What are the treatment options for acne vulgaris?

Treatment Options for Acne Vulgaris

For optimal acne treatment outcomes, multimodal therapy combining multiple mechanisms of action is strongly recommended as the standard approach for managing acne vulgaris. 1

First-Line Topical Treatments

Cornerstone Therapies

• Topical Retinoids (Strong recommendation, moderate evidence) 1

  • Tretinoin (0.025-0.1% in cream, gel, or microsphere gel)
  • Adapalene (0.1%, 0.3% cream, or 0.1% lotion)
  • Tazarotene (0.05%, 0.1% cream, gel or foam)
  • Mechanism: Comedolytic, resolve microcomedones, anti-inflammatory 1
  • Application: Apply thin film once daily in the evening after washing with mild soap 2

• Benzoyl Peroxide (Strong recommendation, moderate evidence) 1

  • Available in 2.5-10% concentrations
  • Mechanism: Antibacterial, prevents antibiotic resistance
  • Particularly important when using antibiotics to prevent resistance 1

• Fixed-Dose Combinations (Strong recommendations, moderate evidence) 1

  • Retinoid + benzoyl peroxide
  • Antibiotic + benzoyl peroxide (e.g., clindamycin 1%/BP 5%)
  • Retinoid + antibiotic (must be used with benzoyl peroxide to prevent resistance)

Additional Topical Options

• Topical Antibiotics (Strong recommendation, moderate evidence) 1

  • Clindamycin, erythromycin
  • Important: Never use as monotherapy due to resistance risk 1

• Azelaic Acid (Conditional recommendation, moderate evidence) 1

  • 20% formulation
  • Particularly useful for patients with sensitive skin or darker skin types
  • Helps with post-inflammatory dyspigmentation 1

• Dapsone 5% gel (For inflammatory acne, especially in adult females) 1

  • Apply twice daily
  • Note: May cause orange-brown skin discoloration when used with benzoyl peroxide 1

• Salicylic Acid (Conditional recommendation, low evidence) 1

  • Available OTC in 0.5-2% strengths
  • Comedolytic properties 1

• Clascoterone (Conditional recommendation, high evidence) 1

  • Newer topical anti-androgen option

Systemic Treatments for Moderate to Severe Acne

Oral Antibiotics

• Doxycycline (Strong recommendation, moderate evidence) 1

  • First-line systemic antibiotic
  • Should be limited to 3-4 months of use 1
  • Must be combined with topical therapy including benzoyl peroxide 1

• Minocycline (Conditional recommendation, moderate evidence) 1

  • Alternative to doxycycline
  • Higher risk of adverse effects than doxycycline 1

• Sarecycline (Conditional recommendation, high evidence) 1

  • Newer, more targeted tetracycline

Hormonal Therapy

• Combined Oral Contraceptive Pills (Conditional recommendation, moderate evidence) 1

  • For female patients, especially with hormonal pattern acne
  • Can reduce inflammatory lesions by 62% at 6 months 3

• Spironolactone (Conditional recommendation, moderate evidence) 1

  • For female patients with hormonal acne
  • Note: Potassium monitoring not needed in healthy patients 1

Severe, Recalcitrant, or Scarring Acne

• Oral Isotretinoin (Strong recommendation) 1
  • For severe acne, acne causing psychosocial burden/scarring, or acne failing standard treatments
  • Requires iPledge registration due to teratogenicity risk 4
  • Only agent effective against all 4 major pathophysiologic features of acne 5

Adjunctive Therapy

• Intralesional Corticosteroid Injections (Good practice statement) 1
  • For larger acne papules or nodules
  • Use judiciously to minimize local corticosteroid adverse events
  • Particularly for patients at risk of scarring or needing rapid improvement 1

Treatment Algorithm by Acne Severity

Mild Acne

1. First-line: Topical retinoid + benzoyl peroxide
2. Alternative: Topical retinoid + topical antibiotic + benzoyl peroxide

Moderate Acne

1. First-line: Topical retinoid + benzoyl peroxide + oral antibiotic (preferably doxycycline)
2. Alternative for females: Topical therapy + hormonal therapy (COC or spironolactone)

Severe Acne

1. First-line: Oral isotretinoin
2. Alternative: Topical retinoid + benzoyl peroxide + oral antibiotic + consider intralesional corticosteroids for nodules

Important Clinical Considerations

• Limit systemic antibiotic use to 3-4 months to prevent bacterial resistance 1
• Maintenance therapy with topical retinoids is essential after successful treatment 1
• Adapalene has superior tolerability compared to other retinoids while maintaining efficacy 6
• Combination therapy targets multiple pathogenic factors simultaneously and is more effective than monotherapy 5
• Patient education about proper application and expected timeline for improvement is crucial 2
• Tretinoin application: Wait 20-30 minutes after washing face, apply small amount, avoid eyes/mouth/nose corners 2

Common Pitfalls to Avoid

1. Topical antibiotic monotherapy - leads to bacterial resistance
2. Excessive washing or scrubbing - can worsen acne 2
3. Discontinuing treatment too early - improvement typically takes 6-12 weeks 2
4. Using too much topical medication - increases irritation without improving efficacy 2
5. Failure to address maintenance therapy - leads to relapse after successful treatment
6. Not combining benzoyl peroxide with antibiotics - increases resistance risk

The 2024 guidelines 1 represent the most current evidence-based approach to acne management, emphasizing multimodal therapy targeting different aspects of acne pathogenesis for optimal outcomes.