What medications, including over-the-counter (OTC), prescription, and supplements, are used to treat acne?

Medications for Acne Treatment

The American Academy of Dermatology recommends a stepwise approach to acne treatment based on severity, with topical retinoids and benzoyl peroxide as first-line treatments for mild acne, adding antibiotics for moderate acne, and using oral isotretinoin for severe, recalcitrant nodular acne. 1

First-Line Topical Treatments

Topical Retinoids

• Mechanism: Comedolytic effects, resolves microcomedones
• Options:
  • Tretinoin (0.025-0.1%)
  • Adapalene (0.1-0.3%)
  • Tazarotene (0.05-0.1%)
• Considerations: Cornerstone of acne therapy, indicated for all acne severities and maintenance therapy 1, 2

Benzoyl Peroxide (BPO)

• Mechanism: Antimicrobial effects, prevents bacterial resistance
• Concentrations: 2.5-5% (typically sufficient for mild acne) 1, 3
• Caution: May bleach clothing, bedding, and hair due to oxidative potential 4
• Safety: Safe for use during pregnancy and lactation 4

Treatment Algorithm by Acne Severity

Mild Acne

• First-line: Topical retinoid + benzoyl peroxide 2.5-5% 1
• Alternative: Azelaic acid (has antibacterial and modest comedolytic effects) 4

Moderate Acne

• First-line: Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%) 1
• If ineffective: Add systemic antibiotic (doxycycline 50-100 mg twice daily) 1
• Important: Systemic antibiotics should always be combined with benzoyl peroxide to prevent bacterial resistance 1, 2

Severe Acne

• First-line: Systemic antibiotic + topical retinoid + benzoyl peroxide 1
• For recalcitrant nodular acne: Oral isotretinoin 0.25-0.4 mg/kg/day for 15-20 weeks 1, 5
  • FDA indication: Severe recalcitrant nodular acne unresponsive to conventional therapy 5
  • Monitoring: Requires iPledge program registration, pregnancy testing, liver function tests, lipid panels 1, 5
  • Retreatment: If needed, wait at least 8 weeks after completion of first course 5

Hormonal Acne

• Additional options:
  • Combined oral contraceptives
  • Spironolactone (100-150 mg daily) 1, 6
  • Consider for women with persistent acne 6

Topical Antibiotics

• Options:
  • Clindamycin 1%
  • Erythromycin
  • Dapsone
• Important: Should not be used as monotherapy to avoid resistant P. acnes strains 7
• Mechanism: Both antibacterial and anti-inflammatory effects 4
• Side effects: Risk of gram-negative folliculitis with long-term use 4

Common Pitfalls and Considerations

1. Treatment expectations: Inform patients that treatments typically take 6-8 weeks to show results 6
2. Antibiotic use: Avoid antibiotic monotherapy; always combine with benzoyl peroxide and limit to maximum 12 weeks 2
3. Hormonal factors: Consider hormonal therapy in women with treatment-resistant acne 1
4. Isotretinoin precautions:
   • Teratogenicity risk requires strict adherence to iPledge program 5, 2
   • Monitor for potential mental health effects, though evidence remains controversial 6
   • Not for use in pregnant or breastfeeding women 5
5. Skin irritation: Counsel patients about potential irritation when starting topical treatments, especially retinoids and benzoyl peroxide 6

Over-the-Counter Options

• Benzoyl peroxide: Available OTC in various concentrations (2.5-10%) 3, 8
• Salicylic acid: Mild exfoliating properties 8
• Tea tree oil: Some evidence for mild anti-inflammatory effects 1
• Niacinamide: May help with inflammation 1

Supplements

• Limited evidence for effectiveness of supplements in acne treatment 2
• Some evidence for low-glycemic-load diet potentially helping acne 2

When selecting acne treatments, always consider the severity of acne, potential for scarring, and patient preferences regarding side effects and treatment regimens. The goal of treatment should be to reduce inflammation, prevent scarring, and minimize the psychosocial burden of the disease.