What are the treatment options for acne?

Treatment Options for Acne

Topical therapies are the mainstay of acne treatment and should be used in multimodal combination therapy targeting different mechanisms of action to optimize efficacy and reduce antibiotic resistance. 1

First-Line Topical Therapies

• Topical retinoids are the cornerstone of acne treatment as they are comedolytic, anti-inflammatory, and prevent microcomedone formation 1

  • Four FDA-approved options: tretinoin, adapalene, tazarotene, and trifarotene 1
  • Adapalene 0.1% gel is available over-the-counter; other retinoids require prescription 1
  • Common side effects include erythema, dryness, and irritation which can be mitigated by reduced frequency of application and concurrent emollient use 1, 2
  • Apply once daily before bedtime after washing face and allowing skin to dry for 20-30 minutes 2
  • Therapeutic results typically appear after 2-3 weeks but may require more than 6 weeks for definitive benefits 2

• Benzoyl peroxide (BP) is an over-the-counter antimicrobial agent with mild comedolytic properties 1

  • Strongly recommended based on moderate certainty evidence 1
  • No bacterial resistance has been reported with BP use 1
  • Side effects include irritation, dryness, and fabric bleaching; lower concentrations and water-based formulations may be better tolerated 1

• Topical antibiotics (erythromycin, clindamycin) are effective but should never be used as monotherapy due to risk of bacterial resistance 1

  • Must be combined with BP to prevent development of antibiotic resistance 1

Combination Topical Therapies

• Fixed-dose combination products are strongly recommended and improve patient adherence 1, 3

  • Topical antibiotic + BP (e.g., clindamycin 1%/BP 5%) 1, 4
  • Topical retinoid + topical antibiotic (with concomitant BP use) 1, 5
  • Topical retinoid + BP 1

• Additional topical options with conditional recommendations:

  • Clascoterone (androgen receptor inhibitor) 1
  • Salicylic acid (comedolytic agent) 1
  • Azelaic acid (useful for post-inflammatory dyspigmentation) 1
  • Topical dapsone 5% gel (particularly effective for inflammatory acne in adult females) 1

Systemic Therapies

• Oral antibiotics for moderate to severe inflammatory acne 1

  • Doxycycline is strongly recommended (first-line) 1
  • Minocycline and sarecycline are conditionally recommended 1
  • Should be limited to shortest possible duration (3-4 months) and always used with topical therapy 1
  • Always combine with BP to prevent antibiotic resistance 1

• Hormonal agents for female patients 1

  • Combined oral contraceptives 1
  • Spironolactone (potassium monitoring generally not needed in low-risk patients) 1

• Isotretinoin for severe acne or patients who have failed standard treatment 1

  • Patients with psychosocial burden or scarring should be considered candidates 1
  • Traditional daily dosing is recommended over intermittent dosing 1
  • Monitoring of liver function tests and lipids is recommended, but CBC monitoring is not needed in healthy patients 1
  • Mandatory pregnancy prevention for persons of childbearing potential 1
  • No increased risk of neuropsychiatric conditions or inflammatory bowel disease based on population studies 1

Treatment Algorithm Based on Severity

Mild Acne

• First-line: Topical retinoid monotherapy for primarily comedonal acne 1, 6
• For mild inflammatory acne: Topical retinoid + BP or topical antibiotic/BP combination 1, 7

Moderate to Severe Acne

• Combination therapy with topical retinoid + BP + topical or oral antibiotic 1, 7
• For females: Consider hormonal therapy (oral contraceptives or spironolactone) 1
• For larger inflammatory lesions: Consider intralesional corticosteroid injections 1

Severe, Recalcitrant Acne

• Isotretinoin is recommended 1, 7

Important Considerations and Pitfalls

• Retinoid application tips to minimize irritation:

  • Wait 20-30 minutes after washing face before applying 2
  • Use a pea-sized amount for the entire face 2
  • Some tretinoin formulations should be applied in the evening due to photolability and should not be used with BP simultaneously 1
  • Sunscreen use is essential due to increased photosensitivity 1, 2

• Maintenance therapy:

  • Topical retinoids are recommended for maintenance after achieving control 6, 3
  • They prevent formation of new microcomedones with no risk of bacterial resistance 6

• Common pitfalls to avoid:

  • Using topical antibiotics as monotherapy 1
  • Excessive washing or harsh scrubbing which can worsen acne 2
  • Discontinuing treatment too early or at first signs of improvement 2
  • Failing to warn patients about initial "purging" phase with retinoids where acne may temporarily worsen 2