Deciding between topical and oral acne treatments is not a simple escalation from “mild” to “strong” treatment. It’s actually a complex process that needs to take a lot of data points. Doctors tend to make this decision by assessing key variable like acne type, location, severity, recurrence, skin and overall health. Of course patient preference and compliance are also factors that need consideration. That’s why two people with similar-looking skin may get very different treatments. Luckily, this is a decision your doctor will be well accustomed to making. However, understanding this logic can help you make sense of their recommendation. In this article, we’ll explore how doctors decide between oral vs topical treatments for acne.
What’s the Difference between Oral vs Topical Acne Treatments?
First of all, there are lots of acne treatments. Most come in both oral and topical forms but some are only available as one or the other. Other than how you use them, the key difference between oral vs topical acne treatments is where they act, what they influence and side effects. Topical treatments usually come in lotion, cream or gel forms. They work locally within the skin, targeting processes such as follicular blockage, hormone actions and surface-level inflammation. This makes them very effective for acne which only affects a small and accessible area such as the face or neck.
Oral treatments go into the blood stream and then reach target cells throughout the body. They can influence oil production, inflammatory signalling or hormonal pathways as well as skin cell turnover. As they act systemically, they are extremely useful when acne is widespread and affects multiple or hard to reach areas. The choice between the two isn’t a matter if which is strongest but rather depends on the type of acne, drivers and overall patient health.
How do Doctors Decide Between Them?
Doctors decide between oral vs topical acne treatments by taking into account a number of data points regarding the acne and the patient as a whole. This requires a detailed consultation to identify things like which acne drivers are dominant, behaviour of the acne, historic responses including recurrence and the general health of the patient. The critical factors to deciding between topical vs oral acne treatments include:
- Acne Behaviour: How acne behaves over time is often more important than severity. A history of rapid relapse after stopping treatment, cyclical flares or progressive worsening despite using effective topical treatments may suggest systemic control is necessary.
- Type & Location: Acne that is widespread, affects hard-to-reach areas such as the back or chest or presents with deep nodulocystic lesions is often less practical to manage with topicals alone. In some cases, oral treatment might be more appropriate for both efficacy and adherence reasons.
- Response History: If acne improves on oral antibiotics but rebounds quickly after stopping them, it indicates that the inflammatory component has been suppressed without addressing the underlying driver. This usually suggests a need for acne modifying treatments such as oral or topical retinoids.
- Key Drivers: Things like adult onset, lower-face distribution or cyclical flares point towards hormonal or systemic influences as the main driver. This makes oral or hormonal therapies more appropriate and which one often depends on distribution and behaviour of acne. Inflammatory patterns necessitate antimicrobial and immune suppressive treatment the choice of which and administration route depend on distribution, severity and past responses.
- Associated Conditions: Scarring, significant post-inflammatory pigmentation, widespread distribution or psychological distress may lower the threshold for oral retinoid treatment. This is because the cost of ongoing disease outweighs the risks of systemic intervention.
- Patient-Specific Factors: Side effects, adherence, medical history and lifestyle strongly influence treatment choice. Poor tolerance of topical irritation or purging, difficulty maintaining consistent application or contraindications to certain medications may all shift the balance toward or away from oral therapies.
What Can Topical Treatments do?
Topical acne treatments work in a number if different ways depending on the agent but what they have in common is they work at the local level. So their impact is on the patch of skin they are used on and rarely absorb into the blood stream so can not act on distant parts of the body. The value of this is it ensures you treat only the area of concern and minimise side effects. However the limitation of this is that it’s hard to target extensive body acne.
There’s also a wide variety of topical treatments including retinoids like adapalene and tretinoin which help normalise follicle behaviour and hence reduce pore clogging a key step in acne formation. Other topical agents include azelaic and salicylic acid which also help keep pores clear. Topical antibiotics and benzoyl peroxide help kill acne forming bacteria and reduce inflammation. Where hormone sensitivity is a key driver of acne, topical spironolactone and other blockers can help counteract this. Whilst topical treatments can tackle acne from a wide range of pathways, they are particularly effective in the following situations:
- Acne is localised and hence affects limited areas such as the face and neck or smaller easy to reach areas on the body. This ensures that these areas can be treated consistently and progress easily monitored.
- Lesions are predominantly comedonal or mild to moderate inflammatory pustules or papules.
- Relapse after stopping treatment is slow and gradual.
- Acne has a history of responding to topical treatments (even if modest).
- Maintenance after successful oral therapies.
- Minimising possibility of side-effects especially in those with underlying risk factors.
- Mild to moderate post acne marks and skin texture.
What do Oral Treatments do?
There are lots of different types of oral acne treatments and like topicals they target acne in a number of ways. The main actions of oral treatment include follicle normalisation and oil reduction by roaccutane, inflammatory suppression by antibiotics and hormonal treatments like spironolactone and the combined contraceptive pill. What differentiates oral acne treatments vs topicals is that they act systemically. This means they travel through the blood stream and act on the cells throughout the body. The advantage of this is they can reach deeper into the skin and target multiple areas of the body at the same time. However, there is the disadvantage of side increased side effects as these medicines also impact non-acne skin and even other organs in the body. They can also potentially interfere with other medicines that a patient might be taking. The main reasons doctors opt for oral acne treatments vs topicals include:
- Acne is widespread or affects large or hard-to-reach areas such as the back, chest or multiple body sites.
- Inflammation is deep or aggressive with nodules, cysts or rapidly spreading infection.
- Relapse is rapid after stopping topical treatment.
- There is a key ongoing hormonal driver.
- Topical treatment is unable to manage acne despite good adherence and tolerance
- Severe scarring or significant psychological impact is present
Can You Use both?
Whilst most people with mild to moderate acne respond to topical tretamenst alone, a small number require oral treatment. However, treatments like oral antibiotics often always work best in combination with topical agents like retinoids. Even doctors prescribing oral treatments may recommend using topical agents. Examples of this include benzoyl peroxide alongside oral roaccutane or pairing topical retinoids with oral hormonal treatments. The key logic behind combining them is to help address different mechanisms of the same disease process. The main benefits for combining topical acne treatments with orals is it allows doctors to:
- Stabilise active or rapidly progressing acne using oral therapy to reduce inflammatory burden whilst topical treatments begin to exert effect.
- Reduce reliance on long-term systemic treatment by transitioning control to topical maintenance once acne settles.
- Minimise relapse risk by having topicals working in the background whilst oral therapy is withdrawn.
- Adapt treatment over time by stepping oral therapy up or down as acne biology, life-style and response evolve.
Effective acne treatment requires a thoughtful and personalised approach. Whilst there are many types of acne treatments, there’s no single product or medication that works for everyone all the time. That’s why doctor’s take a data-driven approach which takes into account acne and patient specific factors to decide which treatment is best for you. Most people will require several acne treatments and the choice between oral vs topical depends on these factors. Ultimately, most people end up with a combination of both oral and topical acne treatments initially or switching between them depending on response.
At City Skin Clinic, we believe that skincare is personal and should always centre around your individual needs. Our doctors offer custom topical skin treatments for acne using ingredients like tretinoin, azelaic acid, clindamycin and spironolactone where appropriate. If you are interested in a personalised skincare treatment please use our online skin consultation form or book a video consultation. Start your treatment journey today and take your first step towards great skin.
This article is intended for general informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical provider for any medical concerns or questions you might have.
