Treating Acne Vulgaris: Systemic, Local and Combination Therapy

Laura J Savage; Alison M Layton


Expert Rev Clin Pharmacol. 2010;13(4):563-580. 

In This Article


Acne remains a very common inflammatory dermatosis, which is often associated with significant psychological morbidity. It frequently affects young adults at a time when they are undergoing maximal physical, emotional and social changes. Late-onset and persistent adult acne are now more widely recognized and may necessitate consideration of an alternative approach to therapy. A focus on early aggressive intervention is paramount for all patients to reduce the physical and psychological scarring that can result from acne of any severity.

A better understanding of the pathophysiological mechanisms driving acne has allowed for the development of more effective topical and systemic therapies. These can be prescribed in logical combinations to target each relevant pathological factor and thus ensure optimal acne management. Clear guidelines now exist, such as those published by the Global Alliance to Improve Outcomes in Acne, to guide clinicians in their prescribing.[13,14] Such guidelines take into account the increasing emergence of antibiotic-resistant strains of P. acnes and offer strategies to minimize this. Topical retinoids are advocated as first-line treatment for any patient with mild-to-moderate acne, especially with comedonal lesions, and should be employed in combination with BPO, antibiotics and/or hormonal treatments for more severe or treatment-resistant disease. Systemic retinoids provide extremely efficacious therapy for severe disease that has not responded to combination therapy. However, the importance of comprehensive counseling for all women of child-bearing potential must not be overlooked as the risks of teratogenicity are significant. In female patients with persistent or late-onset acne, hormonal investigations and treatments may also be warranted.

Each patient should receive education regarding acne and the available treatment options. A realistic explanation of the benefits, risks and expected outcomes of each therapy must be provided to promote autonomy. Patients also need to understand that, although most cases of acne can be cleared with available treatments, therapy requires time, and in the early weeks of treatment their acne may worsen. However, with frequent reassurance and follow-up, many patients will comply with treatment and achieve an acceptable outcome. Maintenance therapy is an important consideration as acne represents a chronic disease and frequently recurs without an ongoing treatment regimen. Topical retinoids are recommended for maintenance therapy as they target microcomedones, the precursor lesions of acne. BPO may be alternated with a topical retinoid, using BPO in the morning and topical retinoid in the evening. Antibiotics, topical or systemic, should not be used as monotherapy and/or in the long term as a maintenance therapy owing to the emergence of antimicrobial resistance.


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