What are the treatment options for acne?

Treatment Options for Acne Vulgaris

Topical therapies are the mainstay of acne treatment, with multimodal therapy combining multiple mechanisms of action recommended as the standard approach for optimal efficacy and to reduce the risk of antibiotic resistance. 1

First-Line Topical Treatments

Topical Retinoids

• Strongly recommended as cornerstone of acne treatment for their comedolytic and anti-inflammatory properties 1
• FDA-approved options include tretinoin, adapalene, tazarotene, and trifarotene 1
• Effective as monotherapy for primarily comedonal acne or in combination with antimicrobials for inflammatory acne 1
• Adapalene 0.1% gel is available over-the-counter; other retinoids require prescription 1
• Common side effects include erythema, dryness, and irritation which typically subside after 2-4 weeks 2
• Application tips:
  • Apply once daily before bedtime 2
  • Wait 20-30 minutes after washing face before application 2
  • Use a pea-sized amount for the entire face 2

Benzoyl Peroxide (BP)

• Strongly recommended with moderate certainty evidence 1
• Over-the-counter antimicrobial agent that releases free oxygen radicals and is mildly comedolytic 1
• No bacterial resistance reported with BP use 1
• Available in various concentrations (2.5%-10%) and formulations (gels, washes, creams) 1
• Side effects include dryness, irritation, and bleaching of fabrics 1
• Lower concentrations and water-based formulations may improve tolerability 1

Topical Antibiotics

• Strongly recommended but should not be used as monotherapy due to risk of bacterial resistance 1
• Common options include clindamycin and erythromycin 1
• Most effective when combined with BP to prevent development of resistant bacteria 1

Fixed-Dose Combination Products

• Strongly recommended for improved efficacy and convenience 1
• Options include:
  • Topical antibiotic with BP (strongly recommended) 1
  • Topical retinoid with topical antibiotic (strongly recommended) 1
  • Topical retinoid with BP (strongly recommended) 1
• Combination therapy targets multiple pathogenic factors simultaneously 3, 4

Other Topical Options

• Clascoterone: Conditionally recommended with high certainty evidence 1
• Salicylic acid: Conditionally recommended with low certainty evidence 1
• Azelaic acid: Conditionally recommended with moderate certainty evidence; useful for post-inflammatory dyspigmentation 1
• Topical dapsone 5% gel: Recommended for inflammatory acne, particularly in adult females 1

Systemic Treatments

Oral Antibiotics

• Recommended for moderate to severe inflammatory acne 1
• Options include:
  • Doxycycline: Strongly recommended with moderate certainty evidence 1
  • Minocycline: Conditionally recommended with moderate certainty evidence 1
  • Sarecycline: Conditionally recommended with high certainty evidence 1
• Should be limited to shortest possible duration (typically 3-4 months) to minimize bacterial resistance 1
• Always use with concomitant topical therapy (BP and/or retinoid) 1

Hormonal Therapy

• Combined oral contraceptives: Conditionally recommended for female patients 1
• Spironolactone: Option for female patients with hormonal acne 1
• Potassium monitoring generally not needed in patients without risk factors for hyperkalemia 1

Isotretinoin

• Recommended for severe acne or patients who have failed standard treatment with oral or topical therapy 1
• Also indicated for patients with psychosocial burden or scarring 1
• Monitoring recommendations:
  • LFTs and lipids should be monitored 1
  • CBC monitoring not needed in healthy patients 1
• Traditional daily dosing is conditionally recommended over intermittent dosing 1
• Pregnancy prevention is mandatory for persons of childbearing potential 1
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 1

Adjunctive Treatments

• Intralesional corticosteroid injections: Useful for larger acne papules or nodules at risk of scarring or for rapid improvement in inflammation and pain 1
• Physical modalities: Limited evidence for efficacy; pneumatic broadband light is conditionally recommended against when added to adapalene 0.3% gel 1

Treatment Algorithm Based on Severity

Mild Acne

1. First-line: Topical retinoid monotherapy 1
2. Alternative: BP or combination therapy with BP + topical retinoid 1

Moderate Acne

1. First-line: Combination therapy with topical retinoid + BP + topical antibiotic 1
2. Alternative: Oral antibiotic (doxycycline or minocycline) + topical retinoid + BP 1

Severe Acne

1. First-line: Isotretinoin 1
2. Alternative: Oral antibiotic + topical retinoid + BP 1
3. For females: Consider hormonal therapy (combined oral contraceptives or spironolactone) 1

Important Clinical Considerations

• Topical retinoid side effects can be mitigated by reduced frequency of application and concurrent emollient use 1
• Some tretinoin formulations should be applied in the evening due to photolability and should not be applied with BP to avoid oxidation 1
• Therapeutic results with topical retinoids should be noticed after 2-3 weeks, but more than 6 weeks may be required for definite beneficial effects 2
• An apparent exacerbation of inflammatory lesions may occur during early weeks of retinoid therapy due to action on deep, previously unseen lesions 2
• Maintenance therapy with topical retinoids is recommended after achieving control to prevent recurrence 5, 3