What are the treatment options for acne?

Treatment Options for Acne

The most effective approach to acne treatment involves a stepwise algorithm based on severity, with topical retinoids plus benzoyl peroxide as first-line therapy for mild acne, adding topical antibiotics for moderate acne, and considering systemic treatments for severe or resistant cases. 1

Treatment Algorithm Based on Acne Severity

Mild Acne

• First-line therapy: Topical retinoid + benzoyl peroxide 2.5-5% 1
  • Topical retinoids (tretinoin, adapalene, isotretinoin) act against comedones and microcomedones while providing anti-inflammatory effects 2
  • Adapalene 0.1% gel has better tolerability than tretinoin or isotretinoin with similar efficacy 2
  • Benzoyl peroxide helps prevent bacterial resistance

Moderate Acne

• First-line therapy: Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%) 1
  • Topical clindamycin 1% is effective for mild to moderate inflammatory acne 1
  • Should not be used as monotherapy due to risk of bacterial resistance 1

Severe or Resistant Acne

• First-line therapy: Oral antibiotics + topical combination therapy 1, 3

  • Doxycycline 200mg once daily or 100mg twice daily 1
  • Standard adult dosing: 200mg on first day, then 100mg/day maintenance 1
  • Maximum duration: 12 weeks to prevent antibiotic resistance 4

• For severe, recalcitrant nodular acne: Isotretinoin 1, 4

  • Requires enrollment in iPledge program due to teratogenicity risk 4
  • Contraindicated in pregnancy and breastfeeding 1, 5
  • Potential side effects include bone mineral density changes in adolescents 5

Hormonal Treatment Options

• For women with hormonal acne patterns:
  • Drospirenone-containing combined oral contraceptives are most effective for treating acne while providing contraception 1
  • Spironolactone may be considered as an adjunct therapy 1
  • Contraindicated in pregnancy and breastfeeding 1
  • May take 3-6 months to show maximum benefit 1

Maintenance Therapy

• After achieving control: Continue topical retinoid therapy 1
  • Consider reducing frequency if irritation occurs 1
  • Adapalene 0.1% is well-tolerated for long-term use 6, 7

Adjunctive Approaches

Lifestyle Modifications

• Reduce consumption of high-glycemic foods 1
• Limit dairy intake 1
• Strict sun protection to prevent post-inflammatory hyperpigmentation 1

Scar Treatment

• Important: Control active acne before initiating scar treatment 1
• Treatment options based on scar severity:
  • Mild: Topical retinoids and chemical peels
  • Moderate: Fractional laser therapy, microneedling
  • Severe: Laser punch-out technique, punch excision/elevation procedures 1

Important Clinical Considerations

• Topical retinoid side effects: Erythema, dryness, itching, and stinging, particularly during initial treatment phase 2, 7
• Monitoring for isotretinoin: Regular assessment for potential side effects including bone mineral density changes in adolescents 5
• Treatment duration: Oral antibiotics should be limited to maximum 12 weeks and always used with benzoyl peroxide and retinoids 4
• Referral to dermatologist is recommended if:
  • Acne is moderate to severe
  • Lifestyle changes don't improve acne after 4-6 weeks
  • Acne is causing psychological distress or scarring 1

Treatment Efficacy

• Tretinoin 0.025% gel can reduce acne lesion counts by 63% at 12 weeks 3
• Combination oral contraceptives can reduce inflammatory lesions by 62% at 6 months 3
• Oral antibiotics can reduce inflammatory lesions by 58% at 6 months 3