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IndianJDermatol.2011JanFeb56(1):713.

PMCID:PMC3088940

doi:10.4103/00195154.77543

ACNEVULGARISTREATMENT:THECURRENTSCENARIO
SanjayKRathi
FromtheConsultantDermatologist,Siliguri,WestBengal,India.
Addressforcorrespondence:Dr.SanjayRathi,143,HillCartRoad,Siliguri,WestBengal,IndiaEmail:drsrathi2@gmail.com
Received2010AugAccepted2010Dec.
Copyright:IndianJournalofDermatology
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
AcneVulgarisisoneofthemostcommonskindisorderswhichdermatologistshavetotreat.Itmainlyaffect
adolescent,thoughmaypresentatanyage.Inrecentyears,duetobetterunderstandingofthepathogenesis
ofacne,newtherapeuticmodalitiesandvariouspermutationandcombinationshavebeendesigned.In
topicalagentsbenzoylperoxide,antibiotics,retinoids,etcarethemainstayoftreatmentcanbegivenin
combinations.Whilesystemictherapyincludesoralantibiotics,hormonaltherapy,andisotretinoin,
dependingupontheneedofpatientsithastobeselected.Physicaltreatmentintheformoflesionremoval,
phototherapyisalsohelpfulinfewofthem.Sincevariousoldandnewtopicalandsystemicagentsare
availabletotreatacne,itsometimeconfusetreatingdermatologist.Toovercomethis,panelofphysiciansand
researchersworkedtogetherasaglobalallianceandtaskforcetoimproveoutcomesinacnetreatment.They
havetriedtogiveconsensusrecommendationforthetreatmentofacne.Successfulmanagementofacne
needscarefulselectionofantiacneagentsaccordingtoclinicalpresentationandindividualpatientneeds.
Keywords:Acne,treatment,consensusrecommendation
Introduction
Acnevulgarisisoneofthecommonestskindisorderswhichdermatologistshavetotreat,mainlyaffect
adolescents,thoughitmaypresentatanyage.Acnebydefinitionismultifactorialchronicinflammatory
diseaseofpilosebaceousunits.[1]Variousclinicalpresentationsincludeseborrhoea,comedones,
erythematouspapulesandpustules,lessfrequentlynodules,deeppustulesorpseudocysts,andultimate
scarringinfewofthem.Acnehasfourmainpathogeneticmechanismincreasedsebumproductions,
follicularhyperkeratinization,Propionibacteriumacne(P.acne)colonization,andtheproductsof
inflammation.[25]
Inrecentyears,duetobetterunderstandingofthepathogenesisofacne,newtherapeuticmodalitiesare
designed.[3]Availabilityofnewtreatmentoptionstocomplimenttheexistingarmamentariumshouldhelpto
achievethesuccessfultherapyofgreaternumbersofacnepatients,ensureimprovedtolerabilityandfulfil
patientexpectations.Successfulmanagementofacneneedscarefulselectionofantiacneagentsaccordingto
clinicalpresentationandindividualpatientneeds.
Thepurposeofthisarticleistoreviewthetreatmentoptionsavailablewithusinthepresentscenario.
Topicaltherapy Topicaltherapyisusefulinmildandmoderateacne,asmonotherapy,incombinationand

alsoasmaintenancetherapy.
A.Benzoylperoxide

Itisaneffectivetopicalagentsincemanyyearsandisavailableindifferentformulations(washes,lotions,
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creams,andgels)andconcentrations(2.510%).[4,6]
Thestabilityisverydependentonitsvehicle.Gelsaregenerallymorestableandactiveandwaterbasedgel
beinglessirritantismorepreferredovercreamsandlotions.[7,8]Benzoylperoxideisabroadspectrum
bactericidalagentwhichiseffectiveduetoitsoxidizingactivity.[7]
Thedrughasanantiinflammatory,keratolytic,andcomedolyticactivities,andisindicatedinmildto
moderateacnevulgaris.Cliniciansmustmakeabalanceamongdesiredconcentration,thevehiclebase,and
theriskofadverseeffects,ashigherconcentrationisnotalwaysbetterandmoreefficacious.[9]
Themainlimitationofbenzoylperoxideisconcentrationdependentcutaneousirritationordrynessand
bleachingofclothes,hair,andbedlinen.[10]Itcaninduceirritantdermatitiswithsymptomsofburning,
erythema,peeling,anddryness.[11]Thisoccurswithinfewdaysoftherapyandmostlysubsideswith
continueduse.
B.Topicalretinoids

