For a long time, acne plateaus were seen as a sign of failure or acne resistance to treatment. As always, the truth is much more complex and interesting. A better way to understand plateaus is that they are the product of a biological transition or evolution of acne. This is because acne is a dynamic condition with numerous drivers. What often happens is even if you successful treat the dominant driver, a remaining unaddressed one can takeover. That’s why you can get improvement for weeks or months before stopping or even relapsing despite consistently using the same treatment. In this article, we’ll explore the biology behind acne plateaus and how to avoid them.
What Happens in the Early Stage of Acne Treatment?
Acne is a complex process involving an interplay between follicle dysfunction, excess oil production, hormone sensitivity and barrier stress. These can block pores leading to breakouts which may present as comedones or inflammatory acne lesions. Most acne treatments act on one of these pathways and usually address the dominant pathway. For example, antibiotics reduce bacterial overgrowth and suppress inflammation which reduces inflammatory acne lesions like papules, pustules and cysts. Retinoids like tretinoin and exfoliants like salicylic acid accelerate follicular turnover which helps prevent pore clogging. Where there is hormone sensitivity, medications like spironolactone can help reduce oil production by the sebaceous glands to reduce.
Usually, if the treatment targets the correct dominant driver (or drivers as there may be more than one), there is a gradual improvement of the acne. This takes at least 8-12 weeks but patients who respond then see progress compound over the following weeks or months. However, once the dominant driver is under control, a switch happens where residual untreated ones become the rate limiting step. At this stage, without treatment to address these secondary drivers the rate of progress stalls.
Why Does Driver Switching Happen?
Driver switching occurs because acne is a dynamic and highly adaptic skin condition. Although multiple biological pathways contribute to acne at the same time, they don’t all exert equal influence. So when therapy successfully suppresses the dominant driver, the skin rebalances. As a result, secondary drivers that were previously masked become more influential and begin sustaining the acne instead. A typical example of this is hormonal sensitivity. This often becomes more apparent once you address other common drivers of acne like abnormal cell turnover. This shift presents as plateaus and is a sign that the biology of the acne has changed. The main reasons driver switching happens include:
- Changes in the follicular environment: Acne treatments alter oil composition, microbial balance, oxygen levels and immune signalling within the pore. These changes can often lead to a change in acne behaviour. For example immune and bacterial suppression can control inflammatory acne but make the environment more favourable to comedonal acne instead.
- Barrier stress: Many effective acne treatments can disrupt the skin barrier. Over time and without support, persistent barrier impairment and micro-inflammation can emerge as new drivers and usually lead to inflammatory acne lesions.
- Microbiome shifts: Changes in the follicular microbiome can also influence plateaus and can occur due to factors like use of antimicrobials or changes in oil levels. Imbalance of the skin microbiome can result in acne forming bacteria overgrowth cause flareups or plateaus.
Does Driver Switching Always Happen?
It’s worth pointing out that although driver switching is common, it is not inevitable. It is less likely when acne is mild, driven by a single mechanism or if treatment targets multiple pathways. Even if you have severe acne and are using a single treatment, you shouldn’t automatically assume you’re in a plateau. This is because treatment of acne takes time and initially progress can be cyclical or even non existent. You see, follicles operate on a cycle measured in weeks. As such, microcomedones (the precursors to acne) form long before visible pimples appear.
When you start an acne modifying treatment like retinoids or hormone blockers, it prevents future microcomedones from forming. It does not really do much for the existing ones and in fact treatments like retinoids and exfoliating acids can speed up their journey to the surface of the skin which is why you get purging. This means that the breakouts you see at any given time are due to a process that started 4-8 weeks earlier. So if you start a treatment and notice a slow down in response, give it at least 8-12 weeks to make sure before making changes.
How to Hack the Biology of Acne Plateaus
Avoiding an acne plateau centres around anticipating change. Because the biology of acne evolves over time, the most effective treatment plans are those that adapt before progress plateaus. As such, the goal is to prevent a single pathway from becoming over-controlled while others are left unaddressed and ready to take over. You can hack the biology of acne plateaus to reduce the risk of driver switching through:
- Treat multiple pathways from the outset: Acne responds best when follicular turnover, inflammation, oil production and barrier health are addressed together. This reduces reliance on a single dominant mechanism and makes it less likely that another driver will step in to sustain breakouts.
- Support the skin barrier alongside active treatment: Barrier stress is a common secondary driver of acne. Maintaining hydration and lipid balance also allows you to consistently tolerate active acne treatments without triggering inflammation.
- Adjust treatment as the acne changes: A shift in acne type like fewer comedones, more inflamed spots or increasingly cyclical flares is often an early sign that the dominant driver has changed. Small, adjustments can help prevent plateau.
- Avoid over-reacting: Increasing strength or frequency of the same treatment without addressing the new limiting factor is not usually effective and may even make things worse.
- Reassess at biological milestones: Acne should be reviewed at key intervals, particularly around the 8–12 week mark and again after several months of stability. These are common points at which driver switching begins to emerge.
Acne is a complex and dynamic condition which can make it hard to treat. Even with the right treatment, progress is rarely linear. Plateaus are part of this journey and are a sign that the underlying biology of acne has shifted. The best way to avoid them is to tackle several drivers of from the beginning, protect your skin barrier and adapt your treatment to how your acne responds.
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 provider for any medical concerns or questions you might have.
