What is the treatment for back acne potentially caused by Nexplanon (etonogestrel implant)?

Treatment for Back Acne from Nexplanon

For back acne potentially caused by Nexplanon (etonogestrel implant), the recommended treatment is a combination of topical retinoid with benzoyl peroxide, with consideration of hormonal therapy such as spironolactone or combined oral contraceptives for women with hormone-related acne. 1

Understanding the Cause

Nexplanon contains etonogestrel, a progestagen with androgenic activity that can stimulate sebaceous glands and trigger acne vulgaris, even at low doses 2. This hormonal influence explains why some patients develop acne after implantation.

First-Line Treatment Approach

Topical Therapy (For Mild to Moderate Back Acne)

1. Combination Therapy (strongly recommended):

   • Adapalene 0.1% gel + Benzoyl peroxide 2.5-5% 3, 1
   • Apply once daily in the evening after gentle cleansing

2. Application Tips for Back Acne:

   • Use applicators with extended handles for hard-to-reach areas
   • Consider spray formulations
   • Use benzoyl peroxide washes in the shower 1

Important: Never use topical antibiotics as monotherapy due to risk of bacterial resistance 3

For Moderate to Severe Back Acne

Add oral antibiotic therapy:

• Doxycycline 100mg once or twice daily for 8-12 weeks 3, 1
• Always combine with topical benzoyl peroxide to prevent bacterial resistance
• Limit antibiotic use to 3-4 months maximum 1
• Alternative: Minocycline if doxycycline is not tolerated 1

Addressing the Hormonal Component

Since the acne is likely related to Nexplanon's hormonal effects, consider:

1. Hormonal Therapy Options:

   • Spironolactone 50-200mg daily (for females) 1
   • Combined oral contraceptives (COCs) with anti-androgenic properties 1, 4

2. Contraceptive Management:

   • Discuss potential removal of Nexplanon if acne is severe and persistent
   • Consider switching to a COC containing cyproterone-ethinyloestradiol or drospirenone 2

For Severe, Scarring, or Treatment-Resistant Acne

Isotretinoin (0.25-0.4 mg/kg/day) with monitoring of liver function tests and lipids 3, 1

• Mandatory pregnancy prevention for women of childbearing potential
• Requires close medical supervision

Treatment Evaluation and Maintenance

• Evaluate treatment response after 8-12 weeks 1
• Most patients should see improvement within 6-12 weeks of consistent treatment
• For maintenance after improvement:
  • Continue topical retinoid + benzoyl peroxide 5
  • Gradually taper oral medications

Practical Considerations

• Start with lower concentrations of topical retinoids to minimize irritation
• Apply moisturizer to reduce dryness and irritation
• Be aware that benzoyl peroxide may bleach clothing and bedding
• Use sunscreen daily, especially with retinoid use 1
• For large, painful nodules, consider intralesional corticosteroid injections for rapid improvement 1

Treatment Algorithm Based on Severity

1. Mild Back Acne:

   • Benzoyl peroxide 2.5-5% + Adapalene 0.1%

2. Moderate Back Acne:

   • Benzoyl peroxide 2.5-5% + Adapalene 0.1% + Oral antibiotic (doxycycline)
   • Consider hormonal therapy

3. Severe Back Acne:

   • Consider isotretinoin
   • Hormonal therapy if Nexplanon-related

This treatment approach targets multiple pathogenic factors of acne: normalizing follicular desquamation with retinoids, reducing P. acnes with antibiotics and benzoyl peroxide, and addressing hormonal influence with appropriate therapies 6.