choice for mild to moderate acne with comedones and inflammatory lesions.
• Duac (clindamycin 1% plus benzoyl peroxide). Good for patients whose acne is predominantly inflammatory and who cannot tolerate retinoids.
• Differin (adapalene 0.1% or 0.3% alone) for patients whose skin does not tolerate benzoyl peroxide.
• Aknemycin (erythromycin-based topical), a second-line topical antibiotic option used in niche cases.
• Clindamycin topical, useful in pregnancy where benzoyl peroxide or retinoids are not preferred.

Application technique matters more than patients realise:

• Apply a pea-sized amount to the whole affected area, not spot-by-spot.
• Apply to dry skin 20 minutes after washing.
• Moisturise liberally. Dryness and irritation are why most people abandon topical retinoids prematurely.
• Use sunscreen daily. Retinoids and benzoyl peroxide increase photosensitivity.
• Expect a six to eight week purge phase before improvement.

Step 2: adding an oral antibiotic

If topicals alone are not enough at twelve weeks, or if acne is moderate from the outset, we add an oral tetracycline for no longer than three months to reduce resistance risk:

• Doxycycline 100 mg once daily. The NHS workhorse. Take with food and plenty of water, avoid lying down for 30 minutes, use sunscreen.
• Tetralysal (lymecycline) 408 mg once daily. Similar efficacy, often better tolerated gastrointestinally than doxycycline.

Key rules:

• Always combine with a topical (usually benzoyl peroxide plus a retinoid) to prevent resistance.
• Review at twelve weeks. If responding, plan to stop the oral antibiotic and maintain with topicals.
• If not responding at twelve weeks, escalate rather than repeating antibiotic courses.

The British National Formulary at bnf.nice.org.uk is unambiguous on these durations. Prolonged tetracycline monotherapy is outdated practice.

Step 3: hormonal options in women

For female patients whose acne flares premenstrually, involves the lower face and jawline, or is accompanied by hirsutism or menstrual irregularity, hormonal therapy often outperforms antibiotics.

• Co-cyprindiol (cyproterone acetate 2 mg plus ethinylestradiol 35 mcg), commonly known as Dianette. Licensed specifically for severe acne in women where other treatments have failed. Provides contraception alongside acne benefit. Higher VTE risk than standard combined pills; limited to three to four months beyond clearance.
• Drospirenone-containing combined pills (e.g. Yasmin) are a reasonable alternative where cyproterone is not appropriate.
• Spironolactone, off-label, at 50 to 100 mg daily, is increasingly used in adult female acne, particularly where combined hormonal contraceptives are contraindicated.

Patient.info on acne has a useful lay summary for women weighing up hormonal options.

Step 4: referral and oral isotretinoin

Severe acne, nodulocystic disease, scarring, or failure of twelve weeks of adequate combination therapy are indications for dermatology referral.

Oral isotretinoin is the definitive treatment: a six-to-nine-month course, usually 0.5 to 1.0 mg/kg/day, clears the majority of patients and produces long-term remission in most.

It is consultant-initiated in the UK because of teratogenicity, baseline bloods, and the pregnancy prevention programme required.

Side effects, notably dryness, lip chapping, and (rarely) mood effects, need explaining and monitoring.

It is not a drug to be afraid of, but it is one that deserves proper support.

Scarring: the under-discussed issue

Acne scars are far easier to prevent than to treat.

The single most important message in any acne consultation is: if you have inflammatory or nodular disease, do not let it sit untreated for a year before seeking help.

Picking and squeezing multiply scarring risk.

Once scars exist, treatments include fractional laser, microneedling, chemical peels and dermal filling, but none of these are as effective as preventing scars in the first place.

Post-inflammatory hyperpigmentation

Patients with darker skin tones are often more distressed by brown marks after the acne than by the acne itself. Key points:

• Sunscreen every morning, SPF 30 minimum. UV is the main driver of persistent hyperpigmentation.
• Topical azelaic acid 15 to 20 per cent combines anti-inflammatory, antimicrobial and depigmenting effects and is underused on the NHS.
• Tretinoin or adapalene accelerate fading over months.
• Hydroquinone is occasionally used under dermatology supervision.

