What are the treatment options for acne?

Treatment Options for Acne Vulgaris

For patients with acne vulgaris, multimodal topical therapy combining multiple mechanisms of action is recommended as first-line treatment, with systemic therapies reserved for moderate to severe cases. 1

Topical Therapies (First-Line)

Cornerstone Treatments

• Topical retinoids are strongly recommended as the foundation of acne treatment due to their comedolytic and anti-inflammatory properties 1, 2

  • Options include tretinoin (0.025-0.1%), adapalene (0.1%, 0.3%), tazarotene (0.05%, 0.1%), and trifarotene 1, 3
  • Apply once daily before bedtime; wait 20-30 minutes after washing face 4
  • May cause initial irritation, dryness, and peeling during first 2-4 weeks of use 4
  • Adapalene 0.1% gel is available over-the-counter and may be better tolerated than tretinoin 1, 5

• Benzoyl peroxide (BP) is strongly recommended for its antimicrobial properties 1

  • Available in 2.5-5% strengths; lower concentrations may be better tolerated 1, 2
  • No bacterial resistance has been reported with BP 1
  • May cause dryness, irritation, and can bleach fabrics 1

Additional Topical Options

• Topical antibiotics (clindamycin, erythromycin) are effective but should never be used as monotherapy due to bacterial resistance risk 1, 2

  • Always combine with benzoyl peroxide 1, 6

• Fixed-dose combination products are strongly recommended for improved efficacy and convenience 1, 7

  • Topical retinoid + benzoyl peroxide 1, 6
  • Topical antibiotic + benzoyl peroxide 1, 6
  • Topical retinoid + topical antibiotic (with concomitant BP use) 1, 7

• Other topical agents with conditional recommendations:

  • Clascoterone (androgen receptor inhibitor) 1
  • Azelaic acid (useful for post-inflammatory hyperpigmentation) 1, 2
  • Salicylic acid (0.5-2%, mild comedolytic effect) 1

Systemic Therapies (For Moderate to Severe Acne)

Oral Antibiotics

• Doxycycline is strongly recommended for moderate to severe inflammatory acne 1

  • Limit use to 3-4 months to minimize bacterial resistance 1
  • Always combine with topical therapy 1

• Minocycline and sarecycline are conditionally recommended alternatives 1

Hormonal Therapy

• Combined oral contraceptives are conditionally recommended for female patients, particularly those with signs of hyperandrogenism 1, 2

  • Effective for reducing inflammatory lesions by approximately 62% at 6 months 8

• Spironolactone is useful for female patients with treatment-resistant acne 1, 2

  • Potassium monitoring is generally not needed in patients without risk factors for hyperkalemia 1

Isotretinoin

• Isotretinoin is recommended for severe acne or patients who have failed standard oral/topical therapy 1
  • Also recommended for patients with psychosocial burden or scarring 1
  • Traditional daily dosing is conditionally recommended over intermittent dosing 1
  • Requires monitoring of liver function tests and lipids 1
  • Mandatory pregnancy prevention for persons of childbearing potential 1

Treatment Algorithm Based on Acne Severity

Mild Acne

1. Start with topical therapy:
   • Topical retinoid (adapalene 0.1% gel or tretinoin 0.025%) OR
   • Benzoyl peroxide 2.5-5% 1, 2
2. If inadequate response after 6-8 weeks, switch to combination therapy:
   • Topical retinoid + benzoyl peroxide OR
   • Topical retinoid + topical antibiotic with benzoyl peroxide 1, 2

Moderate Acne

1. Start with combination topical therapy:
   • Topical retinoid + benzoyl peroxide OR
   • Topical retinoid + topical antibiotic with benzoyl peroxide 1, 2
2. If inadequate response after 6-8 weeks, add oral therapy:
   • Oral doxycycline OR
   • For females: consider hormonal therapy (combined oral contraceptives or spironolactone) 1, 8

Severe Acne

1. Consider isotretinoin as first-line therapy 1
2. Alternative approach:
   • Oral antibiotic + topical retinoid + benzoyl peroxide 1
   • For females: hormonal therapy + topical combination therapy 1

Adjunctive Treatments

• Intralesional corticosteroid injections for larger acne papules or nodules at risk of scarring 1, 2
  • Use judiciously with lower concentration and volume to minimize adverse effects 1

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy (increases bacterial resistance) 1, 2
• Expecting immediate results (improvement typically takes 6-12 weeks) 4, 8
• Stopping treatment at first signs of improvement (maintenance therapy is essential) 4, 8
• Excessive application of topical products (can increase irritation without improving efficacy) 4
• Ignoring sun protection when using retinoids (increases photosensitivity risk) 4