Acne Vulgaris

General Principles of Acne Management

  • The clinical subtype, severity, prior treatment, psychological impact, and presence of scarring should be considered for all patients with acne.
  • The treatment of acne usually involves initial therapy followed by long-term maintenance therapy.
  • Treatment should target as many pathophysiological causes as possible.
  • Comedonal versus inflammatory acne requires distinct therapeutic approaches.
  • There is strong evidence now recommending against the use of topical or systemic antibiotic monotherapy, as antibiotic resistance may develop as quickly as 6 weeks with the use of topical antibiotic monotherapy. Use of systemic antibiotic monotherapy may give rise to antibiotic-resistant colonizing bacteria on skin and at remote sites, including streptococcal colonization of the throat.
  • There are multiple strategies that can be employed to limit emergence of antibiotic resistance: combination of a topical retinoid and benzoyl peroxide, antibiotic and benzoyl peroxide, topical retinoid and antibiotic, and use of either topical retinoid or benzoyl peroxide alone. However, use of combination therapy in many cases is more effective for the treatment of acne and several combination formulations are available. The convenience of combination formulations may also improve patient adherence to their acne skin regimen.
  • Topical retinoids used alone or as part of a combination therapy is considered first-line in the initial treatment of all types of acne except for severe nodular disease, which requires systemic retinoid therapy.
  • A combination formulation containing a topical retinoid and the antimicrobial agent benzoyl peroxide (such as EpiDuo) may accomplish the treatment goal of providing a first-line topical retinoid and a strategy to prevent antibiotic resistance consistent with the best practice of avoiding long-term topical antibiotic use.
  • Severe disease–especially scarring or trunk involvement–requires systemic therapy.
  • Some female patients may benefit greatly from hormonally targeted treatment.
  • It is essential to align the treatment regimen with the patientÂ’’s goals and preferences for treatment: systemic versus topical, complexity of regimen.