A dermatologist will examine your skin, determine your acne type and severity, rule out conditions that look like acne, and build a treatment plan tailored to what’s driving your breakouts. That plan typically combines prescription topicals, possibly oral medications, and sometimes in-office procedures. Here’s what each step actually looks like.
What Happens at Your First Appointment
Your dermatologist will start by reviewing your medical history. Expect questions about your family’s history of skin conditions, what skincare products you currently use, your diet, stress levels, allergies, and any treatments you’ve already tried. If over-the-counter products haven’t worked (which is likely why you’re there), they’ll want to know exactly what you used and for how long.
Next comes a physical exam. You’ll change into a gown, and the dermatologist will inspect your skin closely, sometimes using a small magnifying device called a dermatoscope to look at the surface layers in detail. They’re not just counting pimples. They’re looking at the types of lesions you have (blackheads, whiteheads, inflamed bumps, deep cysts), where they cluster on your face or body, and whether scarring has already started. Come to this appointment without makeup, and wear your hair loose so they can see your hairline and forehead clearly.
One critical thing happening during this exam: your dermatologist is confirming it’s actually acne. Several conditions mimic acne closely, including rosacea, folliculitis, and perioral dermatitis. The distinguishing feature of true acne is the presence of comedones (clogged pores that form blackheads and whiteheads). If those aren’t present, your breakouts may be something else entirely, which changes the treatment approach.
How They Grade Your Acne
Dermatologists classify acne by severity, and this directly determines what they prescribe. One widely used method counts inflammatory spots on half the face: 0 to 5 is mild, 6 to 20 is moderate, 21 to 50 is severe, and more than 50 is very severe. Your dermatologist may not share these numbers with you explicitly, but the category your acne falls into shapes the entire treatment plan. Mild acne usually means topical treatments alone. Moderate to severe acne often requires oral medications on top of topicals.
Prescription Topicals You’ll Likely Get
For most people, the first line of treatment is a combination of prescription creams or gels that attack acne through different mechanisms. Current clinical guidelines recommend using topicals that combine multiple approaches rather than relying on a single product.
Retinoids are the backbone of prescription acne treatment. Tretinoin, adapalene, and tazarotene all speed up skin cell turnover, which prevents pores from clogging in the first place. They come as creams, gels, and lotions. Adapalene is available over the counter at lower strengths, but your dermatologist can prescribe stronger versions.
Topical antibiotics paired with benzoyl peroxide kill acne-causing bacteria and reduce inflammation. The pairing matters because benzoyl peroxide prevents the bacteria from becoming resistant to the antibiotic. Common combinations include clindamycin with benzoyl peroxide and erythromycin with benzoyl peroxide.
Azelaic acid at prescription strength (20%) works about as well as many conventional acne treatments when applied twice daily. It’s particularly useful for people who can’t tolerate retinoids or who also have post-inflammatory dark spots, since it helps even out skin tone.
Clascoterone is a newer option that blocks hormonal activity at the skin’s surface. It’s one of the few topicals that targets the hormonal component of acne directly.
When Oral Medications Enter the Picture
If topicals alone aren’t enough, or if your acne is moderate to severe from the start, your dermatologist will add oral medications. The options differ depending on the type of acne and your sex.
Antibiotics
Oral antibiotics like doxycycline, minocycline, and sarecycline reduce inflammation and bacterial overgrowth from the inside. Guidelines recommend limiting how long you stay on them to reduce the risk of antibiotic resistance. Your dermatologist will typically pair them with benzoyl peroxide and other topicals, and the goal is usually to transition off the antibiotic once things are under control.
Hormonal Options for Women
For women whose acne is driven by hormonal fluctuations, combined oral contraceptives and spironolactone are both recommended options. Spironolactone is typically started at 50 mg daily and increased to 100 mg if needed, with further increases possible up to 200 mg for stubborn cases. It works by blocking the hormones that trigger oil production. Healthy young women generally don’t need blood work monitoring while on it. A study of nearly 1,000 young women taking spironolactone for acne found no increased rate of potassium problems compared to women not taking it. Results take time, though. Your dermatologist will reassess every few months and adjust the dose gradually.
Isotretinoin
For severe, scarring, or treatment-resistant acne, isotretinoin (once known by the brand name Accutane) is the most powerful option available. It’s the only treatment that can produce long-term remission in many patients after a single course. However, it comes with significant side effects that your dermatologist will manage carefully.
The most universal side effect is dryness: dry skin, dry lips, dry eyes. Your dermatologist will walk you through a specific skincare routine to manage this. Key strategies include applying oil-free moisturizer while skin is still damp after cleansing, using lip balm with SPF 30 or higher outdoors, and choosing products with ingredients like hyaluronic acid, glycerin, ceramides, and squalane that help the skin barrier retain moisture. Because isotretinoin causes birth defects, women of childbearing age must follow strict pregnancy prevention protocols throughout treatment.
In-Office Procedures
Beyond prescriptions, your dermatologist has several tools they can use during office visits to speed up clearing or address specific problems.
Cortisone injections are one of the most immediately satisfying. If you come in with a large, painful cyst, your dermatologist can inject a small amount of corticosteroid directly into it. This shrinks the inflammation dramatically, often within 24 to 48 hours. Clinical guidelines list these intralesional injections as a recommended practice for individual stubborn lesions.
Comedone extractions involve using a small tool to manually clear clogged pores. This is something your dermatologist does under sterile conditions, and it’s far safer than attempting it yourself at home, where you risk pushing bacteria deeper and causing scarring.
Chemical peels apply acids to the skin surface that remove the top layer, helping unclog pores and improve the appearance of mild scarring and discoloration. Recovery depends on the depth of the peel, ranging from a day or two of mild flaking to up to two weeks of peeling for deeper treatments.
Light and Laser Treatments
Dermatologists also offer various light-based therapies for acne, though these are generally used as add-ons rather than standalone treatments. No single laser or light device can treat every type of acne lesion. In studies, photodynamic therapy (which combines a light-sensitizing solution with specific wavelengths of light) reduced acne spots by about 50% over a four-week treatment period.
Results vary significantly from person to person, and most people need a series of sessions. Multiple treatments consistently deliver better results than a single session. These therapies tend to be most useful for inflammatory acne that hasn’t responded fully to conventional treatments, or when someone can’t tolerate standard medications.
What the First Few Months Look Like
One thing your dermatologist will prepare you for: acne treatment takes time, and things sometimes look worse before they improve. When you start a retinoid, your skin may go through a period of increased breakouts and irritation in the first few weeks as clogged pores are pushed to the surface faster. This is a normal part of the process, not a sign the treatment isn’t working.
Most topical treatments take 6 to 12 weeks to show meaningful improvement. Oral medications like spironolactone are assessed in three-month intervals. Your dermatologist will schedule follow-up appointments to track your progress, adjust your regimen, and address side effects. If one approach isn’t working after a reasonable trial period, they’ll pivot rather than ask you to keep waiting. The goal is always to find the combination that controls your acne with the fewest side effects, then shift into a long-term maintenance plan that keeps breakouts from returning.