Retinoidshavebeeninuseformorethan30years.Topicalretinoidstargetthemicrocomedoprecursor
lesionofacne.Thereisnowconsensusthattopicalretinoidshouldbeusedasthefirstlinetherapy,aloneor
incombination,formildtomoderateinflammatoryacneandisalsoapreferredagentformaintenance
therapy.
Itseffectivenessiswelldocumented,asittargetstheabnormalfollicularepithelialhyperproliferation,reduces
follicularpluggingandreducesmicrocomedonesandbothnoninflammatoryandinflammatoryacnelesions.
[1214]Theirbiologicaleffectsaremediatedthroughnuclearhormonereceptors(retinoicacidreceptorRAR
andretinoidsXreceptorRXRwiththreesubtypes,,and)andcytosolicbindingproteins.[15]Retinoic
acidmetabolismblockingagents(RAMBAs)suchasliarozolehavebeendevelopedrecentlytoovercome
theemergenceofalltransretinoicacidresistance.[16]
Tretinoin,adapalene,tazarotene,isotretinoin,metretinide,retinaldehyde,andretinoylglucuronideare
currentlyavailabletopicalretinoids.[17]Themoststudiedtopicalretinoidsforacnetreatmentworldwideare
tretinoinandadapalene.[18]Thereisnoconsensusaboutrelativeefficacyofcurrentlyavailabletopical
retinoids(tretinoin,adapalene,tazarotene,andisotretinoin).Theconcentrationand/orvehicleofany
particularretinoidmayimpacttolerability.[19]Adapalenewasgenerallybettertoleratedthanallother
retinoidwithwhichitwascompared.[20,21]Tretinoinhasrecentlybecomeavailableinformulationswith
noveldeliverysystemswhichimprovestolerability.OnesuchproductRetinAMicro(0.1%gel)contains
tretinointrappedwithinporouscopolymermicrospheres.Avita,thetretinoinisincorporatedwithina
polyoylprepolymer(PP2).Eachofthethesesformulationsreleasestretinoinslowlywithinthefollicleand
ontotheskinsurface,whichinturnreducesirritancywiththesameefficacy.[22]
Themainadverseeffectswithtopicalretinoidisprimaryirritantdermatitis,whichcanpresentaserythema,
scaling,burningsensationandcanvarydependingonskintype,sensitivity,andformulations.
C.Topicalantibiotics

Manytopicalantibioticsformulationsareavailable,eitheraloneorincombination.Theyinhibitthegrowth
ofP.acneandreduceinflammation.Topicalantibioticssuchaserythromycinandclindamycinarethemost
popularinthemanagementofacneandavailableinavarietyofvehiclesandpackaging.[23]Clindamycin
anderythromycinwerebotheffectiveagainstinflammatoryacneintopicalformincombinationof14%
withorwithouttheadditionofzinc.[2426]Anadditionoftopical2%zincsulfateandnicotinamidewasno
differentthanplaceboforthetreatmentofacne.[2729]Topicalclarithromycin,azithromycin,and
nadifloxacinareavailableinIndia,buttrialsfortheirefficacyandsafetyarelacking.
Sideeffectsthoughminorincludeserythema,peeling,itching,dryness,andburning,pseudomembranous
colitiswhichisrare,buthasbeenreportedwithclindamycin.[30]Amostimportantsideeffectoftopical
antibioticsisthedevelopmentofbacterialresistanceandcrossresistancetherefore,itshouldnotbeusedas
monotherapy.
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D.Othertopical/newagents

