Acne Treatment Guidelines

Introduction to Acne Treatment

Acne treatment options include topical and systemic therapies, as well as lifestyle modifications, with a moderate strength of evidence supporting these approaches, as recommended by the American Academy of Dermatology 1, 2
The American College of Obstetricians and Gynecologists recommends advising patients that combined oral contraceptives (COCs) may take 3-6 months to show maximum benefit for acne, with a moderate strength of evidence supporting this approach 3

Topical clindamycin 1% is generally effective for the treatment of mild to moderate inflammatory acne, with its main action being the prevention of new lesions, but may induce bacterial resistance if used as monotherapy, as recommended by the American Academy of Dermatology 2
Topical retinoid + benzoyl peroxide 2.5-5% is recommended for mild acne, with a moderate strength of evidence supporting this approach 1
Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%) is recommended for moderate acne, with a moderate strength of evidence supporting this approach 1, 2

Doxycycline 200mg once daily is an acceptable alternative to 100mg twice daily for acne treatment, with similar efficacy, as recommended by the American Academy of Dermatology, with a moderate strength of evidence supporting this approach 2
Standard adult dosing for doxycycline is 200mg on the first day, followed by a maintenance dose of 100mg/day, with a strength of evidence supporting its effectiveness against Cutibacterium acnes, and a moderate strength of evidence supporting this approach 2
Doxycycline (100 mg daily) is recommended as first-line treatment for Cutibacterium acnes infections, due to its longer half-life, once-daily dosing, and effectiveness against C. acnes, with a moderate strength of evidence supporting this approach 1, 2, 4
Contraindications for various medications are as follows:
| Medication | Contraindications | | --- | --- | | Doxycycline | Children under 8 years, pregnant or breastfeeding women | | Isotretinoin | Pregnancy, breastfeeding women | | Spironolactone | Pregnancy, breastfeeding women | | Metformin | Renal impairment, diabetic ketoacidosis | | Finasteride | Pregnancy, breastfeeding women | 1, 2, 4

Drospirenone-containing combined oral contraceptives (COCs) are recommended as the most effective oral birth control option for treating acne in women who also desire contraception, due to their anti-androgenic properties, with a moderate strength of evidence supporting this approach 1
Hormonal therapy (combined oral contraceptives or spironolactone) may be considered in addition to topical therapy for hormonal acne, with a moderate strength of evidence supporting this approach 1, 2

Lifestyle modifications, such as reducing consumption of high-glycemic foods and limiting dairy intake, may be beneficial for acne treatment, with a moderate strength of evidence supporting this approach, and referral to a dermatologist is recommended if acne is moderate to severe, or if lifestyle changes don't improve acne after 4-6 weeks, or if acne is causing psychological distress or scarring, as recommended by the American Academy of Dermatology 1, 2

Continue topical retinoid therapy for maintenance after achieving control, and consider reducing frequency if irritation is problematic, with a moderate strength of evidence supporting this approach 1
Strict sun protection is essential to prevent hyperpigmentation after treatment, and patients should be advised to take necessary precautions, such as using sunscreen and protective clothing, with a high strength of evidence supporting this recommendation 1
Recommended treatments for scars are as follows:
| Scar Severity | Recommended Treatment | | --- | --- | | Mild | Topical retinoids and chemical peels | | Moderate | Fractional laser therapy, microneedling with topical growth factors or PRP, and combination approaches | | Severe | Laser punch-out technique, punch excision/elevation procedures, and multiple modalities used in sequence | 1
The American Academy of Dermatology recommends that patients with active acne should have their acne controlled before scar treatment, highlighting the importance of managing acne before addressing scars, with a high strength of evidence supporting this approach 1