Acne — what works, what doesn't, and why most over-the-counter routines disappoint

In brief

• Acne is a chronic inflammatory condition of the hair follicle and its oil gland, not a sign of dirty skin.
• Most acne is controlled by daily topical treatment, usually a retinoid with benzoyl peroxide, given 8 to 12 weeks to work.
• Moderate or severe acne may need oral doxycycline, a contraceptive pill in women, or isotretinoin.
• In Asian skin, dark marks after spots (PIH) are common; good acne control and daily SPF 50+ sunscreen are the best prevention.
• Don’t pick spots or switch products every few weeks.
• Get same-day help for a severe, painful flare with fever, or for low mood or thoughts of self-harm on any acne treatment.

We assess and treat acne and acne marks at our Punggol clinic. Book a skin appointment.

What acne actually is

Acne is a chronic inflammatory disease of the pilosebaceous unit: the hair follicle and its oil (sebaceous) gland. Four things combine to cause it:

1. More oil (sebum), driven by androgens, the “male” hormones present in both sexes from puberty.
2. Plugged follicles. Skin cells and oil form a comedone (a blackhead or whitehead), the basic non-inflamed spot.
3. Overgrowth of Cutibacterium acnes, a normal skin bacterium that thrives in the plugged, oily follicle.
4. Inflammation from the bacteria and the immune response, causing red papules, pustules and deeper nodules.

• Acne is not caused by dirty skin. Scrubbing or “deep cleaning” worsens inflammation and can’t reach the plug inside the follicle.
• Acne is not a phase to wait out. Many teenagers outgrow it, but meanwhile, sometimes for years, uncontrolled acne causes scarring and marks that outlast the spots. Treat it early.
• Acne is chronic, more like asthma or eczema than a one-off rash. Most people need a maintenance routine after the spots settle, or it returns.

What acne looks like at different ages

Adolescent acne (typically ages 11–18)

It usually starts around puberty, often earlier in girls:

• Comedones on the T-zone (forehead, nose, chin), then red papules and pustules spreading over the cheeks.
• In more severe cases, deep nodules and cysts on the face, upper chest and back.
• Often worse with exams, sport, hot weather and periods.

Boys tend to have more severe acne, from higher androgen levels, and more back and chest involvement. Girls more often have a mix of comedones and inflamed spots.

Adult acne (typically ages 25–40s)

A real and increasingly common pattern, particularly in women:

• Mainly on the lower face, jawline and chin (the “U-zone”).
• More inflamed papules than comedones, often deep, tender and slow to settle.
• Cyclical, often worse before periods.
• May coexist with adult-onset rosacea, a different condition that may need different treatment.
• Sometimes triggered or worsened by stopping the combined oral contraceptive pill, by PCOS, or by stress and lack of sleep.

Adult acne can continue from the teens or start in adulthood. It is mostly hormonal and inflammatory, not a sign of being unclean or using the wrong products.

Late adult-onset acne (40s and beyond)

Less common, and worth a closer look. Possible triggers include:

• Hormonal changes: perimenopause or, rarely, androgen-secreting conditions.
• Medications: corticosteroids (oral or inhaled), lithium, certain anti-epileptics, anabolic steroids, some immunosuppressants, and hormonal supplements bought online.
• PCOS that has been low-grade for years and is now showing.
• Cushing’s syndrome: rare, but worth considering if other features are present.

If acne first appears in your 40s or later, see us rather than buying over-the-counter products. Treatment depends on the cause.

The Asian-skin angle — post-inflammatory hyperpigmentation (PIH)

In Asian and other deeply pigmented skin, an inflamed spot is likely to leave a brown, grey or violet mark, even without scarring. The mark can last weeks to many months. This is post-inflammatory hyperpigmentation (PIH), and many of our patients find it more distressing than the acne.