Combinationtherapy:BenzoylperoxidehastheadvantagetopreventandeliminatethedevelopmentofP.
acneresistance.Thereforeitisbeingmorepreferredascombinationtherapy.Itsefficacyandtolerabilityare
enhancedwhencombinedwithtopicalerythromycinorclindamycin,confirmedonvarioustrials.[6,3134]
Benzoylperoxidecanbecombinedwithtretinoinandfoundtobesuperiortomonotherapy.Boththe
moleculesshouldnotbeappliedsimultaneouslyasbenzoylperoxidemayoxidizetretinoin.[35]A
combinationoftopicalretinoidandtopicalantimicrobialismoreeffectiveinreducingbothinflammatoryand
noninflammatoryacnelesionsthaneitheragentusedalone.[36]Topicalclindamycinandbenzoylperoxide
appliedoncedailyandfixedclindamycinphosphate1.2%andtretinoin0.025%inaqueousbasedgel
formulationusedoncedailyarebothfoundtobeeffectivetreatmentforacne.Additionofzincacetateto
clindamycinanderythromycingelshowedequivalentefficacybutprobablyreducesthedevelopmentof
microbialresistance.[37]
Salicylicacid:Ithasbeenusedformanyyearsinacneasacomedolyticagent,butislesspotentthantopical
retinoid.[38]
Azelaicacid:Itisavailableas1020%topicalcreamwhichhasbeenshowntobeeffectiveininflammatory
andcomedonalacne.[39,40]
Lacticacid/Lactatelotion:Itisfoundtobehelpfulinpreventingandreductionofacnelesioncounts.[41]
Teatreeoil5%:Initialclinicalresponsewiththispreparationisinevitablyslowercomparedtoother
treatmentmodalities.[42]
Picolinicacidgel10%:Itisanintermediatemetaboliteoftheaminoacid,tryptophan.Ithasantiviral,
antibacterial,andimmunomodulatoryproperties.Whenappliedtwicedailyfor12weeksfoundtobe
effectiveinbothtypeofacnelesions,butfurthertrialsareneededtoconfirmitssafetyandefficacy.[43]
Dapsonegel5%:Itisasulfonewithantiinflammatoryandantimicrobialproperties.Thetrialshave
confirmedthattopicaldapsonegel5%iseffectiveandsafeasmonotherapyandincombinationwithother
topicalagentsinmildtomoderateacnevulgaris.[44]
SystemicTherapy
Systemicantibiotics 0Oralantibioticsareindicatedinmainlymoderatetosevereinflammatoryacne.[5]

Tetracyclinesandderivativesstillremainthefirstchoice.Macrolides,cotrimoxazole,andtrimethoprimare
otheralternativesforacne.[45]Thefollowingagentsshouldnotbeusedinacneduetolackofefficacyand
safetyconsiderationsuchascephalosporins,sulphonamide,andgyraseinhibitors.[4]
Tetracycline(500mg1g/day),doxycycline(50200mg/day),minocycline(50200mg/day),lymecycline
(150300mg/day),erythromycin(500mg1g/day),cotrimoxazole,trimethoprim,andrecently
azithromycin(500mgthriceweekly)arebeingusedsuccessfullyinacne.[4650]Minocyclineand
doxycyclinearemoreeffectivethantetracyclineanderythromycin.[46,47]Recently,doxycyclinein
subantimicrobialdose(20mgtwicedaily)andanextendedreleaseminocyclinetablet(1mg/kg/day)were
usedandfoundtobeeffective,butfurthercontrolledtrialsareneeded.[37,51]
Gastrointestinalupsetandvaginalcandidiasisaremostcommonsideeffects.Doxycyclinecanbeassociated
withphotosensitivity.Minocyclinemayproducepigmentdepositionintheskin,mucousmembrane,and
teeth.Autoimmunehepatitis,systemiclupuserythematosuslikesyndrome,andserumsicknesslikereactions
occurrarelywithminocycline.
LongtermtherapywithoralantibioticnotonlythreattoresistantofP.acne,butalsotocoagulasenegative
staphylococciontheskin,Staphylococcusaureusinthenares,andstreptococciintheoralcavity.[52,53]
Thereisasignificantassociationbetweenantibioticusedinacneandtheincidenceofupperrespiratorytract
infection.[54]
Optimizingantibiotictherapy:ResearchhasdemonstratedthatproblemofantibioticresistantP.acneis
increasing,anditismostcommonwitherythromycin.Thereforethereisneedtoconsiderforantibiotic
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prescribingpoliciesandtoadvocatetheuseofnonantibioticpreparationswhereverpossible.
Antibioticmonotherapyistobeavoidedanditcanbecombinedwithtopicalretinoidorbenzoyl
peroxideasperneed.
Whereverpossiblethedurationoftherapyshouldbelimited.Theusualminimumdurationof
therapyis68weeksbutcanbegivenupto1218weeksandmore.
Itisadvisabletousethesameantibioticifretreatmentisnecessaryandusebenzoylperoxidefora
minimumof57daysbetweenantibioticcoursestoreduceresistantorganism.
Concomitantuseoforalandtopicaltherapywithchemicallydissimilarantibioticsistobeavoided.
Hormonaltherapy Itmaybeneededinfemalepatientswithsevereseborrhoea,clinicallyapparent

androgeneticalopecia,seborrhoea/acne/hirsuitism/alopecia(SAHA)syndrome,lateonsetacne(acnetarda),
andwithprovenovarianoradrenalhyperandrogenism.
Themainapproachofhormonaltherapyinacneistopreventtheeffectsofandrogensonthesebaceous
glandandprobablyfollicularkeratinocytesaswell.Itiswisertotakeconsultationwithgynecologistbefore
startingtherapy.
a)Oralcontraceptives

