ACNE IN CLINICAL PRACTICE: TREATMENT APPROACHES FOR THE INTERPROFESSIONAL HEALTHCARE TEAM
Faculty:
L. Austin Fredrickson, MD, FACP
L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care.
Liz Fredrickson, PharmD, BCPS, is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy. She has eight years of experience in medical writing and research.
Pamela Sardo, PharmD, BS
Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.
Abstract
Acne vulgaris is a common chronic inflammatory skin disorder that is associated with significant physical and psychosocial consequences. Many view acne as a self-limited condition of adolescence, but this condition frequently continues into adulthood and can result in permanent issues, including scarring and post-inflammatory hyperpigmentation. The effective management of acne requires an accurate assessment of disease severity, recognition of its risk factors, and selection of evidence-based therapies tailored to patient characteristics and preferences. This continuing education activity will review the epidemiology and etiology of acne, as well as its clinical presentation, diagnosis, and patient-centered management strategies. Pharmacologic and nonpharmacologic treatment options will be discussed, with a focus on the role of combination therapy, appropriate escalation of care, and long-term control. This activity also addresses counseling considerations and interprofessional collaboration to optimize adherence, minimize complications, and improve patient-reported outcomes.
Accreditation Statements
In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation CouncilTM for Continuing Medical Education (ACCME®), the Accreditation Council for Pharmacy Education (ACPE®), and the American Nurses Credentialing Center (ANCC®), to provide continuing education for the healthcare team.
This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credits for learning and change.
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit.
Credit Types:
IPCE Credits - 2 Credits
AAPA Category 1 Credit™️ - 2 Credits
AMA PRA Category 1 Credit™️ - 2 Credits
Type of Activity: Application
Media: Computer-Based Training (i.e., online courses)
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation.
Release Date: April 10, 2026 Expiration Date: April 10, 2029
Target Audience: This educational activity is for Physicians and Physician Assistants
How to Earn Credit: From April 10, 2026, through April 10, 2029, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Study the section entitled “Educational Activity;” and
Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
CME Credit: Credit for this course will be uploaded to CPE Monitor® for pharmacists. Physicians may receive AMA PRA Category 1 Credit™️and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners shall verify their individual licensing board’s specific requirements and eligibility criteria.
Statement of Need:
Acne vulgaris is one of the most common dermatologic conditions, affecting approximately 85% of adolescents and often persisting into adulthood. Despite its high prevalence, gaps persist in accurate severity assessment, recognition of psychosocial impact, and timely differentiation of patient presentation that require escalation of care or referral, particularly in adults and those at risk for scarring. Many healthcare professionals rely on episodic rather than chronic management strategies. This leads to suboptimal combination treatment and potentially avoidable scarring and post-inflammatory hyperpigmentation. Challenges remain in distinguishing appropriate OTC versus prescription treatment, counseling on treatment application and adherence, identifying dosage forms, and interprofessional collaboration. This activity aims to address practice gaps, provide individualized treatment options based on mechanisms, safety, and patient factors to improve long-term outcomes and quality of life.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Differentiate common clinical presentations and severity of acne across age groups, including features that warrant escalation of therapy or referral
Evaluate available treatment options for acne based on disease severity, patient characteristics, and safety considerations
Describe patient-centered management strategies to support adherence, minimize adverse effects, and reduce the risk of scarring
Disclosures
The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Liz Fredrickson, PharmD, BCPS; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2026: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity Pre-Test
Which of the following clinical features most strongly indicates the need for escalation of acne therapy?
Presence of closed comedones on the forehead
Mild papules limited to the cheeks
Nodular lesions with early scarring on the back
Occasional pustules during menstruation
Which of the following represents the most appropriate first-line treatment for moderate inflammatory acne?
Topical retinoid monotherapy
Oral isotretinoin
Combination topical therapy with retinoid and benzoyl peroxide ± oral antibiotic
Salicylic acid monotherapy
Which of the following best reflects a patient-centered approach to acne management?
