When a new acne treatment seems to make things worse

Starting acne treatment can be a frustrating experience. You have finally decided to do something about your skin, only to notice more spots, redness or inflammation. The immediate question is usually: “Is this purging, or is my skin reacting badly?”

That distinction is important. Although some treatments can be followed by an initial flare or adjustment period, not every new breakout should be dismissed as purging.

At Adare Dermatology Clinic London, we see patients who have spent weeks or months trying to work out why their skin is not responding as expected. Sometimes the answer is simply that a treatment needs more time. Sometimes the skin needs a gentler approach. And sometimes what looks like acne is actually another condition altogether.

Purging is not a catch-all explanation

The word “purging” is widely used in skincare, particularly when discussing products that increase skin-cell turnover. It describes the idea that existing microcomedones come to the surface more quickly, resulting in a temporary increase in blemishes.

However, the term can be misleading if it is used to explain every deterioration in the skin. A persistent rash, intense burning, marked swelling or widespread irritation may point towards intolerance rather than purging.

The same principle applies to prescription acne treatment: the expected response depends on the medicine, the severity of the acne and the individual patient.

What happens when severe inflammatory acne is treated with isotretinoin?

Isotretinoin remains an important treatment for severe acne, particularly when acne is inflammatory, scarring or has not responded adequately to other treatments. It is a prescription medicine that requires appropriate medical assessment and monitoring.

One issue we discuss carefully with patients is the possibility of a significant early worsening of acne. This can be particularly relevant in patients who begin treatment with severe inflammatory disease.

Patients are advised to contact their dermatology team if they develop a substantial deterioration. We also ask them to pay attention to changes outside their usual pattern of acne. For example, new and significant breakouts on the chest or shoulders, where acne was not previously present, should not simply be labelled as a purge without medical advice.

In selected cases, a dermatologist may adjust the treatment plan and may use a short course of low-dose oral corticosteroids to help settle a severe inflammatory flare.

The important point is that patients should have a clear route back to their specialist if their skin changes significantly.

Most people with acne need a plan, not necessarily isotretinoin

Isotretinoin is not the answer for every patient. In fact, many people with acne vulgaris can achieve substantial improvement through a well-designed skincare routine combined with appropriate topical or oral treatment when needed.

A good routine should be realistic enough to follow every day. Acne is influenced by sebum production, blocked pores, inflammation and the activity of Cutibacterium acnes. Consistency therefore matters.

At Adare Dermatology, skincare may form part of the overall treatment plan. For suitable patients, we may recommend the Reform Skincare anti-blemish range to help manage oiliness and exfoliate the skin.

But effective acne care is not simply about removing oil. Over-cleansing and excessive exfoliation can leave the skin irritated and compromise the barrier.

The balance between treating acne and protecting the skin

Acne-prone skin still needs hydration. Depending on the patient's skin and treatment, products such as vitamin B5 gel and an oil-free moisturiser may be useful for supporting the skin barrier.

Daily sunscreen is also important. This becomes particularly relevant when using active acne treatments, as the skin can be more sensitive to the effects of the sun.

The aim is to create a routine that controls oil and congestion without leaving the skin uncomfortable, excessively dry or inflamed.

When prescription treatment is the next step

Sometimes skincare alone is not sufficient. A dermatologist may recommend medicines such as benzoyl peroxide, topical retinoids such as tretinoin, or topical antibiotics where clinically appropriate.

For some patients, oral treatment is more suitable. Depending on the type of acne and the patient's circumstances, options can include oral antibiotics, spironolactone or certain hormonal contraceptive treatments.

One of the biggest challenges is expectations. Acne medicines are not overnight treatments. Many need around eight to twelve weeks before their effectiveness can be properly judged.

So if you have started an appropriate treatment and your skin has not transformed after a week or two, that does not necessarily mean it has failed. Conversely, a significant deterioration should not simply be ignored because someone has told you to “wait for the purge.”

Could it be something other than acne?

One of the advantages of a dermatology assessment is that the diagnosis can be reconsidered if the skin is not behaving as expected.

Not every facial spot is acne. Folliculitis, perioral dermatitis and other inflammatory conditions can produce acne-like bumps. Some patients also have overlapping conditions, making the picture more complicated.

Occasionally, less common diagnoses need to be considered as well. This is why repeatedly changing products without establishing what is actually causing the problem can become an expensive and frustrating cycle.

If your skin has been treated as acne for a long time without satisfactory improvement, it may be worth stepping back and asking whether the diagnosis is correct.

When should you speak to a dermatologist?

There is no need to wait for a routine follow-up if you are experiencing a major change in your skin. Contact your treating clinician if you develop significant worsening, marked inflammation, a new rash, substantial irritation or breakouts in areas that are unusual for you.

For routine acne management, we often reassess treatment after around three months. This gives many therapies enough time to demonstrate whether they are working.

If the original approach has not achieved enough improvement, the plan can then be adapted rather than simply continuing with something that is not delivering the result you want.

Beyond the basics: peels, lasers and personalised treatment

For some patients, the priority is controlling active acne. For others, the focus eventually moves towards residual pigmentation, texture or scarring.

Once the acne itself is appropriately managed, treatments such as chemical peels or laser procedures may be considered for suitable patients. These should always be selected according to skin type, the problem being treated and the patient's expectations.

The most effective plan is therefore rarely a single product. It is usually a combination of diagnosis, skincare, medical treatment and, where appropriate, procedural treatment.

A more convenient way to access dermatology advice

Finding timely specialist dermatology care can be difficult, particularly when you are trying to fit appointments around work and family commitments.

Adare Dermatology Clinic London offers virtual dermatology consultations, providing patients with an alternative way to access specialist advice without always needing to attend the clinic in person.

We also offer photo consultations for selected concerns. This can be useful for patients who already have a skincare routine but need additional advice or may benefit from prescription treatment.

For people who are primarily looking for help choosing skincare rather than a medical diagnosis, Reform Skincare also offers an AI-based skin analysis. This can provide product guidance, although it should not replace medical assessment where acne is severe, persistent, scarring or otherwise concerning.

The bottom line: don't guess what your skin is doing

An increase in spots after starting a new acne treatment does not automatically mean that your skin is purging. It could be a temporary treatment response, irritation, an allergic reaction, a medication-related flare or a sign that the underlying diagnosis needs another look.

The right response depends on the treatment you are using and what your skin is doing.

For patients with severe inflammatory acne, particularly those taking isotretinoin, having access to a dermatology specialist is especially important. For everyone else, a carefully chosen skincare routine and evidence-based treatment can often make a substantial difference.

If your acne is persistent, changing or simply not responding as expected, getting the diagnosis right may be the most important step of all.