Adult female acne

Onset in the twenties or thirties, lower-face distribution, premenstrual flare, deeper tender lesions: this pattern often responds better to hormonal therapy than topicals alone. Polycystic ovary syndrome should be considered if there are other features. Screening bloods and consideration of combined hormonal contraception or spironolactone often reshape the plan. More on the endocrine aspects is on our dermatology pages.

What to bring to your GP appointment

1. A list of every treatment you have tried, for how long, and at what dose.
2. Photographs of the current state if they are hard to see in the lighting of the room.
3. A simple statement of what is bothering you most: appearance, pain, scarring, mental impact.
4. Your current skincare routine, including any over-the-counter products.
5. If female, current contraceptive method and menstrual pattern.

Realistic expectations

Topical treatments take six to twelve weeks to show benefit. Oral antibiotics typically show improvement at four to six weeks. Hormonal treatments work over three to six months.

Isotretinoin clears most patients over six to nine months. Patience is part of the prescription.

Switching every three weeks because nothing seems to be happening is the single most common reason for treatment failure that is not actually a treatment failure.

Final word

Acne responds to systematic, consistent treatment with a GP who is willing to follow the ladder rather than hand out repeat scripts for short antibiotic courses.

If your current plan is not working after a properly completed twelve weeks, escalate. If scarring is starting, escalate faster.

The goal is clear skin and, equally, the prevention of the psychological and cosmetic legacy that untreated acne can leave behind. The tools are excellent.

We just have to use them properly.

Further reading: our acne treatment overview, acne therapy options and general dermatology pages.

the Prescriptsy editorial team

Skincare basics around any prescribed regimen

Topical prescriptions fail when the underlying routine undermines them. My standard advice:

• Cleanser: a gentle, non-foaming, pH-balanced cleanser twice daily. Nothing gritty, nothing with alcohol, nothing marketed as "deep pore".
• Moisturiser: non-comedogenic, fragrance-free. Apply morning and night. A well-moisturised skin tolerates retinoids much better than dry skin.
• Sunscreen: broad-spectrum SPF 30 minimum, every morning, whether sunny or not. Many modern gel or fluid sunscreens feel imperceptible on acne-prone skin.
• Avoid: physical scrubs, alcohol-based toners, high-concentration AHA/BHA products during active prescription therapy.

When to start combination therapy from the outset

For patients with moderate acne and visible scarring or strong psychological impact, I skip the pure topical monotherapy tier and start at:

1. Topical: adapalene plus benzoyl peroxide (Epiduo) every evening.
2. Oral: lymecycline 408 mg or doxycycline 100 mg once daily for twelve weeks.
3. Review at six weeks for side effects, at twelve weeks for efficacy.
4. In females: hormonal option considered alongside or after the antibiotic course.

Psychological impact

Acne is strongly associated with low mood, anxiety and social withdrawal, particularly in adolescents and young adults.

I screen for this at every acne review because it changes the urgency of escalation.

A patient whose acne is "only" moderate but whose mental health is suffering is a candidate for faster referral and sometimes earlier isotretinoin consideration.

If you feel low or anxious about your skin, say so to your GP. It is not cosmetic. It is clinical.

Managing flares

Cystic or nodular single lesions can be treated in clinic with an intralesional steroid injection (dilute triamcinolone), producing rapid flattening within 48 hours. Useful before an important event or when a single painful nodule is disproportionate to the rest.

Maintenance once clear

Relapse is common if treatment is stopped abruptly. Topical retinoid (adapalene) maintenance three to five nights a week, with continued sunscreen and gentle skincare, is the evidence-based approach to keep skin clear. Antibiotics should not be part of long-term maintenance.

Acne mechanica and masks

Friction from helmets, sports equipment, face masks and chin straps can trigger acne mechanica. Keep skin clean, use a non-occlusive moisturiser, and rotate mask styles or materials where possible. This is a common accelerator I still see in post-pandemic practice.