It’s extremely disheartening if despite using your acne treatment consistently and exercising the patience of a monk, you still get nowhere. When this happens and especially if it was previously responsive, most people fear that their acne has become treatment resistant. Whilst this makes sense and is understandable label, it is not usually what’s happening. More often, the problem is that the treatment strategy has stopped matching what is driving the acne now. Identifying this is crucial to getting your acne under control. In this article, we’ll explore whether acne can become resistant to treatment. We’ll also review what to do if your acne is no longer responding to treatment.
Does Acne Actually Become Resistant to Treatment?
To answer this, it’s crucial to realise that acne is not a single process. It is a complex condition that is driven by several overlapping processes. This includes blocked follicles, inflammation, excess oil production, hormonal signalling and the skin barrier. Often one or two of will be the main driver but this varies from person to person. Even for an individual, the main driver of their acne can change. This occurs especially in response to illness, inappropriate skincare or stress. If the main driver changes then the type of acne may also change.
When improvement stops or even worse regresses, it’s usually because the dominant driver has changed or you were not targeting the key drivers in the first place. In the case of the main driver changing, there is often a period of successful acne control or even full clearance for sometime before plateauing or recurrence. If the issue was that the main driver wasn’t being properly targeted then usually there’s some improvement. However, there’s never full clearance and at some point progress stalls or rolls back if something has exacerbated this driver. There is also a situation where acne can become resistant to treatment if you were dependent for a long time on antibiotics. In this situation, the bacteria that drives inflammatory acne can mutate and become antibiotic resistant. This can either present as no improvement at all or a period of improvement before rapid worsening.
Why Does the Dominant Driver Change?
Acne drivers change over time because acne involves multiple interacting pathways and suppressing one does not neutralise the condition as a whole. Most treatments act selectively, targeting a specific mechanism such as inflammation, bacterial activity, follicular turnover or sebum production. For example, retinoids help prevent microcomedones (which are the precursor to acne) by normalising follicular turnover. Benzoyl peroxide reduces inflammatory lesions and helps suppress bacterial overgrowth. Antibiotics reduce inflammatory signalling and bacterial load. Hormonal treatments reduce androgen-driven oil production. Each of these acne treatments can be effective, but none treat every single driver by itself.
When the target driver is under control, it often stops being the factor limiting improvement. This leads to another driver to become dominant. This is why progress can slow or plateau despite continued treatment adherence. The best way to treat acne is as a dynamic condition that is shaped by ongoing follicular changes, hormonal signalling, skin barrier function and lifestyle or environmental stressors. As such, successful treatment should seek to address more than one driver from the beginning. It should adapt to how the acne behaves over time.
What Happens if Acne Becomes Antibiotic Resistant?
Antibiotic resistance in acne occurs when Cutibacterium acnes and surrounding skin microbiome adapt to prolonged or repeated antibiotic exposure. A particular risk is using the same antibiotic again. This is especially problematic in the absence of other anti-inflammatories or acne modifying drugs like retinoids and oil regulators. This results in new strains of bacteria becoming dominant that are resistant to the antibiotics. As such this reduces the treatment’s ability to kill bacteria and suppress inflammation. It’s important to point out that this does not necessarily mean the bacteria has become more aggressive or that the acne itself has become worse. Instead, it means that the antibiotics have lost their effectiveness as an anti-inflammatory tool. As a result Inflammatory lesions become slower to respond or stop improving altogether despite continued antibiotic use. This can have a serious impact on tackling inflammatory acne as it limits the overall number of available treatments.
How Can You Tell if Acne Has Become Treatment Resistant?
As we mentioned earlier, resistance is not an absolute diagnosis but rather a signal that there’s a mismatch between the current treatment and the dominant driver of the acne. The best approach is to first of all avoid jumpoig to consluions. Acne is a dynamic process so avoid knee-jerk reactions. A good timeline is to monitor your skin for at least 8-12 weeks if you are worried that your treatment has stopped controlling you acne. Common signs that your acne has become treatment resitent usually include:
- You improved initially then plateaued for several months with no further reduction in breakouts despite consistent use.
