What is the assessment and treatment protocol for Acne (Acne) Syndrome?

Assessment and Treatment Protocol for Acne Vulgaris

The most effective approach for managing acne vulgaris is a multimodal therapy combining topical retinoids with benzoyl peroxide as first-line treatment, with additional agents selected based on acne severity and patient characteristics. 1, 2

Assessment and Classification

• Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide treatment selection 1, 2
• Evaluate impact on quality of life, satisfaction with appearance, and presence of scarring, as these factors may warrant more aggressive treatment 1, 2
• For patients with signs of hyperandrogenism (hirsutism, oligomenorrhea, androgenic alopecia, infertility, clitoromegaly, truncal obesity), endocrine testing is warranted 1
• Laboratory evaluation may include free and total testosterone, dehydroepiandrosterone sulfate (DHEA-S), androstenedione, luteinizing hormone, and follicle-stimulating hormone 1, 3

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoid (tretinoin, adapalene, tazarotene) + benzoyl peroxide 1, 2
• Alternative options: Azelaic acid for patients with post-inflammatory dyspigmentation 2
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 2

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, 2
• Fixed-combination products (erythromycin/BP, clindamycin/BP) enhance treatment compliance 2

Moderate-to-Severe Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline and minocycline are recommended oral antibiotics 2
• For females with hormonal component: Combined oral contraceptives or spironolactone 2, 4
• Limit oral antibiotic use to maximum 3-4 months to prevent resistance 2

Severe, Scarring, or Treatment-Resistant Acne

• Isotretinoin is the most effective therapy for severe, recalcitrant nodular acne 1, 5
• Recommended dosage: 0.5 to 1 mg/kg/day given in two divided doses with food for 15-20 weeks 5
• Monitor liver function tests and lipids during treatment 1
• Due to teratogenicity risk, patients, pharmacists, and prescribers must register with iPLEDGE program 5, 6

Special Considerations

Hormonal Acne

• For female patients with hormonal acne: Combined oral contraceptives and spironolactone 2, 4
• Spironolactone is first-choice oral anti-androgen therapy, starting at 50-100 mg daily 4
• Potassium monitoring is of low usefulness in patients without risk factors for hyperkalemia 1, 4

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 2
• If no improvement is seen after initial treatment, consider adjusting treatment based on severity or adding additional agents 2

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 1, 2
• Underestimating severity when scarring is present 2
• Extended use of systemic antibiotics beyond 3-4 months 2
• Failing to consider psychological impact of acne, especially with scarring 2
• Not using benzoyl peroxide concurrently with antibiotics to prevent resistance 1, 2
• Failing to consider underlying endocrine disorders in patients with signs of hyperandrogenism 1

Adjunctive Treatments

• Intralesional corticosteroids for larger acne papules or nodules at risk of scarring 1
• Chemical peels (salicylic or mandelic acid) may be effective for mild-to-moderate acne 7
• Photodynamic therapy may be beneficial for moderate-to-severe acne 7
• Limited evidence exists for complementary therapies such as low-glycemic-load diet and tea tree oil 6