What are the treatment options for acne vulgaris?

Treatment Options for Acne Vulgaris

The first-line treatment for acne vulgaris is a combination of topical retinoid plus benzoyl peroxide 2.5-5%, with treatment selection based on acne severity and patient-specific factors. 1

Treatment Algorithm Based on Severity

Mild Acne

• First-line: Topical retinoid (tretinoin, adapalene, tazarotene, or trifarotene) + benzoyl peroxide 2.5-5%
  • Retinoids are comedolytic, resolve microcomedones, and have anti-inflammatory properties
  • Benzoyl peroxide has antimicrobial properties without causing bacterial resistance 1
• Alternative options:
  • Topical clascoterone
  • Salicylic acid
  • Azelaic acid (particularly beneficial for post-inflammatory hyperpigmentation in darker skin types) 1

Moderate Acne

• First-line: Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%) 1, 2
• If insufficient response: Add systemic antibiotic (preferably doxycycline)
  • Low-dose doxycycline (40 mg daily or 20 mg twice daily) is recommended
  • Treatment duration should be limited to 12 weeks when possible to prevent bacterial resistance 1

Severe Acne

• First-line: Systemic antibiotic + topical retinoid + benzoyl peroxide 1
• If ineffective or scarring present: Oral isotretinoin 0.25-0.4 mg/kg/day for 16-20 weeks 1

Hormonal Acne

• Consider adding: Hormonal therapy (combined oral contraceptives or spironolactone) in addition to topical therapy 1
• FDA-approved COCs for acne:
  • Ethinyl estradiol/drospirenone
  • Ethinyl estradiol/norgestimate
  • Ethinyl estradiol/norethindrone acetate/ferrous fumarate
  • Ethinyl estradiol/drospirenone/levomefolate 1

Proper Application of Topical Treatments

Tretinoin Application

1. Wash with mild soap and dry skin gently
2. Wait 20-30 minutes before applying (skin must be completely dry to minimize irritation)
3. Use a small amount (half inch or less) for the entire face
4. Apply lightly by dabbing on forehead, chin, and cheeks, then spreading over affected areas
5. Apply once daily before bedtime 3

Important Considerations for Tretinoin

• May cause initial discomfort or peeling during first 2-4 weeks
• New blemishes may appear at 3-6 weeks (purging phase)
• Significant improvement typically seen after 6-12 weeks
• Keep away from corners of nose, mouth, eyes, and open wounds
• Apply moisturizer in the morning 3

Treatment Monitoring and Follow-up

• Assess improvement after 6-8 weeks of treatment
• Initial improvement should be noticeable within 3 weeks
• Maximum lesion reduction typically occurs after 8-12 weeks
• Continue treatment even after improvement is seen 1

Special Considerations and Contraindications

Contraindications

• Tretinoin: Pregnancy, breastfeeding 3
• Doxycycline: Children under 8 years, pregnant or breastfeeding women 1
• Isotretinoin: Pregnancy, breastfeeding women 1
• Spironolactone: Pregnancy, breastfeeding women 1
• COCs: Women over 35 who smoke (increased cardiovascular risk) 1

Potential Side Effects

• Topical retinoids: Dryness, peeling, erythema, burning/stinging 4
• Isotretinoin: Teratogenicity (requires iPledge registration), potential mental health effects 5, 6
• COCs: Slightly increased risk of venous thromboembolism with drospirenone (10 per 10,000 woman-years) compared to levonorgestrel-containing COCs (3-9 per 10,000 woman-years) 1

Adjunctive Measures

Lifestyle Modifications

• Reduce consumption of high-glycemic foods
• Consider limiting dairy intake 1

Maintenance Therapy

• Topical retinoids are indicated for maintenance therapy to prevent recurrence
• Studies show adapalene gel 0.1% maintains improvement with a maintenance rate of 84.7% vs. 63.5% with vehicle 7

When to Refer to a Dermatologist

• Moderate to severe acne
• Acne causing psychological distress or scarring
• No improvement with lifestyle changes after 4-6 weeks 1