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 shift in acne. This is because acne is a dynamic condition with many drivers. What often happens is that even if you successfully treat the dominant driver, a remaining unaddressed one can take over. That’s why you can improve for weeks or months, then stall or even relapse despite 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 a mix of follicle problems, excess oil, 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 one. 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 speed up follicular turnover, which helps prevent pore clogging. Where there is hormone sensitivity, medicines like spironolactone can help reduce oil from the sebaceous glands.
Usually, if the acne treatment targets the correct dominant driver (or drivers), the acne improves slowly. This takes at least 8 to 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 adaptive 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 once masked become more active and begin sustaining the acne instead. A typical example of this is hormonal sensitivity. This often becomes clearer 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 make-up, microbial balance, oxygen levels and immune signalling within the pore. These changes can often lead to a change in how acne behaves. For example, immune and bacterial suppression can control inflammatory acne but make the environment friendlier to comedonal acne instead.
- Barrier stress: Many strong acne treatments can disrupt the skin barrier. Over time and without support, ongoing barrier damage 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 the use of antibiotics or changes in oil levels. An imbalance of the skin microbiome can allow acne-forming bacteria to overgrow and cause flare-ups 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 treated across multiple pathways. Even if you have severe acne and are using a single treatment, you shouldn’t just assume you’re in a plateau. This is because treatment of acne takes time, and progress can initially 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. In fact, treatments like retinoids and exfoliating acids can speed up their journey to the surface. This is why you get purging. This means the breakouts you see now began as a process 4 to 8 weeks earlier. So if you start a treatment and notice a slowdown in response, give it at least 8 to 12 weeks before making changes.
How Do You Hack the Biology of Acne Plateaus?
Avoiding an acne plateau centres on expecting change. Because the biology of acne changes over time, the best treatment plans are those that adapt before progress plateaus. As such, the goal is to stop one pathway from becoming over-controlled. You do not want others left unaddressed and ready to take over. You can hack the biology of acne plateaus and reduce the risk of driver switching in the following ways:
- Treat multiple pathways from the outset: Acne responds best when follicular turnover, inflammation, oil production and barrier health are addressed together. This leans less on a single dominant driver and makes it less likely that another 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 lets you keep tolerating 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 a plateau.
- Avoid over-reacting: Increasing the strength or frequency of the same treatment without addressing the new limiting factor does not usually work and may even make things worse.
- Reassess at biological milestones: Acne should be reviewed at key intervals, around the 8 to 12 week mark and again after several months of calm. 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 acne 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 from the beginning. You should also 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 professional with any concerns about your skin or treatment options.
