Acne Vulgaris: Treatment

Treatment should address both the physical and psychological effects of acne, and should be guided by the severity and type of lesions. Light and laser therapies may be used to treat acne in the future.

Noninflammatory Acne

A number of topical therapies are used to treat noninflammatory acne.

• Retinoids (eg, tretinoin, adapalene, tazarotene) decrease follicle hyperkeratinization. Treatment for 8 weeks is required before assessing efficacy, and acne may initially worsen. Retinoids are available in various preparations, including creams, gels, and microgels (which are less irritating), solutions, and pads. Skin irritation and photosensitivity may occur. Tazarotene is contraindicated during pregnancy.
• Acid preparations (eg, salicylic acid, azelaic acid, glycolic acid)also decrease follicle hyperkeratinization. Salicylic acid is the most commonly used acid and is available over–the–counter. Azelaic acid may be effective for acne–induced hyperpigmentation.
• Benzoyl peroxide is an effective topical treatment that has antibacterial and comedolytic properties. In patients with inflammatory lesions, it may be used in combination with a topical antibiotic, such as erythromycin, or a topical retinoid.

Extraction of comedones may be performed by a trained clinician after first treating the patient with a retinoid.

Inflammatory Acne

Inflammatory acne is often treated with multiple topical therapies. Benzoyl peroxide, topical antibiotics (eg, erythromycin, tetracycline, azealic acid, clindamycin), retinoids, and acids are commonly used.

Antibiotics attack the proprionibacterium in the hair follicles. Bacterial resistance may occur, but is reduced by combination therapy with benzoyl peroxide.²

Severe Acne

Severe acne can be treated with intensive topical treatment, but may require oral therapy.

Oral antibiotics are usually prescribed for 6 months and then tapered. Resistance may occur with prolonged therapy.

Isotretinoin is usually reserved for the most severe cases of nodulocystic acne, or acne that is refractory to combination treatment. It is extremely effective, but is expensive and has many potential adverse effects, including teratogenicity. Close follow–up is necessary for laboratory work, including pregnancy tests, liver function tests, lipid panels, and complete blood counts. Treatment usually lasts 6 months.

Systemic corticosteroids should be added if the acne worsens with initiation of isotretinoin.