Estrogeniscommonlycombinedwithprogestintoavoidtheriskofendometrialcancer.Antiacneeffectof
oralcontraceptivegovernedbydecreasinglevelofcirculatoryandrogensthroughinhibitionofluteinizing
hormones(LH)andfolliclestimulatinghormone(FSH).[55,56]ThecurrentlyFDAapprovedagentsinclude
norgestimatewithethinylestradiol,andnorethindroneacetatewithethinylestradiol.
b)Spironolactone

Theyfunctionsprimarilyasasteroidalandrogenreceptorblocker.Itmaycausehyperkalemia(whenhigher
dosesareprescribedorwhenthereiscardiacorrenalcompromise),menstrualirregularities.[57,58]
c)Cyproteroneacetate

Itisthefirstandrogenreceptorblockingagenttobewellstudiedandfoundtoeffectiveinacneinfemales.
[59,60]Higherdoseshavebeenfoundtobemoreeffectivethanlowerdose.Itisalsocombined(2mg)with
ethinylestradiol(35or50g)asanoralcontraceptiveformulationtotreatacne.
d)Flutamide

Itisusefulinacnewhengiveninfemaleswithhirsuitism.[60,61]
Oralretinoidisindicatedinsevere,moderatetosevereacneorlesserdegreeofacne
producingphysicalorpsychologicalscarring,unresponsivetoadequateconventionaltherapy.[62,63]Itisthe
onlydrugthataffectsallfourpathogenicfactorsimplicatedintheetiologyofacne.
Oralisotretinoin

Althoughtherearemanystudies,butverylargeevidencebasedstudyislackingtoconfirmthedosing
schedule.Theapproveddoseis0.52mg/kg/day,whichisusuallygivenfor20weeks.[6466]
Alternatively,lowerdosecanbeusedforlongerperiod,withatotalcumulativedoseof120mg/kg.[65]New
developmentsandfuturetrendsarelowdoselongtermisotretinoinregimensandnewisotretinoin
formulations(micronizedisotretinoin).[51]
Sideeffectsincludethoseofmusculoskeletal,mucocutaneous,andophthalmicsystems,aswellasheadache,
andcentralnervoussystemeffects.[66]Mostofthesideeffectsaretemporaryandresolvesafterthedrugis
discontinued.Oralisotretinoinisapotentteratogen.Thereforewomenofchildbearingagerequirenegative
pregnancytestbeforetreatment,strictcontraceptivemeasuresessentialbefore,duringandeven6weeks
posttherapy.Duetothis,inUnitedStates,anewriskmanagementprogramme(iPLEDGE)hasbeen
developedwhereallthepatientsreceivingthisdrughavetoregister.[67,68]
PhysicalTreatment
A.Lesionremoval
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a)Comedones

Bothopenandclosedcomedonescanberemovedmechanicallywithcomedoneextractorandafineneedle
orapointedblade.[4]Preproceduretopicalretinoidapplicationmakestheprocedureeasier.Gentlecautery
andlaserpunctureofmacrocomedonesarealsousefulprocedure.[69]Thelimitationsofcomedoextraction
includeincompleteextraction,refilling,andtheriskoftissuedamage.
b)Activedeepinflammatorylesions

AspirationofdeepinflamedlesionmaybeneededinfewcaseswhicharefollowedbyILsteroidinjectionin
cystsandsinustract.[4,70]
B.Phototherapy

a)Visiblelight

Theyareindicatedformildtomoderateinflammatoryacne.Invitroandinvivoexposureofacnebacteriato
405420nmofultravioletfreebluelightresultsinthephotodestructionthroughtheeffectontheporphyrin
producednaturallybyP.acne.[71]Useoflimitedspectrumwavelength,suchasbluelight(peakat415nm),
andmixedblueandredlight(peakat415and660nm)havebeenfoundtobeeffectiveinreducingacne
lesionsafter412weeks.[72,73]
b)Photodynamictherapy

