What are the treatment options for acne?

Acne Treatment Options

The most effective treatment for acne vulgaris is a multimodal approach combining topical retinoids with benzoyl peroxide as first-line therapy, with additional agents selected based on acne severity and patient characteristics. 1

Treatment Algorithm by Severity

Mild Acne

• First-line treatment: Topical retinoids (tretinoin, adapalene, tazarotene) + benzoyl peroxide (BP) 1
• Alternative options include azelaic acid for patients with post-inflammatory dyspigmentation 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1
• Adapalene 0.1% gel is available over-the-counter for mild acne 2

Moderate Acne

• First-line treatment: Fixed-dose combination of topical retinoid + benzoyl peroxide 1
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, but always in combination with benzoyl peroxide to prevent bacterial resistance 1
• Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) may enhance treatment compliance 1

Moderate-to-Severe Acne

• First-line treatment: Oral antibiotics + topical retinoid + benzoyl peroxide 1
• Doxycycline and minocycline are recommended as oral antibiotics for moderate-to-severe acne 1, 2
• Limit systemic antibiotic use to 3-4 months to minimize bacterial resistance 2, 3
• For severe, recalcitrant acne that fails standard treatment, isotretinoin is recommended 2, 4

Hormonal Therapy Options

• For female patients with a hormonal component to acne, combined oral contraceptives and spironolactone are effective treatment options 1, 3
• Consider switching to a different combined oral contraceptive with proven efficacy for acne if current one is insufficient 3

Proper Application of Topical Treatments

• Apply tretinoin once daily before bedtime 5
• Wait 20-30 minutes after washing face before applying medication to minimize irritation 5
• Use a small amount (half-inch or less) for the entire face 5
• Expect possible initial worsening of acne during the first 3-6 weeks of treatment 5
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required for definite beneficial effects 5

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 1, 2
• Once acne is under control, continue regular application of tretinoin until physician instructs otherwise 5

Special Considerations

• Minimize sun exposure during tretinoin treatment and use sunscreen products and protective clothing 5
• Benzoyl peroxide can bleach clothing and bedding; wear old clothing or white pajamas when applying 2
• Tretinoin should be kept away from eyes, mouth, angles of nose, and mucous membranes 5

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 1, 3
• Underestimating severity when scarring is present 1
• Extended use of systemic antibiotics beyond 3-4 months 1
• Stopping treatment once acne clears without maintenance therapy 2, 5
• Using products with high concentrations of alcohol, astringents, spices or lime concurrently with tretinoin 5

Dietary Considerations

• Emerging evidence suggests high glycemic index diets may be associated with acne exacerbations 3
• Limited evidence suggests some dairy products, particularly skim milk, may influence acne 3

By following this evidence-based approach to acne treatment based on severity, patients can expect significant improvement in their acne with appropriate management and maintenance therapy.