Acne actives: salicylic acid, benzoyl peroxide, azelaic acid and when to stop self-treating

Acne is not one thing, which is why one product rarely fixes it. Blackheads, whiteheads, inflamed papules, deep cysts and the brown marks left behind all have different mechanisms and different answers.

Three ingredients cover most mild to moderate cases over the counter. Everything beyond them is a prescription conversation, and getting to that conversation earlier is usually cheaper than the six products bought in between.

Salicylic acid: for clogged pores

A beta hydroxy acid that is oil soluble, so it gets into the pore rather than only working on the surface. It suits blackheads, whiteheads, and the rough, congested texture people describe as bumpy skin.

• Leave-on products typically use 0.5 to 2 per cent; cleansers are usually 2 per cent.
• A cleanser is a gentler introduction, because contact time is short.
• Start three times a week. Daily use from day one is how people end up with a stripped barrier and more oil.
• It is mildly anti-inflammatory too, which helps with early inflamed spots.

Benzoyl peroxide: for inflamed spots

It kills Cutibacterium acnes and, unlike an antibiotic, resistance does not develop against it - which is why dermatologists often pair it with antibiotic treatments. It is the most effective over-the-counter option for red, inflamed pimples.

The concentration point is important: 2.5 per cent is about as effective as 5 or 10 per cent, with substantially less dryness and irritation. Higher strengths are not a stronger cure, just a stronger irritant.

Benzoyl peroxide bleaches fabric. Pillowcases, towels and collars will show it. Use white cotton where it touches, and let it dry fully before dressing.

Azelaic acid: the diplomat

Azelaic acid works on acne, on redness and on pigmentation at the same time, and it is unusually well tolerated. At 10 per cent it is a cosmetic-grade product; 15 to 20 per cent formulations are typically prescription or pharmacy in India.

It is the ingredient most often suggested when a retinoid is off the table - including during pregnancy, though that is a decision to take with your doctor rather than from a blog.

Matching the active to the problem

Mistakes that make acne worse

• Stacking three actives at once, then having no idea which caused the irritation.
• Over-cleansing. Twice a day is the ceiling; stripped skin compensates with more oil.
• Scrubs and harsh physical exfoliants on inflamed skin.
• Skipping moisturiser because skin is oily - dehydration makes oil worse, not better.
• Picking. It converts a spot that would have faded into a mark that lasts months, or a scar that lasts longer.
• Skipping sunscreen. Post-inflammatory hyperpigmentation darkens with UV, and it is the part of acne that lingers on Indian skin.

When to stop shopping and see a doctor

Painful lumps under the skin, acne that is scarring, acne across the chest and back, sudden severe onset, acne with irregular periods or unusual hair growth, or three months of honest over-the-counter effort with no change. All of those are reasons to see a dermatologist rather than buy a fourth serum.

One specific warning for India: the over-the-counter steroid-antifungal-antibiotic combination creams sold for acne and marks are medicines being used without supervision, and they make skin worse in the medium term. If a cream clears your skin in four days and wrecks it when you stop, that is what you were using.