Treatment for Pus-Filled Acne
For pus-filled acne (inflammatory acne), the first-line treatment is a combination of topical retinoids with benzoyl peroxide, with additional agents selected based on acne severity. 1
Treatment Algorithm Based on Severity
Mild Inflammatory Acne
- Use topical retinoids (tretinoin, adapalene, tazarotene) + benzoyl peroxide (BP) 2.5-5% as first-line therapy 1, 2, 3
- Adapalene 0.1% gel is available over-the-counter for mild acne treatment 4
- Benzoyl peroxide effectively kills Cutibacterium acnes with no reported bacterial resistance 5
- Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1
- Azelaic acid can be considered for patients with post-inflammatory dyspigmentation 1
Moderate Inflammatory Acne
- Use fixed-dose combination of topical retinoid + benzoyl peroxide as first-line treatment 1
- Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, but always in combination with benzoyl peroxide to prevent bacterial resistance 1, 5
- Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) enhance treatment compliance 1, 6
- Clindamycin-BP 1.2%/3.75% gel and clindamycin-BP 1.2%/2.5% gel are both effective for inflammatory acne 6
- Consider adapalene 0.3%-benzoyl peroxide 2.5%, which has shown effectiveness in severe acne (the 0.1% adapalene combination is less effective) 6
Severe Inflammatory Acne
- First-line treatment includes oral antibiotics + topical retinoid + benzoyl peroxide 1, 5
- Doxycycline and minocycline are more effective than tetracycline for systemic antibiotic therapy 1, 5
- Limit systemic antibiotic use to 3-4 months to minimize bacterial resistance 1, 7
- For severe, recalcitrant nodular acne that fails standard treatment, oral isotretinoin is recommended 1, 8
- Temporary oral corticosteroid therapy can provide benefit in patients with severe inflammatory acne while starting standard treatment 1
Special Considerations
For Female Patients
- Combined oral contraceptives and spironolactone are effective options for female patients with hormonal component to acne 1, 7
- Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1, 5
For Back Acne
- Treatment follows the same severity-based approach as facial acne 1, 4
- For severe back acne, consider oral antibiotics + topical retinoid + benzoyl peroxide 4
- Be aware that benzoyl peroxide can bleach clothing and bedding; wear old clothing or white pajamas when applying to back 4
Maintenance Therapy
- Topical retinoids are essential for maintenance after clearing to prevent recurrence 1, 5
- Benzoyl peroxide can be continued as maintenance therapy 1
Common Pitfalls to Avoid
- Using topical antibiotics as monotherapy increases the risk of bacterial resistance 1, 5, 9
- Underestimating severity when scarring is present 1
- Extended use of systemic antibiotics beyond 3-4 months 1, 10
- Stopping treatment once acne clears without implementing maintenance therapy 4
- Failing to consider the psychological impact of acne, especially with scarring 1
- Not using benzoyl peroxide concurrently with antibiotics to prevent resistance 1, 11