• PIH is not scarring. It is a flat patch in structurally normal skin, and it fades with time. Scars change the skin’s texture (dips or raised tissue) and behave differently.
• PIH responds to treatment, but slowly: typically 3 to 6 months of consistent topical treatment and sun protection, sometimes longer.
• Good acne control is the best prevention. Less inflammation means less pigmentation, a clear reason to treat acne rather than tolerate “a few spots”.
• Sun protection matters more than any treatment. UV light drives new pigment, slows fading and undoes topical treatment. Use a broad-spectrum SPF 50+ sunscreen daily, applied generously and reapplied every 2–3 hours outdoors, with hats and shade where possible.

We treat PIH actively; see acne scarring and post-inflammatory marks below.

What you can do day-to-day

Skincare for acne is simple, and the principles overlap with our eczema series. The usual mistake is doing too much, not too little.

A simple routine that supports treatment

• Wash twice a day with a gentle, fragrance-free cleanser. Avoid alkaline bar soaps (drying), scrubs and exfoliating brushes (they worsen inflammation), and menthol or alcohol “deep cleanse” foams (they feel fresh but irritate).
• Pat dry; don’t rub.
• Apply treatment to the whole affected area, not just visible spots. It works on the follicles, not on individual pimples.
• Moisturise if treatment dries your skin, with a non-comedogenic, fragrance-free product. “Starving the skin of oil” is a myth that leads to over-drying and rebound.
• Sunscreen every morning: broad-spectrum, SPF 50+ and non-comedogenic. It is essential in Singapore, especially on a topical retinoid or oral doxycycline, and is your main protection against PIH.

What to avoid

• Squeezing, picking or “extracting” spots at home. This drives inflammation deeper, causes scarring and greatly increases PIH. Leaving spots alone is often the biggest difference between people who scar and people who don’t.
• Switching products every 2 weeks. Acne treatments take 6 to 12 weeks of consistent use to show real benefit. Be wary of promises of faster results.
• Spot treatments on broken or popped spots. High-strength benzoyl peroxide or salicylic acid on broken skin worsens inflammation and PIH.
• Layering several actives without advice. Vitamin C in the morning, a retinoid at night, AHA/BHA at weekends and a “brightening serum” mid-week invites irritation. Less, used correctly, is more.

Singapore-specific tips

• Heat and humidity increase oiliness. Blotting paper at midday is fine; repeated washing is not.
• After exercise, rinse with water if you can. A full cleanse is needed only once, at the end of the day.
• Sweat under helmets, masks or sports gear drives forehead and cheek acne (“maskne”). Use breathable fabrics, and clean reusable headgear before wearing it again.
• Pick a sunscreen you will wear daily. Lightweight gels and fluids (Asian and European brands) are widely available if you dislike heavy creams. Ask us for suggestions.

The treatments that actually work — topical first line

Most over-the-counter routines disappoint because they aren’t strong enough or aren’t used for long enough. Topical treatment is the foundation for almost everyone with acne, at any age or severity. People on oral antibiotics or isotretinoin continue it for maintenance.

Topical retinoids — the most useful drug class

Retinoids are vitamin A derivatives that act on the follicle. They normalise the skin-cell turnover that forms comedones, reduce inflammation, and improve texture and tone. Used consistently, they are the most effective long-term acne treatment short of isotretinoin.

The main retinoids used in Singapore:

What to expect:

• Apply at night to dry skin, a pea-sized amount for the whole face. More is not better, just more irritating.
• The first 2 to 6 weeks are often worse: flushing, mild peeling, sometimes a brief flare of comedones (“retinisation”). It settles, so don’t quit at week 3.
• Real improvement comes at 8 to 12 weeks. Plan your follow-up for then.
• Skin becomes sun-sensitive, so use sunscreen every morning.
• Pregnancy: tretinoin and tazarotene are contraindicated in pregnancy and when planning one. Adapalene has limited data, so we usually pause it in pregnancy as a precaution. Tell us before starting if you could be pregnant.

