Mild to moderate acne
- First-line therapy (comedonal acne only): topical retinoid
- First-line therapy (mild inflammatory acne): topical retinoid alone, topical retinoid + topical antimicrobial
- Topical retinoids are considered first line treatment for all forms of acne. Examples are: tretinoin (such as Atralin, Avita, Refissa, Renova, Retin-A, Retin-A Micro, Tretin-X), adapalene (such as Differin), tazarotene (such as Tazorac).
- For comedonal acne or mild inflammatory disease, use of a topical retinoid such as tretinoin cream (0.025%-0.05% for the face, 0.1% for the trunk) or gel (0.01% for the face, 0.025% for the trunk), or adapalene 0.1% cream or 0.1, 0.3% gel is first-line treatment. (See handout How to use topical retinoid medications)
- For moderate disease, add a second topical agent:
- antibiotic erythromycin 2% or clindamycin (such as Cleocin T, Clindagel, ClindaMax, Evoclin) 1% solution, lotion or gel, or dapsone (such as Aczone) 5% gel applied daily
- benzoyl peroxide wash, gel, lotion, or pads (2.5-10%) (such as Benzac AC, Benzac W, Brevoxyl, Desquam-E, Desquam-X, Triaz, or Zoderm
- glycolic acid wash, gel, lotion (2.5-20%)
- Fixed formulations of topical retinoids mixed with antimicrobials are available:
- adapalene 0.1%/ benzoyl peroxide 2.5% gel (such as EpiDuo)
- clindamycin 1.2%/ tretinoin 0.025% (such as Ziana)
- Fixed combination of 2 antimicrobials are available (can be used in conjunction with topical retinoids)
- clindamycin 1%/ benzoyl peroxide 5% gel (such as Acanya, BenzaClin, or Duac)
- erythromycin 3%/ benzoyl peroxide 5% gel (such as Benzamycin)
- Antibiotic monotherapy is strongly discouraged. Use of benzoyl peroxide should always be considered when using topical antibiotics to limit emergence of antibiotic-resistant bacteria.
- Maintenance therapy: topical retinoid
Moderate to severe acne (severe disease, involvement of the trunk, +/- scarring)
First-line therapy: topical retinoid + systemic antibiotic + benzoyl peroxide
- Combine a systemic antibiotic with a topical retinoid such as tretinoin cream (0.025%-0.05% for the face, 0.1% for the trunk) or gel (0.01 % for the face, 0.025% for the trunk), or adapalene 0.1% cream or 0.1, 0.3% gel:
- tetracycline 500 mg b.i.d, doxycycline hyclate (such as Adoxa, Doryx, Oracea) 100 mg q.d.-b.i.d.
- minocycline (such as Minocin or Solodyn) 50-150 mg q.d.)
- Alternative oral antibiotics:
- Cefadroxil (such as Duricef) 500 mg b.i.d.
- Trimethoprim-sulfamethoxazole double-strength tablet (such as Bactrim or Septra DS) q.d. or b.i.d. may work when other antibiotics fail. The high rate of allergic reactions to sulfa (3%) limits use of trimethoprim-sulfamethoxazole.
- Amoxicillin 500 mg b.i.d.
- Addition of benzoyl peroxide should always be considered to limit emergence of antibiotic-resistant bacteria.
- Use systemic antibiotics when there are numerous inflammatory lesions, involvement of the trunk or any scarring resulting from acne.
- Maintenance therapy: topical retinoid +/- benzoyl peroxide
Severe acne (severe disease, presence of nodules, involvement of the trunk, or any evidence of scarring)
- First-line therapy: systemic isotretinoin (such as Accutane, Amnesteem, Claravis, or Sotret)
- Referral to a dermatologist, where available, or systemic isotretinoin should strongly be considered.
- Maintenance therapy: topical retinoid +/- benzoyl peroxide
Managing acne treatment
- Treatment must be applied to the entire affected area, not just the lesions.
