Acne Vulgaris Characteristics and Management
For acne vulgaris treatment, a multimodal approach combining topical retinoids with benzoyl peroxide is strongly recommended as first-line therapy, with additional agents selected based on acne severity and patient characteristics. 1
Characteristics of Acne Vulgaris
- Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older 2
- Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide treatment selection 1
- The psychological impact of acne should be evaluated, as severe acne causing psychosocial burden may warrant more aggressive treatment 2
Treatment Algorithm by Severity
Mild Acne
- First-line treatment: Topical retinoids (tretinoin, adapalene, tazarotene) + benzoyl peroxide 1
- Topical retinoids are essential due to their comedolytic and anti-inflammatory properties 1
- Benzoyl peroxide (2.5-5%) is effective as an antimicrobial agent with no risk of bacterial resistance 1
- Alternative options include azelaic acid (particularly for post-inflammatory hyperpigmentation) and salicylic acid 1
Moderate Acne
- First-line treatment: Fixed-dose combination of topical retinoid + benzoyl peroxide 1
- Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, always in combination with benzoyl peroxide to prevent bacterial resistance 1
- Fixed-combination products (erythromycin/BP, clindamycin/BP) enhance treatment compliance 1
Moderate-to-Severe Acne
- First-line treatment: Oral antibiotics + topical retinoid + benzoyl peroxide 1
- Doxycycline is strongly recommended with moderate evidence 1
- Minocycline and sarecycline are conditionally recommended 2, 1
- Limit systemic antibiotic use to 3-4 months to prevent resistance 1
Severe Acne
- Oral isotretinoin is strongly recommended for acne that is:
- Severe
- Causing psychosocial burden
- Causing scarring
- Failing standard oral or topical therapy 2
Hormonal Therapy Options
- For female patients with hormonal acne:
Special Considerations
Application Guidelines
- When using tretinoin:
- Apply once daily before bedtime
- Wait 20-30 minutes after washing face before application
- Keep away from corners of nose, mouth, eyes, and open wounds
- Use sunscreen during daytime as tretinoin increases sun sensitivity 3
Combination Therapy Best Practices
- Combining topical therapies with multiple mechanisms of action is recommended as good practice 2
- Tretinoin applied in the morning and benzoyl peroxide applied at night may be efficacious with minimal side effects 4
- Adapalene is more stable than tretinoin and can be used in combination with benzoyl peroxide without concern for photo-deactivation 5
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
- Underestimating severity when scarring is present 1
- Extended use of systemic antibiotics beyond 3-4 months 1
- Not considering the psychological impact of acne, especially with scarring 1
- Not using benzoyl peroxide concurrently with antibiotics to prevent resistance 1
- Excessive washing and harsh scrubbing can worsen acne 3
- Failure to protect tretinoin-treated skin from sun exposure 3
Treatment for Special Populations
- For children under 12, benzoyl peroxide is recommended as the primary treatment, starting with a low concentration of 2.5% 6
- For children ≥9 years with predominantly comedonal acne, adapalene 0.1% gel may be considered 6
- Tetracycline antibiotics are contraindicated in children under 8 years due to risk of permanent tooth discoloration 6, 7
By following this evidence-based approach to acne management, clinicians can effectively treat acne vulgaris while minimizing side effects and preventing bacterial resistance.