Benzoyl peroxide (BPO)

A topical antimicrobial that kills C. acnes and reduces inflammation without driving antibiotic resistance. It is sold over the counter in local pharmacies at 2.5% and 5% (for example Benzac AC, Brevoxyl).

• 2.5% is usually enough. Higher strengths irritate more for little extra benefit.
• Apply a thin layer once or twice daily to the affected areas.
• It bleaches fabric, including pillowcases, towels and collars. Use white linen or colours you don’t mind fading.
• Dryness, redness and peeling are common. Use it every other day, apply less, or add a non-comedogenic moisturiser.
• Pregnancy: considered relatively safe at standard topical doses, but discuss it with us.

Topical antibiotics — only with benzoyl peroxide

Topical clindamycin (and, historically, erythromycin) was once used on its own. Current guidance is clear: use it only with benzoyl peroxide, because C. acnes quickly becomes resistant to an antibiotic used alone. Combinations such as Duac (clindamycin 1% + BPO 5%) make this easy. We now rarely prescribe a topical antibiotic alone; if you use one, ask us about pairing it with BPO.

Salicylic acid, glycolic acid, niacinamide and other “actives”

These have a place, particularly salicylic acid for comedonal acne, as it enters the follicle and helps unblock it. But they are add-ons, not replacements for a retinoid and BPO. The brand and concentration matter less than people assume.

When topicals aren’t enough — oral treatments

If you have moderate-to-severe inflammatory acne, or topicals haven’t worked well enough by 12 weeks, the next step is usually oral treatment alongside continued topicals.

Oral antibiotics

The standard choice in Singapore is doxycycline 100 mg once daily, usually for 8 to 12 weeks. It acts as both an antibiotic and an anti-inflammatory.

• Always continue the topical retinoid and BPO, for the best response and to prevent resistance.
• 12 weeks maximum, as a rule. Beyond that, the resistance risk outweighs the small extra benefit.
• Take it with food and a full glass of water, and stay upright for 30 minutes. Doxycycline can cause oesophagitis if it sticks in the gullet.
• It makes skin markedly sun-sensitive, so sunscreen is essential.
• Other side effects include occasional stomach upset, vaginal thrush and, rarely, benign intracranial hypertension. Stop it and see us if you get a severe headache with visual changes.
• Avoid it in pregnancy, breastfeeding and children under 8, as it affects tooth enamel.

If doxycycline isn’t suitable, alternatives include lymecycline, minocycline (used less because of rare but serious side effects) and, in pregnancy, erythromycin.

Hormonal therapy in women — the combined oral contraceptive pill

For women with hormonal-pattern acne (lower face, jawline, premenstrual flares), combined oral contraceptive pills (COCPs) can be a good option, especially if contraception is also wanted. The two most used for acne in Singapore:

• Ethinylestradiol + cyproterone acetate (Diane-35): historically marketed for acne and contraception together, and effective for hormonal acne. It should not be used purely for contraception without acne or hyperandrogenism.
• Ethinylestradiol + drospirenone (Yasmin, Yaz): drospirenone is anti-androgenic, and many women tolerate it well.

Before starting, we check blood pressure, BMI, smoking, migraine, family history of venous thromboembolism (VTE, or blood clots), and any breast cancer or significant liver disease. The pill carries a real, if small, increased risk of VTE, which we discuss openly first.

We review at 3 and 6 months; response is usually seen by 3 months. If the pill suits you, we usually continue it while it works and is tolerated.

Spironolactone is widely used internationally for adult female acne (off-label, as an anti-androgen). We do not currently prescribe it for acne. If you are interested, we refer you to a dermatologist or relevant specialist.

Oral isotretinoin (Roaccutane, Acnotin) — the most effective oral treatment

Isotretinoin is an oral vitamin A derivative. It gives deep, lasting improvement in moderate-to-severe acne in the great majority of patients. One course often brings long-term remission, and most people who finish a full course need no further oral acne treatment.