(withadditionofaminolevulinicacid)andpulseddyelaser(585nm)werealsoeffectiveinacne,but
furthertrialsareneededtoconfirmthesame.[7476]
Physicaltreatmentofscars Acnescarcanbebroadlydividedintotwogroups,thoseinvolvingtissuelosses

(Icepickscar,Boxscar,Rollingscar,andFollicularmacularatrophy)andthoseinvolvingtissueexcess
(hypertrophicscarsorkeloids).Currentlyavailabletreatmentforscarsincludesimpleexcision,andsuturing,
eitheraloneorcombinedwithpunchgraftingandlaserresurfacing,dermabrasion,varioustypeoflasers,
chemicalpeels,andfillers.Forhypertrophicscars,treatmentincludespressuretherapy,ILcorticosteroid,5
fluorouracilandbleomycininjections,surgicalexcision,radiotherapy,lasertherapyandcryotherapy.
Alltheprocedureshavetheirownmeritsanddemeritstobechosencarefullyseeingthemerit.[7779]
Acneanddiet Dietaryrestrictionhasnotbeendemonstratedtobebenefitinthetreatmentofacne.[80,81]The

myththatdietaffectsacneiswidespread,butpreviousstudiesarenotsupportingit.Oflate,variousauthors
againclaimingthatthereisthedefiniteroleofdietinacnebuttoconcludethatfurthercontrolledtrialsare
needed.[8284]Ithasbeenshownthattheprevalenceofacneislowerinrural,nonindustrializedsocieties
thaninmodernizedwesternpopulationsmaybeduetolowerglycemicindexdiet,claimsonetrial.[85]
Althoughnotcurrentlyrecognizedwithinourdermatologystandardofcare,butduetoconsistentandgood
qualitypatientorientedevidence,dietarymanagementofacneappearstobeaccumulating.
Thebenefitofdietarymanagementinthetreatmentofacnehasbeenneitherdemonstratednordisproved.
[85,86]
Conclusion
Varioustopicalandsystemicdrugsareavailabletotreatacne,whichmaysometimesconfusethetreating
dermatologist.Toovercomethissituationapanelofphysiciansandresearchersworkedtogetherasa
GlobalAllianceandTaskForcetoimproveoutcomesinacnetreatment.[8789]Theyhavetriedto
giveconsensusrecommendationforthetreatmentofacne,mostlyevidencebasedandinputsfromvarious
countries.SimilaralliancehasalsobeenformedinIndiarecentlywiththeirrecommendations.[90]
Topicalretinoid

Itshouldbeprimarytreatmentformostformsofacnevulgaris.
Tobeappliedtoentireaffectedarea.
Antimicrobialtobeaddedforinflammatorylesions.
Essentialpartofmaintenancetherapy.
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Combinationtherapy

Itworksbetterandclearingoflesionisfaster.
Stopantibioticifinflammatorylesionsubsides.
Ifwithdrawalisnotpossible,switchtobenzoylperoxideplusanantibiotic.
Topicalretinoidcanbecontinuedtopreventremission.
Antibiotics

Oralandtopicalantibioticsnottobeusedasmonotherapytopreventbacterialresistance.
Helpfulinmoderatetosevereacne.
Generallyoralantibioticsarewelltolerated,sometimesassociatedwithsevereadverseevents.
Alwaysusethesameantibioticifitwaseffectivepreviously.
Doxycyclineandminocyclinesaremoreeffectivethantetracycline.
Donotusechemicallydissimilaroralandtopicalantibiotictogether.
Hormonaltherapy Itisanexcellentchoiceinwomenrequiringoralcontraceptive(estrogencontaining)for

otherreasonandhavingmoderatetosevereacnewithSAHAsymptoms.Oralantiandrogenlike
spironolactoneandcyproteroneacetatecanbeusefulinthetreatmentofacne.
Itisapprovedinsevererecalcitrantnodulocysticacne.Itcanalsobeusedinmoderateto
severeacnevulgarisresistanttoconventionaltherapy,frequentlyrelapsing,withseverepsychologicaland
physicalscarringduetoacne.Pretreatmentcounselling,patientselection,andmonitoringarecriticaldueto
itssideeffectsliketeratogenicity,andadversepsychiatricevents.
Oralisotretinoin

Acknowledgments
SincerethankstoDr.RajeshKumar,Mumbaiforprovidingfewofthereferencearticles.
Footnotes
SourceofSupport:Nil
ConflictofInterest:Nil.

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