What are the treatment options for acne on the face?

Treatment Options for Acne on the Face

For acne on the face, first-line treatment should include topical retinoids (tretinoin, adapalene, tazarotene, or trifarotene) combined with benzoyl peroxide, with additional agents selected based on acne severity. 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 psychological impact, presence of scarring, and quality of life effects when determining treatment aggressiveness 1

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoid (tretinoin, adapalene, tazarotene, or trifarotene) + benzoyl peroxide (2.5-5%) 1, 2
• Adapalene 0.1% gel is available over-the-counter for mild acne treatment 1
• Alternative options include azelaic acid for patients with post-inflammatory hyperpigmentation 1
• Salicylic acid (0.5-2%) is another over-the-counter option with mild comedolytic properties 1

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, but always in combination with benzoyl peroxide to prevent bacterial resistance 1, 3
• Fixed-combination products (erythromycin/BP, clindamycin/BP) may enhance treatment compliance 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1, 4

Moderate-to-Severe Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 2, 1
• Doxycycline is strongly recommended with moderate evidence 1
• Minocycline and sarecycline are conditionally recommended with moderate evidence 1, 2
• Limit systemic antibiotic use to 3-4 months to minimize bacterial resistance 1, 5

Severe Acne

• Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy 2
• Intralesional corticosteroid injections can be added for larger acne lesions 2

Hormonal Therapy Options

• For female patients with hormonal component to acne, combined oral contraceptives and spironolactone are recommended treatment options 1, 6
• These options are particularly useful when acne is resistant to conventional treatments 1

Proper Application of Topical Treatments

• Apply tretinoin once daily before bedtime to clean, dry skin 7
• Wait 20-30 minutes after washing before applying medication to minimize irritation 7
• Use only a small amount (about half an inch) for the entire face 7
• Avoid application near corners of nose, mouth, eyes, and open wounds 7
• During early weeks of therapy, an apparent exacerbation of inflammatory lesions may occur due to action on deep, previously unseen lesions 7
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required for definite beneficial effects 7

Maintenance Therapy

• Continue topical retinoids after clearing to prevent recurrence of acne 1
• Once acne lesions have responded satisfactorily, it may be possible to maintain improvement with less frequent applications 7

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases risk of bacterial resistance 1, 5
• Underestimating severity when scarring is present 1
• Extended use of systemic antibiotics beyond 3-4 months 1
• Discontinuing treatment too early when improvement begins 7
• Excessive washing or harsh scrubbing can worsen acne 7
• Applying too much topical medication can cause unnecessary irritation without improving results 7

Special Considerations

• Topical retinoids may cause photosensitivity; daily sunscreen use is recommended 1
• Tetracycline antibiotics are contraindicated in children under 8 years due to risk of permanent tooth discoloration 8
• Patients with skin of color may require special consideration, as research representation is limited in this population 2