Clearing Up the Acne Purge: Debunking the Misinformation

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What is the “acne purge?”

When starting a new acne treatment, many patients experience a period during which their breakouts get worse instead of better.  This has become widely known as the “acne purge.”  Many are convinced that the “acne purge” is necessary to bring the deeper pimples to the skin surface to finally “purge” them out in order to get rid of their acne once and for all.  They feel that this “purge” is actually a necessary part of the acne healing process.

Some patients are even encouraged when they experience an initial phase of worsening after starting a new acne treatment because they feel that they are finally ridding their skin of pimples that are hiding below waiting for the chance to erupt.

But what is really occurring?  Is it true that “purging” is a necessary part of effective treatment or is this just a myth?   Why do some people experience this initial flare-up of their acne when starting a new treatment?

Let’s start by looking closer at the widely held belief that pimples are hiding beneath the skin surface just waiting for their chance to make their way to the surface where they finally erupt.  This is the first misconception that needs debunking.

While it is true that the formation of pimples can occur deep within an acne-prone pore, there are many steps responsible or the ultimate development of a pimple.  Fully formed pimples are not lying beneath the skin surface waiting to break through in an episode of “purging.”   The reality is that acne-prone pores can be very susceptible to some acne treatments which can provoke the pores to become inflamed and trigger various steps that cause a pimple to form.

For example, some topical acne medications work deep inside the pores and alter the way the pores function. Some can alter the growth of the cells that line the insides of the pores.  Others can affect the bacterial growth within the pores.   These alterations among other changes that acne medications can cause have the potential to activate the pores in such a way as to cause the development of more breakouts.

So the belief that “skin purging” is a necessary step in the acne treatment process to “bring pimples, dirt and debris to the skin surface” where they are finally expelled is not accurate.  The truth is that we really don’t know the exact causes of the so called “acne purge.”  It is also important to understand that we don’t really know all of the ways that different acne medications work on acne-prone pores.

This makes it even more difficult to predict which treatments may be more likely to cause an initial ”purge” to occur.  Moreover, different patients can react differently to each medication; some may “purge” while others may not.

Which acne treatments can cause acne to “purge?”

So what treatments can cause an “acne purge?”  As it turns out, a variety of acne treatments have been associated with an initial phase of increased breakouts.  The culprits include both topical and oral medications.  Some of the most common include:

Topical medications:

Tretinoin

Adapalene

Tazarotene

Oral medications:

Spironolactone

Isotretinoin (Accutane)

Birth control pills

Spironolactone

Spironolactone is a pill that is used by acne experts to treat acne breakouts in women.  It is especially helpful for women experiencing “hormonal pattern acne,”  in which breakouts tend to be along the lower face and jaw lines and tend to worsen with the menstrual cycle.

Hormonal pattern acne also tends to be more resistant to many other acne treatments.  While it is uncommon for spironolactone to cause an initial flare of acne, we do see this occur in a small number of female patients in the beginning of spironolactone treatment.  In our experience, this “purging” phase with spironolactone does not typically improve with continued treatment, necessitating the discontinuation of spironolactone and transitioning to an alternate treatment.

Isotretinoin

Isotretinoin, more widely known by its brand name Accutane, is well known to cause worsening of acne in some patients, usually soon after starting treatment.  Estimates range from 10% to 20% of patients will experience increased acne breakouts when starting Accutane.

Commonly referred to as the “Accutane purge,” the reality is that we really don’t know the real reason that this occurs.  The presence of certain markers such as prominent plugged pores can sometimes be helpful in identifying which patients may be at greater risk of a “purge” but this is not well documented.

If not addressed right away, the “Accutane purge” can become very severe and can lead to very large, cystic breakouts and scarring.  Sometimes patients require treatment with an additional medicine to stop the inflammation if it becomes too severe. Close monitoring at the start of Accutane treatment is very important to be able to identify the early signs of worsening in order to intervene right away.

Oral Contraceptive Pills (Birth Control Pills):

Certain oral contraceptive pills (OCPs) can be very helpful in treating acne in women.  Combination birth control pills are usually the most acne-friendly choices.  The combination pills contain both an estrogen (female) and a progestin (male) hormones.

OCPs that contain only a progestin can cause acne to worsen.  Some types of progestins are worse than others for causing acne to “purge.”  Gynecologists will know which birth control pills are best suited for each patient especially when used to treat acne.  Some OCPs are even FDA-approved as acne treatments, such as Yaz, Ortho Tri-Cyclen, Estrostep Fe and Beyaz.   They can work to offset the unwanted effects of acne-causing hormones and thereby help to improve acne breakouts.

Starting or stopping treatment with a birth control pill can upset the hormone balance and lead to an acne breakout.  It is not uncommon for a woman who has been taking OCPs for many years to experience an acne flare upon stopping her OCP treatment.  The same can occur for some women when beginning a new OCP regimen.  This type of breakout can be difficult to control, often requiring more aggressive treatment.

