What are the treatment options for acne?

Acne Treatment Options

Topical retinoids are the cornerstone of acne treatment and should be used as first-line therapy for most types of acne, combined with other agents for optimal results. 1

First-Line Treatments

Topical Therapies

• Topical retinoids (tretinoin, adapalene, tazarotene, trifarotene) are strongly recommended as they are comedolytic, resolve microcomedones, and have anti-inflammatory properties 1
• Benzoyl peroxide (BP) is strongly recommended as an antimicrobial agent that releases free oxygen radicals and is mildly comedolytic 1
• Multimodal topical therapy combining different mechanisms of action is recommended to optimize efficacy and reduce antibiotic resistance 1
• Fixed-dose combinations are strongly recommended for better efficacy and compliance: 1
  • Topical retinoid + benzoyl peroxide
  • Topical retinoid + topical antibiotic (with concomitant BP to prevent resistance)
  • Topical antibiotic + benzoyl peroxide

Proper Application of Topical Retinoids

• Apply once daily before bedtime after washing with mild soap and allowing skin to dry completely (20-30 minutes) 2
• Use a pea-sized amount for the entire face 2
• Expect potential irritation during first 2-4 weeks of treatment 2
• Therapeutic results typically appear after 2-3 weeks, but may require more than 6 weeks 2
• Avoid excessive sun exposure and use sunscreen while using retinoids 2

Second-Line and Adjunctive Treatments

Systemic Antibiotics

• Doxycycline is strongly recommended for moderate to severe inflammatory acne 1
• Minocycline is conditionally recommended for moderate to severe acne 1
• Sarecycline is conditionally recommended (cost may impact access) 1
• Limit systemic antibiotics to shortest possible duration (re-evaluate at 3-4 months) to minimize bacterial resistance 1
• Always use systemic antibiotics with concomitant topical therapy (BP or retinoid) 1

Hormonal Therapy

• Combined oral contraceptives are conditionally recommended for females with acne 1
• Spironolactone can be useful for female patients with acne 1
• Potassium monitoring is of low usefulness in patients without risk factors for hyperkalemia 1

Severe Acne Treatment

• Isotretinoin is strongly recommended for severe acne or patients who have failed standard treatments 1
• Patients with psychosocial burden or scarring should be considered candidates for isotretinoin 1
• Traditional daily dosing is conditionally recommended over intermittent dosing 1
• Monitor LFTs and lipids; CBC monitoring is not needed in healthy patients 1
• Pregnancy prevention is mandatory for persons of childbearing potential 1

Treatment Algorithm Based on Acne Severity

Mild Acne

1. First choice: Topical retinoid monotherapy 1, 3
2. Alternative: Benzoyl peroxide monotherapy 1
3. For inadequate response: Add fixed-combination product (retinoid + BP or retinoid + antibiotic + BP) 1, 4

Moderate Acne

1. First choice: Combination therapy with topical retinoid + antimicrobial (BP and/or topical antibiotic) 1, 5
2. For inadequate response: Add oral antibiotic (doxycycline preferred) 1
3. For females: Consider hormonal therapy (oral contraceptives or spironolactone) 1

Severe Acne

1. First choice: Isotretinoin 1
2. Alternative: Oral antibiotic + topical combination therapy (retinoid + BP) 1
3. For nodular lesions: Consider intralesional corticosteroid injections as adjunctive therapy 1

Common Pitfalls and Caveats

• Avoid topical antibiotic monotherapy to prevent bacterial resistance 1
• Don't apply tretinoin with BP simultaneously unless using microsphere formulations, adapalene, or tazarotene (tretinoin can be inactivated) 1
• Don't discontinue treatment at first signs of improvement; continue regular application until directed by physician 2
• Don't expect immediate results; apparent worsening may occur in early weeks due to action on deep, previously unseen lesions 2
• Don't overuse topical retinoids; excessive application won't speed results and may increase irritation 2
• Be cautious with concomitant use of medicated soaps, alcohol-based products, and preparations containing sulfur, resorcinol, or salicylic acid with tretinoin 2

Maintenance therapy with topical retinoids is recommended after acne clearance to prevent recurrence 1, 6.