- Breakouts return or become while you are still using the treatment correctly and consistently.
- Restarting a previously successful antibiotic no longer produces impact.
- Type of acne breakouts change for example becoming more comedonal, inflammatory, cyclical or changing location.
- Increasing dose or duration produces little additional benefit.
What to Do if Your Acne Has Become Treatment Resistant?
If your acne has become treatment resistant, the most important thing to do is avoid the temptation to escalate quickly. The solution is rarely ever a simple case of stronger actives, higher doses, more products or repeated antibiotic courses. In fact, this approach usually makes things worse. What works is taking a thoughtful approach and in the case of moderate to severe acne, always seeking medical help especially if you’re currently using prescription acne treatments. A useful approach tends to involve:
- Do No Harm: Avoid the urge to keep switching or adding products, as changing too often makes it impossible to see what is actually helping.
- Patience: Ensure that you have given your current treatment enough time to work and observe in plateau or stalling for an adequate amount of time to be sure it is happening. In general you should give your skin at least 8-12 weeks before making any changes.
- Identify Shift: Look at how your acne has changed and not just how much there is. This will help see if the dominant driver has changed. If you’re on antibiotics and the inflammatory acne has not changed but just gotten worse or stopped responding then it may have become resistant to the antibiotics. If the appearance, location or behaviour of the acne has changed then it may indicate a different driver has become dominant.
- Adherence or Tolerance: Check that you have been using your treatment correctly and consistently. Also review how well you have tolerated it as side effects like irritation, soreness, redness or peeling can lead to skipping applications without realising it. Moreover these can mask progress or make the acne look like it’s worse.
- Support Your Skin: Disruption to the skin barrier can result in inflammation and skin microbiome imbalance. All this can worsen acne as well as reduce tolerance and effectiveness of treatments.
The above approach usually allows you to tackle why your acne appears to have become treatment resistant. If there’s been a change in driver but the acne has simply plateaued rather than rebounded then you usually need to add in another agent to additionally tackle it. If you’re using antibiotics and your doctor suspects resistance then they may stop them and either change to another antibiotic or swap for another antimicrobial and anti-inflammatory like benzoyl peroxide or hypochlorous acid.
How to Prevent Acne Becoming Treatment Resistant?
If there’s one thing to take comfort in is that it’s not really possible for acne to become resistant to all treatment. It’s just a matter of the main driver changing or in the worst case scenario antibiotic resistance. Thankfully, you can help reduce the risk of these happening by taking some simple common sense precautions like:
- Consistency: avoid skipping days, spacing applications too far apart or constantly switching treatments as this undermines results.
- Tolerance: Watch for early signs of irritation such as redness, tightness or stinging and address these early on.
- Skin Barrier: Protect your skin barrier with appropriate cleansing, moisturising and sun protection. This prevents irritation, inflammation and dryness or peeling all of which can limit success and mask progress.
- Multi-Focal Approach: Try to tackle acne from a number of angles by ensuring your treatments include agents that help keep pores clear, control oil and suppress inflammation.
- Stay Flexible: Adapt to how the acne responds and how your skin looks and feels overall.
- Exercise Caution with Antibiotics: Work with your doctor to avoid long-term or repetitive courses of antibiotics. The aim is to use them for short courses when necessary alongside other acne modifying treatments rather than to rely on them.
- Vigilance: Pay attention to changes in the behaviour and appearance of your acne as this may suggest emergence of a new dominant driver.
- Seek Help: If acne persists or worsens despite good consistency especially if you’re using prescription treatments, involve your medical provider early.
If your acne has become resistant to treatment, its important to not panic. Instead, take a thoughtful stock of the situation and seek professional help if your breakouts are severe or you’re using prescription treatments. Usually all that is necessary is adding in something to tackle a driver that has become more dominant. In the case of antibiotic resistance then treatment may need to change completely. Ultimately, treatment resistance can be avoid by addressing acne from a number of angles at the outset, avoiding over reliance on a single agent and adapting to your skin’s needs.
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.
