Moderate Acne Vulgaris Management

Aka: Moderate Acne Vulgaris Management, Acne Vulgaris Pharmacologic Management, Topical Acne Vulgaris Management, Comedolytics in Acne Vulgaris, Topical Antibiotics in Acne Vulgaris

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II. Indication

  1. Mild to moderate Inflammatory Acne Vulgaris
  2. Comedonal Acne Vulgaris

III. Management: Step 1 - OTC Topical Medications (Self-directed treatment)

  1. Approach
    1. Patient typically presents already using Benzoyl Peroxide
    2. Most providers start at step 2
  2. Indications
    1. Comedones
  3. First-Line OTC Medications
    1. Acne wash (e.g. Cetaphil) daily
    2. Topical Benzoyl Peroxide 2.5% gel in morning
      1. Available as a 2.5% to 10% concentrations in various bases (2.5% if preferred for less adverse effects, good efficacy)
      2. First-line agent for all forms of acne and especially in concert with topical and systemic Antibiotics
      3. Antimicrobial and antiinflammatory agent with mild Comedolytic activity
      4. Pregnancy Category C
      5. Dosing
        1. Benzoyl Peroxide 2.5% is as effective as 5-10%
          1. Lower strength is much less irritating than 5-10%
        2. Benzoyl Peroxide is effective against P. acnes
          1. Continue with each step of acne management
  4. OTC Medications that are typically avoided (lack of evidence)
    1. Salicylic acid
      1. Available as 0.5% to 3% formulations in various bases
      2. Not recommended in acne (used in Wart Management)
      3. Pregnancy Category C
    2. Tea tree oil
      1. Not typically used in Acne Vulgaris
      2. Appears to reduce total number of Papules, Pustules and comedones
  5. Follow-up
    1. Return in 6 weeks

IV. Management: Step 2 - Comedolytics

  1. Indications
    1. Comedones
    2. Mild inflammatory Papules and Pustules
  2. Medications
    1. Continue topical Benzoyl Peroxide in morning (from step 1)
      1. Can be used with Adapalene, Tazarotene or trifarotene
      2. Benzoyl Peroxide degrades Tretinoin
    2. Add first-line retinoid Comedolytic at night
      1. Topical Tretinoin (Retin A)
        1. Start with 0.025% cream at bedtime
        2. Also available as microsphere gel
      2. Adapalene (Differin)
        1. Start with 0.1% gel at bedtime
        2. Also available combined with Benzoyl Peroxide as Epiduo gel (0.1%/2.5%)
        3. Best tolerated topical Retinoid
    3. Other Retinoids with similar efficacy
      1. Tazarotene (Tazorac)
      2. Trifarotene (Aklief)
    4. Warn regarding redness and irritation
      1. Use only pea size amount per triangle of face
      2. Use only at night-time
      3. Consider using a skin Emollient to reduce irritation
      4. Use Sunscreen
  3. Follow-up
    1. Return in 12 weeks

