What is the recommended treatment for acne?

Recommended Treatment for Acne Vulgaris

For acne vulgaris, the first-line treatment should be a combination of topical retinoids with benzoyl peroxide, 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 appropriate treatment selection 1
• Consider the impact on quality of life, satisfaction with appearance, and presence of scarring, as these factors may warrant more aggressive treatment 1

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoids (tretinoin, adapalene, tazarotene) + benzoyl peroxide (BP) 1
• Topical retinoids are essential due to their comedolytic, anti-inflammatory properties, and ability to resolve microcomedones 1
• Benzoyl peroxide is available in 2.5-5% concentrations, with lower concentrations causing less irritation while maintaining efficacy 1, 2
• Alternative options include azelaic acid for patients with post-inflammatory dyspigmentation 1, 3
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1, 4

Moderate Acne

• First-line: 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, 4
• Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) enhance treatment compliance 1

Moderate-to-Severe Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 1
• Doxycycline and minocycline are recommended oral antibiotics 1, 5
• Limit systemic antibiotic use to 3-4 months to minimize bacterial resistance 1, 5
• For severe, recalcitrant acne that fails standard treatment, isotretinoin is recommended 1, 6

Special Considerations

Hormonal Therapy

• For female patients with hormonal component to acne, combined oral contraceptives and spironolactone are effective treatment options 1, 5
• Hormonal testing may be warranted in females with signs of hyperandrogenism 4

Topical Agents - Important Notes

• Benzoyl peroxide can bleach clothing and bedding; advise patients accordingly 7
• Benzoyl peroxide may cause skin irritation (redness, burning, itching, peeling, swelling) 7
• Topical retinoids may cause photosensitivity; daily sunscreen use is recommended 1
• Azelaic acid is particularly useful for patients with post-inflammatory hyperpigmentation 1

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 1
• Continue treatment even after acne clears to prevent relapse 8

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 4, 1
• Underestimating severity when scarring is present 1
• Extended use of systemic antibiotics beyond 3-4 months 1, 5
• Stopping treatment once acne clears without implementing maintenance therapy 1
• Using multiple topical acne medications simultaneously may increase skin irritation 7

Treatment Efficacy

• Tretinoin 0.025% gel can reduce acne lesion counts by 63% at 12 weeks compared to baseline 9
• Combination oral contraceptives can reduce inflammatory lesions by 62% at 6-month follow-up 9
• Lower concentrations of benzoyl peroxide (2.5%) provide better tolerability than higher concentrations while maintaining comparable efficacy 2, 10