Incorporating patient preferences, cost, and adherence barriers into treatment selection
Selecting the most potent therapy regardless of patient preference
Discontinuing therapy once visible lesions improve
Avoiding maintenance therapy after initial improvement
Educational Activity
Acne in Clinical Practice: Treatment Approaches for the Interprofessional Healthcare Team
Introduction
Acne vulgaris is one of the most prevalent dermatologic conditions worldwide and a common reason for health care visits in both primary care and specialty care settings.1 It is commonly associated with adolescence, but its age of onset, severity, persistence, and recurrence vary widely.2 Recently, there has been growing recognition of adult acne as a distinct, clinically meaningful condition.2.3 Acne has notable visible manifestations but also commonly impacts a patient’s quality of life and can contribute to the development of anxiety, depression, social withdrawal, and diminished self-esteem.4
Advances in understanding acne pathophysiology have reinforced its classification as a chronic inflammatory disease, driven by interrelated mechanisms including abnormal follicular keratinization, sebaceous gland hyperactivity, microbial colonization, and immune dysregulation.5,6 These insights have informed more modern treatment strategies that emphasize early intervention, combination therapy, and long-term maintenance rather than episodic treatment of flares.6
Given the wide variety of available therapies, including over-the-counter products, prescription topical agents, systemic antibiotics, and hormonal therapies, health care team members must be equipped to individualize treatment based on disease severity, patient characteristics, safety considerations, and psychosocial impact.
This continuing education activity will review the epidemiology and etiology of acne, as well as its clinical presentation, diagnosis, and patient-centered management strategies. Pharmacologic and nonpharmacologic treatment options will be discussed, with a focus on the role of combination therapy, appropriate escalation of care, and long-term control. This activity also addresses counseling considerations and interprofessional collaboration to optimize adherence, minimize complications, and improve patient-reported outcomes.
Epidemiology
Although acne is classically associated with adolescence, there is considerable variability in its age of onset, duration, severity, and persistence.1 Approximately 85% of individuals aged 12-24 will experience at least mild acne, with incidence peaking during puberty.7 Hormonal changes during this period play a central role in disease onset.6 While acne often improves after adolescence, many patients continue to experience symptoms into adulthood, and spontaneous remission may not occur for years if it is left untreated.2
Adult acne is increasingly recognized as a distinct clinical condition. Epidemiologic data show that acne persists beyond age 25 in over half of women and approximately 40% of men, with women disproportionately affected during adulthood.8 Adult females may experience persistent or late-onset acne, often with premenstrual flares that can continue until menopause, which reflects ongoing hormonal influences.8 In contrast, while acne during puberty is more severe in males in a subset of patients, women tend to experience more severe or refractory disease later in life.2
Globally, acne affects approximately 9–10% of the general population, with the reported prevalence varying widely by region, age group, and access to healthcare.9 Higher reported rates in urban compared with rural populations are the result of both environmental influences and differences in healthcare utilization. Genetic factors also contribute to acne risk.10
Importantly, acne is not a benign or self-limited condition for many patients. When inadequately treated, it may persist for years and result in permanent sequelae, including scarring and post-inflammatory dyspigmentation.1 The potential development of these conditions makes early recognition and appropriate management vital.5,6
Etiology and Pathophysiology
Acne vulgaris is a multifactorial chronic inflammatory skin disorder that likely results from a combination of genetic predisposition, hormonal influences, environmental exposures, and lifestyle factors.9 Its development and severity vary widely across individuals, reflecting the complex interplay of biologic and external contributors.9 In addition to its physical manifestations, acne is associated with significant psychological and emotional burdens, including distress, anxiety, and diminished quality of life.9
Acne can be viewed as arising from four connected processes within the pilosebaceous unit:9
Increased sebum production
Abnormal follicular keratinization
Colonization with Cutibacterium acnes
Inflammation
These processes do not occur in isolation; instead, they reinforce one another and collectively drive lesion formation and disease persistence.9