We consider it for:

• Severe acne: nodules and cysts, scarring, or a major psychological impact.
• Moderate acne that hasn’t responded to proper topical treatment plus at least one oral antibiotic course.
• Acne that is scarring or likely to scar, since early treatment reduces lifelong damage.
• Stubborn, frequently recurring acne that topicals alone can’t control.

How we prescribe isotretinoin at KTMC

We prescribe isotretinoin ourselves rather than routinely referring. It is teratogenic (it causes birth defects) and has real effects on the body, so we are strict about safety. Every patient agrees to:

• Baseline blood tests: full blood count, liver function (ALT/AST), fasting lipids and fasting glucose, plus a pregnancy test (urine or serum) for women of child-bearing age.
• Repeat liver and lipid (blood fat) tests after about a month or once you reach your full dose. If the results are normal and you are otherwise healthy, we don’t need to repeat them every month, and a repeat full blood count isn’t needed (AAD, 2024). We test again if your dose goes up or there is a clinical reason.
• A pregnancy test at every visit for women of child-bearing age.
• A signed consent form, kept on file, covering the risks, side effects, the absolute need for contraception, and attending follow-up.
• Effective contraception throughout treatment and for 1 month after the last dose. This is not negotiable: pregnancy on isotretinoin carries a high risk of severe birth defects. We accept the combined pill (often used alongside isotretinoin), progestogen-only contraception, an IUD/IUS, partner vasectomy (confirmed effective), or abstinence clearly chosen as the method.
• Knowing the common side effects: dry lips and skin (universal; use moisturiser and lip balm constantly), dry eyes (use artificial tears, and tell us if you wear contact lenses), occasional muscle aches, a flare in the first 4–6 weeks (sometimes severe), and rarely mood changes. Contact us the same day about any persistent low mood or thoughts of self-harm.
• No blood donation during treatment and for 1 month after.
• No vitamin A supplements or “skin booster” products, because of the risk of hypervitaminosis A.
• No waxing during treatment and for 6 months after, as the product information advises, because the fragile skin can tear.
• Ask us before any skin procedure during treatment or in the 6 months after. The old advice was to delay all procedures, but expert reviews in 2017 found too little evidence to delay many of them, such as laser hair removal, superficial chemical peels and some laser treatments. Mechanical dermabrasion and fully ablative laser are still not recommended during treatment.
• No pregnancy planning during treatment and the month after.

A typical course lasts 6 to 9 months, aiming for a cumulative dose that gives the best chance of long-term remission. We adjust the dose to your response and tolerance rather than rushing to the highest dose.

If you have significant other conditions (significant past depression, severe dyslipidaemia, liver disease, pregnancy plans) or prefer specialist-led care, we refer you to a dermatologist.

Procedures and adjuncts — a brief assessment

• Comedone extraction by a trained provider in clinic (not at home) can help persistent comedonal acne. Done badly, it scars. We do this in clinic when needed.
• Intralesional steroid injection into a single large, painful cyst can settle it within 24–48 hours and reduce the risk of scarring. We offer this in clinic; it takes about 10 minutes.
• Chemical peels: superficial salicylic acid peels can help comedonal acne and PIH. Medium-depth peels belong in aesthetic clinics.
• Light-based treatments (BLU-U blue light, IPL, photodynamic therapy): modest evidence, expensive, and rarely the right first or second step.
• Lasers (for example low-fluence Q-switched Nd:YAG) for PIH and some scarring are supported for selected uses, but specialist-led.
• Salon “acne facials” vary enormously. Some help; many cause more inflammation. We would rather see you in clinic.
• Microneedling or dermarolling at home can spread inflammation and worsen PIH in active acne, so we don’t recommend it. In trained hands it has a role in treating scars.

Acne scarring and post-inflammatory marks

To treat the marks left after acne settles, first tell apart:

• Post-inflammatory hyperpigmentation (PIH): flat brown, grey or violet marks in structurally normal skin. They fade with time.
• Post-inflammatory erythema: flat pink-red marks, more common in lighter skin and often confused with PIH.
• Atrophic scars: dips from tissue loss (ice-pick, boxcar, rolling), permanent without treatment.
• Hypertrophic and keloid scars: raised scars, more common on the chest, shoulders and jawline. The risk is higher in some ethnic groups, and in some individuals regardless of skin colour.

