What are the treatment options for acne?

Acne Treatment Options

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

Assessment and Classification

• Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide treatment selection 1, 2
• Evaluation of impact on quality of life, satisfaction with appearance, and presence of scarring is crucial, as these factors may warrant more aggressive treatment 1, 2
• For patients with signs of hyperandrogenism, endocrine testing is warranted, including free and total testosterone, DHEA-S, androstenedione, LH, and FSH 2

Treatment Algorithm by Severity

Mild Acne

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

Moderate Acne

• First-line treatment: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, always in combination with benzoyl peroxide to prevent bacterial resistance 1
• 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 treatment: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline and minocycline are preferred oral antibiotics for moderate-to-severe acne 1, 2
• Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy in patients with moderate inflammatory acne 1
• Oral corticosteroid therapy can provide temporary benefit in patients with severe inflammatory acne while starting standard acne treatment 1

Topical Retinoids: Foundation of Acne Treatment

• Topical retinoids are essential due to their comedolytic, anti-inflammatory properties, and ability to resolve microcomedones 1
• Options include:
  • Tretinoin (0.025-0.1% in cream, gel, or microsphere gel) 1, 3
  • Adapalene (0.1%, 0.3% cream, or 0.1% lotion) 1, 4
  • Tazarotene (0.05%, 0.1% cream, gel or foam) 1
  • Trifarotene (newer option) 1
• Apply once daily before bedtime, after washing with mild soap and allowing skin to dry for 20-30 minutes 3
• Therapeutic results should be noticed after 2-3 weeks but more than 6 weeks of therapy may be required before definite beneficial effects are seen 3
• During early weeks of therapy, an apparent exacerbation of inflammatory lesions may occur due to action on deep, previously unseen lesions 3

Benzoyl Peroxide

• Effective antimicrobial agent that releases free oxygen radicals and is mildly comedolytic 1
• Available in 2.5-5% concentrations, with lower concentrations causing less irritation 1
• No bacterial resistance has been reported with benzoyl peroxide 1, 5
• Can bleach clothing and bedding; wear old clothing or white pajamas when applying 6

Hormonal Therapy Options

• For female patients with a hormonal component to acne, combined oral contraceptives and spironolactone are recommended treatment options 1, 2
• Spironolactone is the first-choice oral anti-androgen therapy for hormonal acne, starting at 50-100 mg daily 2
• Potassium monitoring is of low usefulness in patients without risk factors for hyperkalemia 2

Special Considerations for Back Acne

• Treatment for back acne follows the same severity-based approach as facial acne 1, 6
• Adapalene 0.1% gel is available over-the-counter for mild back acne 6
• For severe back acne, first-line treatment includes oral antibiotics + topical retinoid + benzoyl peroxide 6

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 1, 6
• Benzoyl peroxide can be continued as maintenance therapy to prevent recurrence 1

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 1, 2
• Underestimating severity when scarring is present 1
• Extended use of systemic antibiotics beyond 3-4 months 1, 6
• Stopping treatment once acne clears without maintenance therapy 6
• Failing to consider underlying endocrine disorders in patients with signs of hyperandrogenism 2
• Not using benzoyl peroxide concurrently with antibiotics to prevent resistance 1, 2
• Excessive application of tretinoin; a pea-sized amount is sufficient for the entire face 3

Precautions with Topical Retinoids

• Minimize exposure to sunlight, including sunlamps, during treatment 3
• Use sunscreen products and protective clothing over treated areas 3
• Keep away from eyes, mouth, angles of nose, and mucous membranes 3
• May cause photosensitivity; daily sunscreen use is recommended 1, 3
• Weather extremes, such as wind or cold, may be irritating to patients under treatment 3