Sebum Overproduction and Hormonal Influences
Excessive sebum production is a central driver of acne pathogenesis. Androgens, including testosterone and insulin-like growth factor-1 (IGF-1), stimulate sebaceous gland growth and lipid synthesis, which creates an environment conducive to follicular obstruction and bacterial proliferation.9 Increased sebum output correlates with both the frequency and severity of acne lesions, underscoring its importance as a therapeutic target.9 Hormonal fluctuations during puberty, the menstrual cycle, pregnancy, and periods of stress further control disease activity.9
Abnormal Follicular Keratinization
In healthy skin, keratinocytes are shed from the follicular epithelium in an orderly manner. In acne-prone individuals, however, hyperproliferation and impaired keratinocyte desquamation lead to accumulation within the follicular canal.9 This abnormal keratinization promotes comedone formation by obstructing sebum outflow, allowing both noninflammatory and inflammatory lesions to develop.9
Cutibacterium acnes Colonization
Cutibacterium acnes is a lipophilic, anaerobic bacterium that preferentially colonizes sebaceous follicles rich in sebum.9 It is actually a normal component of the skin microbiome, but its overgrowth contributes to acne by metabolizing sebum triglycerides into free fatty acids and by activating innate immune pathways.9 These bacterial byproducts and immune responses exacerbate follicular inflammation and lesion progression.9
Inflammation and Immune Activation
Inflammation is now recognized as a core component of acne pathogenesis.9 Immune activation in response to C. acnes and follicular rupture leads to recruitment of neutrophils, macrophages, and lymphocytes, along with the release of inflammatory mediators and reactive oxygen species.9 This cascade results in tissue damage and the formation of papules, pustules, nodules, and cysts.9 It also increases the risk of permanent scarring if inadequately treated.9
A number of risk factors can affect the expression and development of acne. Table 1 summarizes these factors, and some are discussed in more detail below.10
Table 1
Risk Factors for the Development of Acne10
| Category | Risk Factor | Key Associations or Mechanisms |
| Individual Socio-Economic & Biological Factors | Age | Highest prevalence during adolescence due to pubertal hormonal changes; prevalence and severity increase with age during adolescence and often decline thereafter |
| Sex / Gender | Higher prevalence in males during adolescence; higher prevalence and persistence in females during post-adolescence and adulthood, likely related to hormonal fluctuations | |
| Genetic Predisposition / Family History | Strong hereditary component; family history associated with earlier onset, increased severity, scarring, and treatment resistance | |
| Skin Type | Oily and combination skin types are associated with increased sebum production and higher acne risk | |
| Overweight / Obesity | Mixed evidence; insulin resistance and increased IGF-1 may promote acne, though some adolescent studies show inverse associations, highlighting confounding factors | |
| Menstrual Cycle & Hormonal Irregularities (Females) | Premenstrual flares, irregular menses, and dysmenorrhea are associated with increased acne severity, reflecting androgen sensitivity | |
| Dietary Patterns | High-glycemic-load diets, frequent sugary beverages, chocolate, dairy (especially milk), and fatty foods are associated with acne via insulin and IGF-1–mediated pathways | |
| Smoking | Conflicting data; some studies associate smoking with increased inflammatory acne, others suggest a lower prevalence of severe acne in smokers | |
| Sleep Quality | Short sleep duration and poor sleep quality impair skin barrier function and are associated with increased acne prevalence | |
| Psychological Stress | Stress, anxiety, and depression may exacerbate acne through neuroendocrine and inflammatory pathways, and increased lesion manipulation | |
| Natural Environmental Factors | Temperature & Humidity | Hot and humid environments increase sebum production and are associated with higher acne prevalence and severity |
| Sun Exposure | Moderate to high sun exposure may exacerbate acne via inflammatory cytokine activation in sebocytes | |
| Air Pollution | Chronic exposure to pollutants is linked to oxidative stress, impaired skin barrier function, and increased acne visits | |
| Mineral Oils or Halogenated Hydrocarbons | Occupational exposure associated with chloracne and cystic lesions; avoidance reduces risk. | |
| Social Environmental Factors | Social Networks | Shared behaviors (diet, stress, smoking, obesity) among peers may indirectly increase acne risk. |
| Social Media Influence | Inaccurate or non–guideline-based treatment advice may contribute to poor acne control and worsening disease. | |
| Built Environmental & Lifestyle Factors | Cosmetic Use & Skin Care Practices | Frequent cosmetic use, comedogenic products, excessive cleansing, and high-pH soaps disrupt the skin barrier and microbiome balance. |
