What is the recommended treatment for acne vulgaris?

Treatment of Acne Vulgaris

For acne vulgaris, a stepwise approach based on severity is strongly recommended, with topical retinoids and benzoyl peroxide forming the cornerstone of treatment for most patients, while oral isotretinoin is reserved for severe cases or those with scarring. 1, 2

Classification and Assessment

• Acne should be classified as mild, moderate, or severe using standardized scales like the Physician Global Assessment (PGA) to guide appropriate treatment selection 2
• The presence of scarring alone should classify acne as severe, warranting more aggressive treatment approaches 3
• Assessment should include evaluation of psychological impact, as acne with significant psychosocial burden may require more intensive therapy 3, 2

Treatment Algorithm by Severity

Mild Acne

• First-line treatment: Topical retinoids (tretinoin, adapalene, tazarotene) + benzoyl peroxide 1, 2
• Alternative options include azelaic acid (especially for patients with post-inflammatory hyperpigmentation) or topical dapsone 5% gel (particularly effective for inflammatory acne in adult females) 2, 1
• Salicylic acid (0.5-2%) is a conditionally recommended option with limited clinical trial data 1

Moderate Acne

• First-line treatment: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, always in combination with benzoyl peroxide to prevent bacterial resistance 2, 4, 5
• Fixed-combination products (erythromycin/BP or clindamycin/BP) may enhance treatment compliance 2

Moderate to Severe Acne

• First-line treatment: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline is strongly recommended as first-line oral antibiotic 1
• Minocycline and sarecycline are conditionally recommended alternatives 1, 6
• Limit systemic antibiotic use to the shortest possible duration (ideally ≤3 months) to minimize bacterial resistance 1, 2

Severe Acne

• First-line treatment: Oral isotretinoin is strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne failing standard oral or topical therapy 1, 3
• For female patients, combined oral contraceptives or spironolactone are conditionally recommended hormonal therapy options 1, 2

Special Considerations

• Proper application of topical retinoids is crucial: wash with mild soap, wait 20-30 minutes for skin to dry completely, apply a pea-sized amount once daily at bedtime 7
• Initial retinoid-associated irritation (redness, peeling) typically subsides within 2-4 weeks of treatment 7
• Visible improvement typically takes 6-12 weeks of consistent therapy; patients should be counseled to continue treatment even if new blemishes appear during the first 3-6 weeks 7, 8
• Intralesional corticosteroid injections can be used as adjuvant therapy for larger inflammatory nodules at risk of scarring 3
• Maintenance therapy with topical retinoids is essential after clearing to prevent recurrence 2, 8

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy (increases risk of bacterial resistance) 1, 2
• Underestimating severity when scarring is present (scarring alone should prompt consideration of isotretinoin) 3
• Extended use of systemic antibiotics beyond 3-4 months 1, 2
• Excessive washing or harsh scrubbing (may worsen acne) 7
• Discontinuing treatment at first signs of improvement (continued application is needed for maintenance) 7
• Applying excessive amounts of topical medications (does not improve efficacy and increases irritation) 7

Treatment Response Expectations

• Improvement should be noticeable after 6-12 weeks of consistent therapy 7, 8
• If no improvement is seen after 8-12 weeks, treatment should be adjusted based on severity or by adding additional agents 2, 8
• Tretinoin has been shown to reduce acne lesion counts by up to 63% at 12 weeks compared to baseline 8
• Combination oral contraceptives can reduce inflammatory lesions by approximately 62% at 6 months 8