What are the treatments for acne vulgaris?

Treatment of Acne Vulgaris

Strong recommendations for treating acne vulgaris include topical benzoyl peroxide, retinoids, and/or antibiotics and their fixed-dose combinations, with oral isotretinoin strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne failing standard treatment with oral or topical therapy. 1

Treatment Algorithm Based on Acne Severity

Mild Acne

• First-line: Topical retinoid (tretinoin, adapalene, tazarotene, or trifarotene) + benzoyl peroxide 2.5-5% 1, 2, 3, 4
  • Retinoids are comedolytic, resolve microcomedones, and have anti-inflammatory properties
  • Benzoyl peroxide has antimicrobial properties without causing bacterial resistance
• Alternative options:
  • Topical clascoterone (conditional recommendation) 1
  • Topical salicylic acid (conditional recommendation) 1
  • Topical azelaic acid (conditional recommendation) 1
  • Topical dapsone 5% gel (particularly effective for adult females) 1

Moderate Acne

• First-line: Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%) 1, 2
  • Fixed-dose combinations (e.g., clindamycin/benzoyl peroxide, clindamycin/tretinoin) improve compliance 1, 2
• If inadequate response: Add oral antibiotic (preferably doxycycline) 1, 2, 5
  • Strong recommendation for oral doxycycline 1
  • Conditional recommendation for oral minocycline or sarecycline 1
  • Limit systemic antibiotic use to 12 weeks when possible 2
  • Always combine oral antibiotics with benzoyl peroxide and topical therapies 1, 2

Severe Acne

• First-line: Oral isotretinoin (0.25-0.4 mg/kg/day for 16-20 weeks) 1, 2
  • Strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne failing standard treatment 1
• Alternative: Systemic antibiotic + topical retinoid + benzoyl peroxide 2, 5
• For females: Consider hormonal therapy (combined oral contraceptives or spironolactone) in addition to other therapies 1, 2, 5
  • Conditional recommendation for combined oral contraceptive pills 1
  • Conditional recommendation for spironolactone 1

Special Considerations

Combination Therapy Benefits

• Combining topical therapies with multiple mechanisms of action is recommended as good practice 1
• Combination formulations show enhanced efficacy over individual agents with improved tolerance and better patient compliance 2

Antibiotic Stewardship

• Avoid monotherapy with topical antibiotics to prevent bacterial resistance 2
• Always combine antibiotics with benzoyl peroxide 1, 2
• Limit systemic antibiotic use to 12 weeks when possible 2

Treatment for Specific Populations

• Women with hormonal acne: Consider combined oral contraceptives or spironolactone 1, 2, 5
• Patients with darker skin types: Azelaic acid is beneficial for post-inflammatory hyperpigmentation 1

Important Precautions

• Isotretinoin: Powerful teratogen requiring strict precautions; patients, pharmacists, and prescribers must register with iPLEDGE program 5, 6
• Retinoids: May cause photosensitivity; recommend daily sunscreen use 2
• Antibiotics: Risk of bacterial resistance with prolonged use; rare risk of C. difficile colitis with topical clindamycin 1

Treatment Evaluation Timeline

• Initial improvement should be noticeable within 3 weeks 2
• Reassess efficacy after 6-8 weeks 2, 7
• Maximum lesion reduction typically occurs after 8-12 weeks 2

Adjunctive Treatments

• Intralesional corticosteroid injections for larger acne lesions (good practice statement) 1
• Consider lifestyle modifications such as reducing high-glycemic foods and limiting dairy intake 2

Common Pitfalls to Avoid

1. Using topical antibiotics as monotherapy (increases risk of bacterial resistance)
2. Not allowing adequate time for treatments to work (minimum 6-8 weeks)
3. Failing to address psychosocial impact of acne, especially with severe cases
4. Not providing proper counseling regarding potential side effects of treatments
5. Overlooking the importance of maintenance therapy after initial improvement

The most recent evidence strongly supports a stepwise approach to acne treatment based on severity, with combination therapies targeting multiple pathogenic factors being most effective for moderate to severe cases 1, 2.