- 2-3 months of treatment are necessary. Treatment of truncal lesions may take longer. Continue any effective treatment for at least 3-6 months before slowly tapering off to maintenance therapy.
- Topical retinoids are the mainstay of maintenance therapy once the acne is clear. It can be used in combination with benzoyl peroxide products in previously moderate-to-severe disease.
- Acne will often flare after 2-3 weeks of tretinoin use, resolving within 6-8 weeks. Tretinoin flares can be prevented by starting the applications every 2-3 nights only for the first month, and using a topical antibiotic in the mornings.
- Topical retinoids may induce photosensitivity, so encourage the use of a non-comedogenic sunscreen. (See handout Choosing a Sunscreen)
- Facial comedones (especially of the forehead) are often related to oily products applied to the scalp/hair as well as other facial products (make-up). (See handout Skin & hair care for acne patients.)
- Dryness is a common side effect of many acne treatments. Choosing cream or lotion-based vehicles, minimizing use of soap-based or medicated facial washes, and use of a non-comedogenic moisturizer reduces excessive dryness. (See handout Skin & hair care for acne patients.)
Overzealous use of topical retinoids and/or benzoyl peroxide products may irritate skin. Only small amounts of topical retinoids (pea-sized for the entire face) should be applied. Strategies for reducing retinoid irritation are:
- Only small amounts of topical retinoid (pea-sized for the entire face) should be applied.
- Start by using 2-3 times a week only with slow increase in frequency as tolerated
- Wait 20 minutes after washing skin to apply topical retinoid (skin is dry)
- Short-contact exposure (apply for one hour and then rinse off)
- Add a moisturizer directly on top of the topical retinoid one hour after application
- Avoid application on eyelids or lips
- Use a retinoid such as adapalene (See handout How to use topical retinoid medications.)
Principles of acne treatment in special patient populations
Children (see Acne Vulgaris for Pediatricians)
Pregnant women or women planning to conceive
- Most acne treatments carry risk to fetal development. It is important to consider plans for pregnancy in the initial discussion of acne treatment with all female patients.
- A general guideline is to discontinue all potentially teratogenic medications at least one month prior to attempts for conception.
- Azelaic acid (15 or 20% cream) b.i.d. and topical or systemic erythromycin base are safe options in pregnant patients.
Situations requiring dermatologic consultation
- Lack of response to treatment (6 months) or uncertain diagnosis
- Widespread involvement
- Possible endocrine disorder or acne treatment in the setting of complex medical disease
- Need for systemic retinoid therapy (isotretinoin). Systemic retinoid therapy is first-line therapy indicated for nodular or scarring acne.
- Medication-induced acne
- Three external factors that trigger the acne must be avoided for therapy to be effective:
- comedogenic medications (steroids, psychiatric medications, oral contraceptives, etc.)
- comedogenic cosmetics and creams
- friction (e.g., from rubbing or self-manipulation/picking)
- In female patients with a clear premenstrual trigger, consider spironolactone (such as Aldactone) 50 mg to 100 mg daily with or without oral contraceptive pills. Common side effects of spironolactone include breast tenderness and menstrual spotting, and it is a teratogen, and thus should not be used in pregnant individuals. Oral contraceptives with ethinyl estradiol with drospirenone or norgestimate are optimal for acne, such as drosperinone 3 mg & 0.03 mg ethinyl estradiol; drosperinone 3mg & 0.02 mg ethinyl estradiol (such as Ocella, Yasmin, or Yaz); norgestimate + ethinyl estradiol 35 mcg (such as MonoNessa, OrthoTri-Cyclen, Ortho Tri-Cyclen Lo, Previfem, Sprintec, Tri-Lo Sprintec, Tri-Previfem, Tri-Sprintec, or TriNessa).
- Amenorrhea, androgenetic alopecia, and/or hirsutism, are signs of a hyperandrogenic state, and endocrine evaluation and correction or suppression of the condition may lead to improvement of the acne when other approaches fail. Consider referral to a dermatologist and/or endocrinologist.