What are the treatment options for severe acne vulgaris?

From the Guidelines

For severe acne, I strongly recommend oral isotretinoin as the most effective treatment option, typically prescribed at 0.5-1mg/kg/day for 4-6 months, due to its ability to reduce oil production, kill bacteria, prevent clogged pores, and reduce inflammation, as supported by the most recent guidelines of care for the management of acne vulgaris 1.

Treatment Options

The treatment of severe acne vulgaris involves a multi-faceted approach, including prescription-strength treatments, lifestyle modifications, and gentle skincare routines.

• Oral isotretinoin is the most effective option for severe acne, with a strong recommendation for its use in patients with severe or scarring acne, or those who have failed standard oral or topical therapy 1.
• Alternative treatments include oral antibiotics like doxycycline (100mg twice daily) or minocycline (50-100mg daily) for 3-6 months, combined with topical treatments such as tretinoin (0.025-0.1%) or adapalene (0.1-0.3%) applied nightly, and benzoyl peroxide (2.5-10%) applied in the morning 1.
• For females, hormonal options like spironolactone (50-200mg daily) or certain birth control pills containing ethinyl estradiol with norgestimate or drospirenone can help 1.

Skincare Routine

Consistent gentle skincare is essential for managing severe acne, including:

• Using a mild cleanser twice daily
• Avoiding picking or scrubbing
• Applying oil-free moisturizer and sunscreen

Important Considerations

Severe acne treatment requires patience, as most regimens take 2-3 months to show significant improvement, and consulting with a dermatologist is crucial for personalized care 1. Before starting isotretinoin, baseline blood tests and pregnancy prevention are necessary, as it can cause birth defects 1. Limiting systemic antibiotic use and combining topical therapies with multiple mechanisms of action are also recommended as good practice statements 1.

From the FDA Drug Label

Tretinoin is indicated for topical application in the treatment of acne vulgaris. Tretinoin Cream and Tretinoin Gel are used for the topical treatment of acne vulgaris.

The treatment options for severe acne vulgaris are not explicitly stated in the provided drug labels. However, tretinoin is indicated for the topical treatment of acne vulgaris.

• Tretinoin can be used as a treatment option for acne vulgaris.
• The provided drug labels do not specify the severity of acne vulgaris that tretinoin can treat 222.

From the Research

Treatment Options for Severe Acne Vulgaris

The treatment options for severe acne vulgaris include:

• Topical therapies such as retinoids (eg, tretinoin, adapalene), benzoyl peroxide, azelaic acid, and/or combinations of topical agents as first-line treatments 3
• Combinations of topical agents with systemic agents (oral antibiotics such as doxycycline and minocycline, hormonal therapies such as combination oral contraception [COC] or spironolactone, or isotretinoin) for more severe disease 3
• Isotretinoin, which is approved by the US Food and Drug Administration for treating severe recalcitrant nodular acne, but is often used to treat resistant or persistent moderate to severe acne, as well as acne that produces scarring or significant psychosocial distress 3

Combination Therapies

Combination therapies have been shown to be effective in treating severe acne vulgaris, including:

• Adapalene and benzoyl peroxide (BPO) in a fixed-dose combination, which acts synergistically on inflammatory patterns through regulation of innate immunity 4
• Clindamycin 1%-benzoyl peroxide 5% gel, which is efficacious and well-tolerated 5
• Low-dose isotretinoin and pulsed oral azithromycin, which has been shown to be effective in moderate to severe acne with a reasonably acceptable adverse-effect profile and low post-treatment relapse rates 6

Oral Antibiotics

Oral antibiotics are commonly used to treat acne vulgaris, primarily in patients presenting with moderate to severe facial or truncal disease severity, and are most appropriately used in combination with a topical regimen containing benzoyl peroxide and a topical retinoid 7

• The most common oral antibiotics for treating acne vulgaris are the tetracycline derivatives, although macrolide agents such as erythromycin have also been used extensively 7
• Doxycycline, minocycline, and other agents, such as trimethoprim/sulfamethoxazole, have increased use due to decreased sensitivity of Propionibacterium acnes to several oral and topical antibiotics 7