PIH treatment — what we use, what we refer for

We tackle PIH on three fronts at once.

1. Stop new pigmentation forming

• Treat any active acne aggressively: less inflammation means less new PIH.
• Daily broad-spectrum SPF 50+ sunscreen, reapplied every 2–3 hours outdoors. Tinted sunscreens with iron oxide also protect against visible light, which adds to pigmentation in darker skin.
• Stop picking and squeezing.

2. Topical lightening — what we use in clinic

• Hydroquinone 2–4%: the most effective topical lightening agent, used in short courses of 8 to 12 weeks with treatment-free breaks. Long-term continuous use carries a small risk of paradoxical pigmentation (ochronosis), so we supervise it.
• Azelaic acid 15–20%: gentler, usable long-term, and reasonable in pregnancy.
• Topical tranexamic acid: a newer option, increasingly available in cosmeceutical-grade products.
• Vitamin C (ascorbic acid) serum: an add-on with modest evidence; pleasant to use.
• Your topical retinoid: it speeds turnover of pigmented cells, helping PIH as well as acne.
• “Kligman-type” combinations (hydroquinone + tretinoin + low-potency steroid): potent and effective, but short courses only, under supervision.

3. Procedures — generally referred out

We do not routinely offer stronger chemical peels, low-fluence Q-switched laser, picosecond laser, or microneedling for scarring. We refer to a dermatologist or aesthetic doctor where appropriate, and tell you whether we think a procedure is worth the cost and downtime in your case.

Scar treatment — referral territory

Atrophic scars (ice-pick, boxcar, rolling) need specialist procedures: fractional CO2 laser, fractional radiofrequency microneedling (Morpheus8 and similar), TCA CROSS, subcision and dermal fillers. We can discuss what is likely to suit your scarring and refer you to colleagues we trust.

For hypertrophic and keloid scars, intralesional steroid injection (which we can do in clinic) is often first-line. Advanced cases may go to a plastic surgeon.

The most reliable way to avoid scarring is to treat acne early and properly. It is a concrete reason not to “wait it out”.

Things that may not help

Some people clearly benefit from specific changes, but the population-level evidence for these is much weaker than the marketing suggests.

• Diet: the evidence is mixed. High-glycaemic-index diets (sugary drinks, large portions of white rice, high-glycaemic snacks) and dairy are linked to worse acne in some people. Cutting them out alone rarely fixes acne; sensible eating plus proper treatment beats strict elimination. There is no good evidence that chocolate or oily food specifically causes acne.
• “Detox” diets, supplements and cleanses: no evidence of acne benefit, and some carry risk.
• Toothpaste on spots: can cause irritant dermatitis and PIH.
• Aggressive scrubbing, exfoliating brushes and “deep cleaning” salons: these usually worsen inflammation.
• Washing more than twice a day: strips the skin, which can rebound oily.
• Hot water and very hot showers: drying and unhelpful.
• Switching products every 2–4 weeks: the commonest reason people say “nothing works”. Allow 8–12 weeks before judging a treatment.
• DIY extraction tools sold online: untrained extraction drives PIH and scarring.
• Probiotic supplements: marginal evidence at best, and no substitute for proper treatment.

If something has clearly helped your skin, tell us. We would rather know.

When to come and see us

Book a visit if:

• You haven’t had a proper combined regimen (topical retinoid + benzoyl peroxide ± a topical or oral antibiotic) and your acne is moderate or worse.
• Your acne hasn’t clearly improved after 12 weeks of a consistent regimen.
• You have any scarring, current or developing.
• Dark marks (PIH) are bothering you.
• You are a woman with hormonal-pattern acne and want to discuss the pill or a referral.
• You are considering isotretinoin and want a balanced discussion of whether it suits you.
• Acne is affecting your mood, work, study or social life. This matters and deserves treatment.
• Your acne started after age 40, or has changed suddenly. Acne is sometimes a clue to something else.

