What is the first-line management option for mild facial acne?

From the Guidelines

The first-line management option for mild facial acne is topical retinoids, particularly adapalene 0.1% gel or tretinoin 0.025% cream, as recommended by the guidelines of care for the management of acne vulgaris 1.

Key Recommendations

• Start with a pea-sized amount for the entire face, applying to clean, dry skin, and begin with application every other night for 2-3 weeks, then increase to nightly use as tolerance develops.
• Combine this with gentle cleansing twice daily using a mild, non-comedogenic cleanser.
• Benzoyl peroxide 2.5% or 5% can be added in the morning if needed, but introduce products gradually to minimize irritation, as supported by the strong recommendation for benzoyl peroxide 1.

Rationale

• Topical retinoids are vitamin A derivatives that are prescription agents with randomized, double-blind, placebo-controlled trials supporting their use for acne treatment, as discussed in the guidelines of care for the management of acne vulgaris 1.
• Retinoids work by normalizing skin cell turnover, preventing follicular plugging, and reducing inflammation, making them an ideal choice for comedonal acne and for use in combination with other agents for all acne variants 1.

Important Considerations

• Sun protection is essential during treatment as retinoids increase sun sensitivity.
• Patients should expect some initial dryness, redness, or mild peeling, which typically improves within 2-4 weeks.
• Improvement usually begins after 6-8 weeks of consistent use, with optimal results seen after 12 weeks of treatment.

Additional Options

• Fixed-dose combination topical retinoid with benzoyl peroxide is also a recommended option, as it combines multiple mechanisms of action and can enhance compliance with treatment regimens 1.
• Other topical agents, such as azelaic acid and salicylic acid, may be considered as adjunctive therapy or for specific skin types or concerns, but their efficacy and safety data are more limited compared to topical retinoids and benzoyl peroxide 1.

From the Research

First-Line Management Options for Mild Facial Acne

• Topical retinoids, such as tretinoin, adapalene, and tazarotene, are effective in treating mild to moderate acne 2
• Adapalene 0.1% gel is equally effective to tretinoin 0.025% or tretinoin microsphere 0.1% gel or tretinoin 0.05% cream or isotretinoin 0.05% gel in treating mild acne 2
• Benzoyl peroxide, azelaic acid, and combinations of topical agents are also first-line treatments for mild acne 3

Efficacy and Tolerability of Topical Retinoids

• Adapalene 0.3% gel is noninferior to tazarotene 0.1% gel in reducing total lesion counts at week 12 4
• Adapalene 0.3% gel has a superior tolerability profile compared to tazarotene 0.1% gel, with lower incidence of treatment-related adverse events 4
• Topical retinoids, such as adapalene and tazarotene, can be used in combination with other topical agents, such as benzoyl peroxide, to create a more targeted and complete treatment strategy 5

Guidelines for Treating Mild-to-Moderate Acne

• The American Academy of Dermatology, European Academy of Dermatology and Venereology, and Italian Society of Dermatology and Venereology guidelines recommend topical retinoids, benzoyl peroxide, and azelaic acid as first-line treatments for mild-to-moderate acne 6
• Combination therapy, including topical and systemic agents, may be necessary for more severe disease 3