One of the most demoralising things about dealing with acne is recurrence. Any acne sufferer will be familiar with the joy of when treatment finally works and the skin clears. However, when you stop treatment, within weeks or months, the acne returns. Even worse, this relapse is often even more severe than before. The natural conclusion is almost always the same. Most people think that either the treatment failed or, worse, the acne has become resistant. Although this seems logical, thankfully it is usually wrong. In fact, one study found that close to half of people had some recurrence after a course of treatment. In this article, we explore why acne improves and then returns after stopping treatment. We also review the best way to maintain results and prevent acne recurrence.
Why Does Treatment Only Improve Acne Temporarily?
The key thing to understand is that acne is a chronic skin condition with a number of underlying drivers. These include hormones, inflammation, excess oil production and abnormal cell turnover. Which of these is the main driver varies from person to person. The end result is either non-inflammatory lesions like whiteheads or blackheads, or inflammatory acne like pustules, papules and cysts. Sometimes it is a combination of both. Most acne treatments work either by suppressing acute inflammatory activity or by modifying the underlying drivers of acne. When effective, acne treatments can:
- Reduce inflammatory signalling
- Slow down pore clogging
- Prevent microbial overgrowth
- Control oil production
Suppressors of active inflammatory acne, such as benzoyl peroxide and antibiotics, are excellent for resolving acute breakouts. They are not normally used long-term. Acne modifying treatments like exfoliating acids, hormone blockers and retinoids can normalise oil production and cell turnover. This helps prevent the pore clogging that leads to acne formation. These acne modifying treatments work for as long as you use them. When you stop, the acne comes back.
What Can the Pattern of Acne Recurrence Tell Us?
Recurrence after stopping treatment is not random. The way acne comes back can give helpful clues as to why it happened. The key patterns to look out for include:
- Rapid: This suggests there are strong underlying drivers of acne that the treatment did not fully address.
- More inflammatory: Here it is likely that, whilst the treatment was effective, it caused a lot of irritation or skin barrier damage.
- Cyclical: This usually points towards hormonal drivers that were controlled by the treatment. You may not see recurrence straight away, and when it returns it tends to relapse and remit.
Which Treatments are More Likely to Cause Acne Relapse?
Short-course treatments, particularly antibiotics, often cause the acne to come back after stopping. This is because they reduce bacterial growth and inflammation, which can quickly improve inflammatory acne. However, they do not address the root causes of acne. So the pore blocking and eventual inflammation return once you stop them. In this case, recurrence is almost certain after stopping antibiotics. That is, unless there is an acne modifying treatment in place for maintenance. It does not mean there is resistance to antibiotics or that the treatment failed.
The same applies to treatments that modify acne behaviour, such as Roaccutane, topical retinoids, hormone blockers, chemical peels or lasers. Whilst these treat the root cause of acne, they need either ongoing use or something for maintenance. Without this, the skin eventually returns to its baseline behaviour and the acne comes back.
What Should You Not Do When Acne Returns?
A lot of people make a mistake once their acne has cleared. They stop treatment to see if it comes back. Then, when it does, they jump to the conclusion that the treatment failed. In reality, the treatment worked whilst it was present, just as it was supposed to. The acne came back because it was withdrawn. This is not a failure of treatment. It is important to understand that no acne treatment is permanent. Most people will need to continue the same treatment, or use something suitable for maintenance. Because of this mix-up, when acne reappears, most people respond in one of two ways:
- Restarting treatment at a higher strength
- Layering on extra active products to “catch it early”
Both of these aggressive approaches often worsen the recurrence, either by causing irritation, a flare-up, purging or sub-optimal treatment. Skin that has recently stopped treatment, and where the acne is relapsing, is often less tolerant of actives. The skin barrier may still be recovering, and there may be higher background inflammation. This means the relapse can look more severe and be harder to control.
How Do You Prevent Acne From Coming Back?
Preventing relapse is usually not about adding something new, but about deciding what stays in place once your skin has improved. Acne is very likely to return without ongoing maintenance. You can achieve this through some simple measures:
- Retinoids: Topical retinoids like tretinoin or adapalene reduce relapse by normalising follicular behaviour over time. As such, they help prevent pore clogging and acne formation.
- Exfoliants: Chemical exfoliants like acids or enzymes can reduce skin congestion and acne formation. Use them no more than 2 to 3 times a week at a tolerable strength, as they can cause irritation and skin barrier damage.
- Antibiotics: Oral or topical antibiotics can quickly control acute inflammatory breakouts. However, they are only for short-term use, and it’s best to avoid repeat courses where possible to reduce the risk of antibiotic resistance.
- Benzoyl peroxide and hypochlorous acid: These two agents reduce bacterial load and inflammation. Like antibiotics, they are most useful as spot treatments for active breakouts. Overusing benzoyl peroxide or hypochlorous acid can cause dryness and irritation.
- Oil control: Ingredients that absorb or modulate oil, including certain clays or mattifying agents like zinc PCA, can help reduce breakouts. However, stripping too much oil may lead to dryness and rebound oil, which can worsen acne, so use them mindfully.
- Hormone blockers: In hormonally driven acne, medicines like spironolactone can reduce the impact of androgen hormones on the oil glands and so control breakouts.
- Barrier support: Ingredients like niacinamide can reduce low-grade inflammation, support skin barrier recovery and improve tolerance to strong actives like retinoids.
Acne is a chronic condition that needs long-term management. So do not fall into the trap of thinking this is failure. Acne that improves and then returns after stopping treatment is completely normal. It simply means the treatment was doing its job while in place. Your skin just needs a suitable maintenance routine. That combines ongoing acne modifying treatments with the odd suppressor for active flare-ups.
At City Skin Clinic, we believe that skincare is personal and should always centre around your 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 professional with any concerns about your skin or treatment options.