Same-day attention

• A severe, painful flare of nodules and cysts with fever or feeling unwell. It is uncommon, but acne fulminans needs prompt treatment.
• Significant low mood, hopelessness or thoughts of self-harm on any acne treatment, particularly isotretinoin. Contact us the same day, or call SOS on 1767 out of hours.

Get in touch

Punggol — 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589

Joo Chiat — 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952

Email — admin@ktmc.sg

References

Guidelines and consensus statements

• Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. American Academy of Dermatology. J Am Acad Dermatol. 2024;90(5):1006.e1–1006.e30. jaad.org
• National Institute for Health and Care Excellence (NICE). Acne vulgaris: management. NICE guideline NG198, 2021 (updated 2023). nice.org.uk
• Thiboutot DM, Dréno B, Abanmi A, et al. Practical management of acne for clinicians: An international consensus from the Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2018;78(2 Suppl 1):S1–S23.e1.
• Goh CL, Noppakun N, Micali G, et al. Meeting the challenges of acne treatment in Asian patients: A review of the role of dermocosmetics as adjunctive therapy. J Cutan Aesthet Surg. 2016;9(2):85–92.

Asian skin and post-inflammatory hyperpigmentation

• Davis EC, Callender VD. Postinflammatory hyperpigmentation: A review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3(7):20–31.
• Sarkar R, Arora P, Garg KV. Cosmeceuticals for hyperpigmentation: What is available? J Cutan Aesthet Surg. 2013;6(1):4–11.
• Chan H, Chan E. A randomized controlled trial of the efficacy of low fluence Q-switched 1064 nm Nd:YAG laser for the treatment of melasma in Asians. Lasers Surg Med. 2010;42(8):712–719.

Isotretinoin — efficacy and safety

• Layton AM, Knaggs H, Taylor J, Cunliffe WJ. Isotretinoin for acne vulgaris — 10 years later: a safe and successful treatment. Br J Dermatol. 1993;129(3):292–296.
• Bremner JD, Shearer KD, McCaffery PJ. Retinoic acid and affective disorders: the evidence for an association. J Clin Psychiatry. 2012;73(1):37–50.
• Pile HD, Sadiq NM. Isotretinoin. StatPearls, 2024. ncbi.nlm.nih.gov
• Xia E, Han J, Faletsky A, et al. Isotretinoin laboratory monitoring in acne treatment: a Delphi consensus study. JAMA Dermatol. 2022;158(8):942–948.
• Spring LK, Krakowski AC, Alam M, et al. Isotretinoin and timing of procedural interventions: a systematic review with consensus recommendations. JAMA Dermatol. 2017;153(8):802–809.
• Waldman A, Bolotin D, Arndt KA, et al. ASDS Guidelines Task Force: consensus recommendations regarding the safety of lasers, dermabrasion, chemical peels, energy devices, and skin surgery during and after isotretinoin use. Dermatol Surg. 2017;43(10):1249–1262.
• Roaccutane 20 mg soft capsules. Summary of Product Characteristics, section 4.4. Electronic Medicines Compendium (UK), revised April 2026. medicines.org.uk

Hormonal therapy in adult female acne

• Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Combined oral contraceptive pills for treatment of acne. Cochrane Database of Systematic Reviews, 2012.
• Ebede TL, Arch EL, Berson D. Hormonal treatment of acne in women. J Clin Aesthet Dermatol. 2009;2(12):16–22.

Diet and acne

• Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63(1):124–141.
• Smith RN, Mann NJ, Braue A, et al. A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr. 2007;86(1):107–115.

This information is for general education only and is not a substitute for medical advice. Acne severity, treatment choice, and dosing must be individualised — please attend a consultation for assessment. v1.1 · October 2026 (v1.0 April 2026) · Review due April 2028.