Other medications can also cause an “acne purge.”

A variety of other medications are known to cause acne breakouts in some patients.  For example, lithium is an important medication used to treat bipolar disorder and can sometimes lead to acne.  Also, patients taking medications for seizures such as barbiturates and anticonvulsants can develop acne as a side effect.  Although stopping these medications would help to clear their acne, this is not an option because these medications are essential for keeping these conditions under control.

Other cases of medication-induced acne however, do not involve medically-necessary medications.  For example, body builders who take androgenic steroids to build muscle can often experience a significant acne breakout, often involving very large pimples and acne cysts.  Also, DHEA, a hormone that is sometimes used as an anti-aging treatment, can also lead to acne breakouts.  Women on hormone-replacement therapy are also known to sometimes develop acne as a side effect of their hormone treatment.

In general, acne caused by medications or hormones can be very difficult to treat.  Many patients depend on their medication to control their medical conditions and cannot stop taking them.  Appropriate treatment for these patients will depend on their individual circumstances.

Other causes of an “acne purge”

While most people think of the “acne purge” as something that is caused only by acne medications, there can be other causes for acne to flare.  One of the most common reasons for acne to “purge” is in response to a period of emotional stress.  For example, students who are under stress during academic exams or those experiencing a stressful work environment or encountering a stressful life event can often experience increased acne breakouts.

Another common occurrence that may prompt one’s acne to flare occurs when someone relocates to another city.  The body is on full alert to navigate within the new environment which can be a source of significant internal stress that may go unrecognized.  At the Advanced Acne Institute it is not uncommon to see a patient who is experiencing a new acne breakout after relocating from another city.

How does stress cause acne to “purge?”

Emotional stress is often implicated as a cause of increased acne break outs. Anecdotally, it is not uncommon to see students in the midst of midterm or final exams experiencing both emotional stress and acne.

Also, stressful life events or emotional circumstances can be associated with a higher tendency to have an acne flare.  Although there is some evidence supporting the connection between emotional stress and acne (1), we don’t yet have all the answers.

Some researchers believe that emotional stress can trigger the production of stress hormones in the body which can cause an increase in testosterone for example, which can be an important trigger of acne (2).  Although evidence is early, some have suggested that behavioral interventions such a biofeedback can help to reduce stress and help calm acne breakouts.

How to lessen the chances of developing an “acne purge”

Many patients prepare themselves for what they feel to be the inevitable “purging” that seems to them to be a necessary and unavoidable part of the acne healing process. Some patients are actually encouraged when their skin begins to break out more because they feel that this is a sign that their acne treatment is working by “forcing the deeper pimples to the surface” in order to finally clear their skin of acne.  This belief, however, needs some debunking.

First of all, we already learned that the “acne purge” is not caused by “forcing fully formed pimples to the top” and that different medications and treatments have varied effects on acne-prone pores which can account for the initial period of worsening.  We generally don’t understand all of the mechanisms responsible for causing acne to become worse during treatment.  Nevertheless, there are ways of lessening the likelihood of “purging.”

At the Advanced Acne Institute, when using a topical medication such a tretinoin or adapalene or another topical medication (especially in the retinoid family), one way we attempt to reduce the chances of an initial “purge” is to start the treatment very slowly.  For example, applying the medications once every two or three days until the skin adapts to the somewhat harsh effects of the therapy can be helpful in preventing an acne flare. Only after the skin accommodates to the new therapy is the frequency of application slowly increased as tolerated.  Also, starting with a low dose of the medication can be another helpful option that we may recommend.

Another helpful tip that we often recommend to our patients is to combine the harsh treatment with an effective moisturizer which can be applied before the topical prescription.  This helps to soothe the skin and maintain optimal hydration which can help to resist the irritation that can otherwise develop.  Maintaining adequate hydration is one of the key ways we attempt to help reduce irritation and the triggering of an acne flare.

Similar considerations are important for lessening the likelihood of developing an acne flare when taking an oral acne treatment as well.  For example, most dermatologists start Accutane at a low dose in the beginning of treatment, partly to lessen the chances of a significant flare. Careful monitoring by the dermatologist is also important to recognize the beginning of an “Accutane purge” so that appropriate changes can be made such as reducing the dose or temporarily stopping the treatment or even adding another medication if necessary to help reverse the initial acne flare.

The Advanced Acne Institute is a unique dermatology practice located in Miami, Florida specializing only in the treatment of acne.   We focus solely on providing the most effective treatments to help our patients achieve clear skin.  We are pleased to share our insights and perspectives in acne treatment as an educational service, however this information is provided strictly for educational purposes only and should not be considered medical advice and is not a substitute for seeking the advice and treatment by an appropriate medical professional.