V. Management: Step 3 - Topical Antibiotics

  1. Indications
    1. Moderate inflammatory Papules and Pustules
    2. Not effective in noninflammatory lesions
  2. Precautions
    1. Topical Antibiotic Resistance is increasing (resistance approaches 50%)
      1. Use Topical Antibiotics with Benzoyl Peroxide to prevent resistance
      2. Limit Topical Antibiotic use to12 weeks
    2. Consider using oral Antibiotic instead
      1. See Severe Acne Vulgaris Management
      2. Indicated for Inflammatory Nodules (deep lesions)
  3. Protocol
    1. Morning
      1. Continue Benzoyl Peroxide AND
      2. Add Topical Antibiotic (e.g. topical Clindamycin such as Cleocin-T)
        1. See preparations below
        2. Consider a combination product with Benzoyl Peroxide (e.g. Benzaclin)
    2. Bedtime
      1. Continue Comedolytic (e.g. Tretinoin or Adapalene) OR
      2. Combine Adapalene with Benzoyl Peroxide (Epiduo) OR
      3. Consider Tazarotene (Tazorac) 0.05% gel or cream
        1. More irritating than Retin A, but more effective
        2. Indicated if no Tretinoin or Adapalene response
        3. Pregnancy Category X
  4. Medications
    1. Antibiotics Half lives
      1. Clindamycin (longest half life)
      2. Erythromycin (mid range half life)
      3. Tetracycline (shortest half life)
    2. Topical Antibiotic Medications
      1. Clindamycin HCl (Cleocin-T, Evoclin)
      2. Erythromycin (Akne-mycin, Erygel) Lotion (1.5% 2%)
      3. Tetracycline HCl (Topicycline) Lotion 2.2 mg/ml
      4. Azelaic Acid (Finacea, Azelex)
        1. Indicated in Postinflammatory Hyperpigmentation or risk (dark or sensitive skin)
        2. Antimicrobial and antiinflammatory agent with mild Comedolytic activity (similar to Benzoyl Peroxide)
        3. Finacea 15% gel has better Bioavailability and is preferred over the Azelex 20% cream
        4. Pregnancy category B
      5. Minocycline (Zilxi, Amzeeq) Topical Foams
        1. Zilxi (minocycline Topical Foam, 1.5%)
        2. Amzeeq (Minocycline foam)
        3. Efficacy
          1. Very expensive (more than $500 for 30 g) while inexpensive alternatives with similar efficacy
          2. Not recommend (consider Clindamycin with Benzoyl Peroxide instead)
          3. (2020) Presc Lett 27(2): 8
      6. Consider sulfa agents if intolerance to other meds
        1. Dapsone (Aczone) 5% gel twice daily or 7.5% gel once daily
          1. Pregnancy Category C
          2. Variable efficacy in inflammatory acne, but more effective in adult women
        2. Sulfur (Acne lotion 10, Liquimat, Sulpho-Lac)
        3. Sulfur 5% and Sodium sulfacetamide 10% (Novacet)
    3. Combination agents (Comedolytic with Antibiotic)
      1. Refrigeration required
        1. Erythromycin with Benzoyl Peroxide (Benzamycin)
      2. Refrigeration not required
        1. Benzoyl Peroxide, Glycolic Acid, Zinc (Triaz)
        2. Clindamycin 1%/Benzoyl Peroxide 5% Gel (Benzaclin, Neuac)
          1. More effective than Clindamycin alone

VI. Management: Step 4 - Systemic Agents

  1. See Systemic Acne Vulgaris Management
  2. Indications
    1. Inflammatory Nodules
    2. Moderate to severe inflammatory Papules and Pustules
  3. Medications
    1. Consider Adjunctive Acne Vulgaris Management
    2. Oral Antibiotics (e.g. low dose Doxycycline)
      1. As with topical Antibiotic Resistance in acne, oral Antibiotic Resistance is also increasing
      2. Stop oral Antibiotics after acne improves (after 3-4 months) and continue topical agents
    3. Isotretinoin (Accutane)

VII. Management: Step 5 - Miscellaneous

  1. Adjunctive Medications
    1. See Adjunctive Acne Vulgaris Management
    2. Oral Contraceptives
    3. Spironolactone
  2. Intralesional Corticosteroid Injection (intralesional Triamcinolone)
    1. See Intralesional Corticosteroid Injection for Acne Vulgaris
    2. Consider for large acne Papules or nodular acne
    3. Consider for those at risk of scarring
    4. Consider for rapid improvement for special occasions (e.g. weddings, graduation pictures)
  3. Avoid other measures with lack of evidence
    1. Acne lesion extraction
    2. Chemical Peels
    3. Laser treatments
    4. Light-based therapy
    5. Microneedle radiofrequency device
    6. Photodynamic therapy

VIII. References

  1. Habif (2004) Dermatology, Mosby, p. 162-94
  2. Parker in Noble (2001) Primary Care p. 758-60
  3. Feldman (2004) Am Fam Physician 69:2123-56 [PubMed]
  4. Gollnick (2003) J Am Acad Dermatol 49:S1-37 [PubMed]
  5. James (2005) N Engl J Med 352(14):1463-72 [PubMed]
  6. Reynolds (2024) J Am Acad Dermatol 90(5):1006.e1-30 +PMID: 38300170 [PubMed]
  7. Strauss (2007) J Am Acad Dermatol 56(4): 651-63 [PubMed]
  8. Titus (2012) Am Fam Physician 86(8): 734-40 [PubMed]

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