What are the treatment options for acne vulgaris?

Treatment Options for Acne Vulgaris

For optimal treatment of acne vulgaris, a multimodal approach combining topical retinoids with benzoyl peroxide should be used as first-line therapy, with additional agents selected based on acne severity and patient characteristics. 1

Assessment and Classification

• Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide treatment selection 1
• Evaluate impact on quality of life, satisfaction with appearance, and presence of scarring, as these factors may warrant more aggressive treatment 1
• The presence of scarring alone classifies the patient as having severe acne and makes them a candidate for isotretinoin therapy 2

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoids (tretinoin, adapalene, tazarotene) + benzoyl peroxide (BP) 1
  • Topical retinoids have comedolytic, anti-inflammatory properties and resolve microcomedones 3
  • Benzoyl peroxide (2.5-5%) kills C. acnes with no reported bacterial resistance 4, 5
• Alternative options:
  • Azelaic acid (conditionally recommended with moderate evidence) 1, 6
  • Salicylic acid (conditionally recommended with low evidence) 1, 6
  • Clascoterone (conditionally recommended with high evidence) 1

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 7
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, but NEVER as monotherapy 1, 5
• Fixed-combination products improve compliance:
  • Erythromycin/BP
  • Clindamycin/BP
  • Retinoid/antibiotic 1, 5

Moderate-to-Severe Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 8
• Recommended oral antibiotics:
  • Doxycycline (strongly recommended with moderate evidence) 1
  • Minocycline (conditionally recommended with moderate evidence) 1
  • Sarecycline (conditionally recommended with high evidence) 1
• Limit systemic antibiotics to 3-4 months to minimize bacterial resistance 1, 5

Severe, Recalcitrant, or Scarring Acne

• First-line: Oral isotretinoin 1, 9, 8
• Patients with psychosocial burden or scarring should be considered candidates for isotretinoin 1, 2
• Monitoring recommendations:
  • Only liver function tests and lipids need monitoring 1, 9
  • Pregnancy prevention is mandatory for persons with pregnancy potential 1, 9
• Daily dosing is preferred over intermittent dosing 1

Hormonal Therapy Options

• For female patients with hormonal component to acne:
  • Combined oral contraceptives 1
  • Spironolactone 1
  • Potassium monitoring is of low usefulness in patients without risk factors for hyperkalemia 1

Special Considerations

Back Acne

• Treatment follows the same severity-based approach as facial acne 3
• Adapalene 0.1% gel is available over-the-counter for mild back acne 3
• Benzoyl peroxide can bleach clothing; advise patients to wear old clothing when applying to back 3

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 1, 3
• Stopping treatment once acne clears often leads to relapse 3, 2

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy (increases bacterial resistance) 1, 5
• Underestimating severity when scarring is present 2
• Extended use of systemic antibiotics beyond 3-4 months 1, 5
• Failing to consider the psychological impact of acne, especially with scarring 2
• Not using benzoyl peroxide concurrently with antibiotics to prevent resistance 1, 5

Safety Considerations

• Topical retinoids: May cause irritation and photosensitivity; contraindicated in pregnancy (FDA Category C for adapalene/tretinoin, X for tazarotene) 6, 10
• Benzoyl peroxide: Generally safe but may cause irritation and bleach clothing 3, 6
• Isotretinoin: Requires mandatory pregnancy prevention program (iPLEDGE) due to teratogenicity risk 9, 8
• Topical antibiotics: Limited systemic absorption but should not be used as monotherapy 5, 10