What are the recommended treatments for acne?

Recommended Treatments for Acne

For effective acne treatment, a combination approach targeting multiple pathogenic factors is strongly recommended, with topical retinoids forming the core of therapy for all acne types.

Treatment Algorithm Based on Acne Severity

Mild Acne

• First-line: Topical retinoid (adapalene 0.1%, tretinoin 0.025-0.1%, or tazarotene 0.05-0.1%) + benzoyl peroxide 2.5-5% 1
• Benzoyl peroxide is crucial for preventing bacterial resistance 2
• Azelaic acid can be added for post-inflammatory dyspigmentation 2

Moderate Acne

• First-line: Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%) 1
• Fixed-combination products (e.g., clindamycin 1%/BP 5%, erythromycin 3%/BP 5%) may enhance compliance 2
• If insufficient response after 4 weeks: Add oral antibiotic (doxycycline 100mg daily) for 3-4 months 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 2

Severe/Nodular Acne

• First-line: Oral isotretinoin 0.5-1 mg/kg/day (divided into two doses) for 16-20 weeks or until reaching cumulative dose of 120-150 mg/kg 1, 3
• Alternative if isotretinoin contraindicated: Oral antibiotic + topical retinoid + benzoyl peroxide 1

Hormonal Acne

• For females with signs of hyperandrogenism: Combined oral contraceptives containing anti-androgenic progestins 1
• Spironolactone 100-150 mg daily (particularly effective when combined with oral contraceptives) 1

Key Treatment Principles

1. Topical retinoids are fundamental for all acne types:

   • They address comedones, microcomedones, and have anti-inflammatory effects 4
   • Adapalene 0.1% has better tolerability than tretinoin or isotretinoin gel 4
   • Should be used for maintenance after improvement to prevent recurrence 5

2. Antibiotic stewardship is essential:

   • Topical antibiotics should never be used as monotherapy due to resistance risk 2
   • Always combine antibiotics with benzoyl peroxide 2
   • Limit oral antibiotic duration to maximum 12 weeks 6
   • Continue topical retinoids and benzoyl peroxide after discontinuing antibiotics 1

3. Isotretinoin considerations:

   • Most effective for severe nodular acne as it addresses all four pathophysiologic features 1
   • Monitor liver function tests and lipids during treatment 1, 3
   • Mandatory pregnancy prevention for women of childbearing potential 3
   • Patients, pharmacists, and prescribers must register with iPledge program 6

Common Pitfalls to Avoid

• Inadequate retinoid use: Retinoids should be the foundation of treatment for almost all acne patients 1
• Antibiotic misuse: Using topical antibiotics without benzoyl peroxide or for extended periods increases resistance risk 2, 1
• Premature treatment discontinuation: Maintenance therapy with topical retinoids is necessary to prevent recurrence 5
• Inadequate isotretinoin dosing: Insufficient cumulative dose can lead to reduced efficacy and recurrence 1
• Ignoring hormonal factors: Consider hormonal therapy for women with signs of hyperandrogenism 1

Application Tips

• Apply a thin layer of topical retinoid in the evening after gentle washing 1
• Start with lower concentrations of retinoids to minimize irritation
• Evaluate treatment response at 4-6 weeks and adjust as needed 7
• For maintenance, continue topical retinoids with or without benzoyl peroxide 5

By following this evidence-based approach targeting multiple pathogenic factors, most patients with acne can achieve significant improvement and maintain clear skin with appropriate maintenance therapy.