Severe acne: Our favourite dermatologist Dr. Lev Naidoo talks about what it is, how to recognise it, and how to treat it.

Following our previous topic, The do’s and don’ts of acne, I now focus on severe acne: which factors mean your acne has become severe? When should you seek medical help? Is acne medication safe? How to look after your skin…

When should you see a doctor or dermatologist for your acne?

If you’ve tried over-the-counter topical products like benzoyl peroxide, addressed your diet, make-up application and skin care products as best you can and your acne persists, or if you would prefer a guided approach to your skin treatment plan from the outset, a visit to a medical practitioner would help a) to get control of your breakout, and b) to limit the extent of scarring.

How does a doctor tell when acne has become severe?

When a patient comes to me for a consultation, I look at both clinical and patient factors.

Clinical factors include the type of acne: has it become nodular (hard lumps under the skin) or cystic (inflamed, tender, red)? Does the acne only involve the face or also the chest and back?

I assess scarring factors – does the acne heal with a tendency to increased pigmentation or surface irregularities, such as underscored dips in the skin or keloidal scars?

Patient factors I take into consideration include how the patient has responded to previous treatment measures and whether the acne is affecting them either personally or professionally.

All these factors direct me to recommend the introduction of a systemic or oral treatment plan.


‘Care for acne-prone skin is often a journey based on how your acne changes, and factors like change in stress levels or season may aggravate it… Go easy on yourself!’


What can you expect from a visit to your healthcare practitioner?

The doctor will take a complete history about your acne, followed by a clinical examination. This will direct them toward a skin-care plan they consider suitable for you.

Acne that presents as blackheads and whiteheads may be treated with a combination of topical agents, such as retinoid (vitamin A) creams, antibiotics or benzoyl peroxide.

Acne that has more raised inflamed or pustular lesions will usually require an oral treatment plan. This could include an oral antibiotic for a period of four to six months. Please remember, acne is an inflammatory and not an infective process. Antibiotics are used for their anti-inflammatory effect.

Most doctors will usually script an oral antibiotic along with a topical cream – for example, a topical retinoid (vitamin A cream such as Differin) – for a synergistic effect.

For women, the combined oral contraceptive pill is an alternative option to an antibiotic. This regulates hormone production and is particularly beneficial in patients with underlying medical conditions like Polycystic Ovarian Syndrome, which may contribute to acne forming.

What can you use if an introductory management plan yields disappointing results?

Are you still experiencing breakouts despite using the above measures? Are you prone to scarring or feel your acne is affecting your personally, emotionally, or professionally?

You may then consider the option of a systemic retinoid, if your dermatologist feels this is appropriate for you. Systemic retinoids are a form of vitamin A, and options available in the country include Roaccutance, Acnetane and Orotrane.

Is Roaccutance, Acnetane and Orotane safe?

Systemic retinoids remain the gold standard for severe acne as well as acne that tends to heal with scarring.

They are an excellent treatment choice, provided dosage is tailored to the patient, you are monitored clinically and biochemically with regular blood tests, as well as advised on the affect of the medication and supportive care needed whilst on the treatment.

Are there contraindications to taking Roaccutane?

There are some situations where Roaccutane may not be taken by a patient. Females should not fall pregnant whilst on treatment, as it is associated with birth defects in the baby. Your doctor will give you more in-depth details about cautions, adverse effects and contraindications before you start treatment.

Are there alternatives to systemic retinoids that may effectively control severe acne?

Spironolactone is a testosterone-blocking medication traditionally used to control blood pressure. It may be used at a low dosage by dermatologists to treat women with severe acne. Blood tests would be required whilst on this medication, and pregnancy should be avoided whilst on it, as it may lead to feminisation of a male baby.

What supportive skin care should you use while you are on systemic retinoid treatment?

As retinoids regulate sebum (oil) production, your skin will become drier while you are on the medication. A switch to a cleanser that is less stripping or irritating on the skin is advised. I like Bioderma’s Sensibio Gel Moussant for its gentle cleansing properties.

Avoid physical scrubs and toners as they may irritate your skin and decrease tolerance of the acne medication.

LBC also recommends gentle cleansing for sensitised skin:

Noreva Actipur Dermo-Cleansing FoamNoreva Dermo-Cleansing Soap-free Gel and Bioderma Sensibio H20

Moisture is a must

Many acne sufferers don’t like to use moisturiser, because they are afraid of the skin feeling oily. Routine use of a moisturiser that is hydrating, but not oily, is important while on any form of acne care, as all forms of treatment have the tendency to dry or irritate the skin. Adding a moisturiser to your skincare routine will increase your tolerance of the medication and make your skin feel much more comfortable.

Moisturisers I recommend for my patients on systemic retinoids include Bioderma’s Sébium Hydra and Noreva’s Exfoliac Reconstructive Cream. Both are excellent products that maintain the integrity of the skin barrier against dehydration and decrease redness and sensitivity.

Lips will also become dry and flaky. This is a sign that shows you are responding to the treatment! Avoid lip-licking, which further dries out your lips, and apply a lip balm frequently. A product I like is Bioderma’s Atoderm Baume Lèvres Restorative Lip Balm. It contains a combination of shea butter, beeswax and vitamin E that restore and maintain a healthy, supple lip texture.

LBC also recommends 

Noreva Xerodiane AP+ Relipidant Balm for skin moisturisation.

Sun protection is not negotiable

Your skin will become more sun-sensitive whilst on a systemic retinoid. It is essential you adopt sun protective behaviours: use a good quality sunscreen, avoid sun exposure during peak intensity hours, seek shade when outdoors, use protective clothing as well as sun hats.

I recommend sunscreens such as Bioderma’s Photoderm Nude Touch and Bioderma’s Photoderm MAX Aquafluide. Both have a light texture with an elegant velvet matte finish.

And lastly…

If you have severe acne – especially if you have a strong family history of acne, or if you’ve been on repeated courses of treatment for control – you may benefit from a maintenance topical cream therapy to preserve the effect of the short-term oral course of treatment. Discuss this with your medical practitioner.

Care for acne-prone skin is often a journey based on how the presentation of your acne changes, and factors like alterations in stress levels or seasonal variation may aggravate the acne. Be flexible to medical advice that is changed accordingly.

As with most skin conditions, acne control works on a timeline of months – not weeks or days. Go easy on yourself!

Here’s wishing you happy skin days,

Dr. Lev






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