What are the treatment options for acne?

Treatment Options for Acne

The most effective approach to acne treatment combines topical retinoids with benzoyl peroxide as first-line therapy, with additional agents selected based on acne severity and patient characteristics. 1

Assessment and Classification of Acne

• Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide appropriate treatment selection 1
• Evaluate the impact on quality of life and presence of scarring, as these factors may warrant more aggressive treatment approaches 1

First-Line Topical Treatments

• Topical retinoids form the foundation of acne treatment due to their comedolytic and anti-inflammatory properties 1
• Available topical retinoid options include:
  • Tretinoin (0.025-0.1% in cream, gel, or microsphere gel) 1
  • Adapalene (0.1%, 0.3% cream, or 0.1% lotion) 1
  • Tazarotene (0.05%, 0.1% cream, gel or foam) 1
• Benzoyl peroxide (2.5-5%) is an effective antimicrobial agent that releases free oxygen radicals, is mildly comedolytic, and prevents bacterial resistance 1, 2

Treatment Algorithm by Severity

Mild Acne

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

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

Moderate-to-Severe Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 1
• Recommended oral antibiotics:
  • Doxycycline (strongly recommended) 1
  • Minocycline (conditionally recommended) 1
• Limit systemic antibiotic use to 3-4 months to minimize bacterial resistance 1

Severe, Recalcitrant Acne

• Isotretinoin is the most effective therapy for severe, recalcitrant nodular acne 1, 4
• Careful monitoring is required due to potential side effects including teratogenicity, skeletal hyperostosis, and vision impairment 4

Special Considerations

Hormonal Therapy Options

• For female patients with hormonal acne, consider:
  • Combined oral contraceptives 1
  • Spironolactone 1

Back Acne

• Treatment follows the same severity-based approach as facial acne 5
• Adapalene 0.1% gel is available over-the-counter for mild back acne 5
• For severe back acne, consider systemic therapy with oral antibiotics or isotretinoin 5

Pediatric Acne

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children 1
• Tetracycline antibiotics are contraindicated in children under 8 years due to risk of permanent tooth discoloration 6

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 1
• 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, 3
• Underestimating severity when scarring is present 1
• Extended use of systemic antibiotics beyond 3-4 months 1
• Stopping treatment once acne clears without implementing maintenance therapy 1
• Neglecting the psychological impact of acne, especially with scarring 1, 7

Emerging Treatments

• Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) shows promise for moderate to severe acne 8
• Light-based treatments including blue/red light therapy, intense pulsed light (IPL), and pulsed dye laser (PDL) may be effective but have limited evidence 8
• Novel topical therapies targeting sebum production are under investigation 8