What are the treatment options for acne?

Treatment Options for Acne

The American Academy of Dermatology recommends a multimodal approach combining topical retinoids with benzoyl peroxide as first-line therapy for acne vulgaris, with additional agents selected based on acne severity and patient characteristics. 1

Treatment Algorithm Based on Acne Severity

Mild Acne

• First-line treatment: Topical retinoids (tretinoin, adapalene, tazarotene, or trifarotene) due to their comedolytic, anti-inflammatory properties, and ability to resolve microcomedones 1, 2
• Adapalene 0.1% gel is available over-the-counter for mild acne, while other retinoids require prescription 1
• Add benzoyl peroxide (BP) 2.5-5% to kill C. acnes and for its mild comedolytic properties with no reported bacterial resistance 1, 2
• Alternative options include azelaic acid for patients with post-inflammatory dyspigmentation 1

Moderate Acne

• First-line treatment: Combination therapy with topical retinoid + benzoyl peroxide 1, 2
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, but always in combination with BP to prevent bacterial resistance 1, 2
• Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) may enhance treatment compliance 1
• Topical dapsone 5% gel is particularly effective for inflammatory lesions, especially in adult females 1, 2

Moderate to Severe Inflammatory Acne

• First-line treatment: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Tetracycline class antibiotics (doxycycline, minocycline) are recommended as first-line systemic therapy 3, 1
• Limit systemic antibiotic use to 3-4 months to minimize bacterial resistance 1, 2
• Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy in moderate inflammatory acne 3

Severe, Recalcitrant Acne

• Oral isotretinoin is recommended for severe, recalcitrant acne that fails standard treatment 1, 2

Hormonal Therapy Options

• Estrogen-containing combined oral contraceptives are effective and recommended for inflammatory acne in females 3
• Spironolactone is useful in the treatment of acne in select females 3
• Oral corticosteroid therapy can provide temporary benefit in patients with severe inflammatory acne while starting standard acne treatment 3
• Low-dose oral corticosteroids are recommended for patients with well-documented adrenal hyperandrogenism 3

Proper Application of Topical Treatments

• Apply tretinoin once daily before bedtime 4
• Wash with a mild soap and dry skin gently 4
• Wait 20-30 minutes before applying medication to minimize irritation 4
• Use only a small amount (about half an inch or less) for the entire face 4
• Avoid applying near eyes, mouth, and mucous membranes 4
• Expect possible initial worsening of acne in the first 3-6 weeks as deep lesions are brought to the surface 4
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required for definite beneficial effects 4

Maintenance Therapy

• Continue with topical retinoids after clearing to prevent recurrence of acne 1, 2
• Once acne lesions have responded satisfactorily, it may be possible to maintain improvement with less frequent applications 4

Common Pitfalls and How to Avoid Them

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 1, 2
• Stopping treatment once acne clears often leads to relapse; maintenance therapy with topical retinoids is essential 1, 2
• Excessive application of topical treatments can increase irritation without improving efficacy 4
• Minimize sun exposure during treatment with retinoids due to increased photosensitivity; use sunscreen and protective clothing 4
• Concomitant use of drying products (medicated soaps, alcohol-based products) can increase irritation with retinoids 4

Evidence Supporting Topical Retinoids as Core Therapy

• Topical retinoids represent a mainstay of acne treatment because they expel mature comedones, reduce microcomedone formation, and exert anti-inflammatory effects 5, 6
• They are suitable as long-term medications with no risk of inducing bacterial resistance 6
• Despite strong recommendations for use, studies show retinoids are underprescribed, with dermatologists prescribing them only 58.8% of the time and non-dermatologists just 32.4% of the time 7