| Electronic Device Exposure | Prolonged exposure to short-wavelength visible light and nighttime screen use are associated with increased acne prevalence. |
Environmental, Lifestyle, and Dietary Factors
Environmental and behavioral factors significantly influence both the development and expression of acne as well as its treatment response.10 Heat, humidity, occlusive clothing, and/or friction may worsen acne or precipitate acne mechanica.10 Excessive cleansing or mechanical manipulation of lesions can further aggravate inflammation.10 Sun exposure may improve acne in some individuals, though others experience worsening symptoms.10
Dietary influences have re-emerged as a relevant area of investigation. Observational and interventional studies suggest associations between acne and high glycemic load, dairy consumption, and whey protein intake.10 While evidence supports limiting excessive sugar intake and skim milk, current guidelines conclude that data are insufficient to universally recommend specific dietary eliminations.10
Psychological stress is also an important modifier of disease activity. Stress-induced increases in glucocorticoids may potentiate androgen effects, trigger flares, and contribute to compulsive lesion manipulation, further worsening acne severity.10
Genetic Influences
Genetic susceptibility plays a substantial role in acne development, with familial clustering and higher severity observed among genetically predisposed individuals.11 Emerging evidence also highlights the role of epigenetic mechanisms, such as DNA methylation, in linking environmental stressors to inflammatory pathways involved in acne progression.11 These findings underscore the dynamic interaction between genetics and environmental exposures in shaping disease expression.11
Diagnosis, Clinical Presentation, and Assessment of Acne Vulgaris
Diagnostic Approach
Acne vulgaris is a clinical diagnosis based on the results of a patient’s history and physical examination.6 Accurate diagnosis requires recognition of characteristic lesion types, anatomic distribution, and disease severity, while also considering psychosocial impact, potential drug-induced acne, and relevant differential diagnoses.6 Laboratory testing is not routinely required but may be indicated when features suggest an underlying endocrine disorder (for example, irregular menses, hirsutism, or alopecia).6
A comprehensive assessment includes evaluation of lesion morphology, determining the extent and location of involvement, evidence of scarring or dyspigmentation, triggering or alleviating factors, medication and cosmetic use, family history, and quality-of-life impairment.6
Clinical Presentation
Lesion Types
Acne lesions are classified as noninflammatory or inflammatory, both of which originate from the microcomedone.6
Noninflammatory Acne
Closed comedones (whiteheads):6 Small (1–2 mm), white papules without a visible follicular opening
Often subtle and best visualized with skin stretching
Represent the earliest clinically visible lesion and may rupture.
Open comedones (blackheads):6 Larger (2–5 mm) lesions with a dilated follicular opening and dark surface caused by oxidized lipids and melanin, not dirt. These lesions are relatively stable and persistent.
Inflammatory Acne
Papules and pustules: result from follicular inflammation and neutrophil accumulation. Pustules are superficial, pus-filled lesions, usually <5 mm, that often resolve without scarring.6
Nodules and cysts: deep, firm, tender lesions ≥5 mm that extend into the dermis or subcutis. Cysts are suppurative nodules that may interconnect via sinus tracts. These lesions carry the highest risk of scarring.6
Inflammatory lesions may be painful or pruritic (itchy) and can rupture, which releases purulent or hemorrhagic material.6 Resolution of this inflammation often causes postinflammatory erythema or hyperpigmentation, particularly in patients with darker skin tones.6
Anatomic Distribution
Acne lesions can occur anywhere except the palms and soles, but most commonly involve the face, chest, shoulders, back, and neck.6 Truncal acne is common and may be underreported.6 The distribution pattern tends to remain consistent over time.
Diagnostic and Assessment Considerations
Clinicians should assess the following factors.6
Provoking or alleviating factors: hormonal fluctuations, heat, humidity, friction, occlusive clothing, cosmetics, diet, stress, and sunlight
Associated symptoms: pain, pruritus, systemic symptoms
Medical history: endocrine disorders, pregnancy, atopy
Medication and product use: prescription drugs, supplements, cosmetics
Social history: diet, smoking
Family history: genetic predisposition
Severity Assessment
Standardized grading systems aid in treatment selection and monitoring and include the following. The severity grading should incorporate lesion count, lesion type, extent, and presence of scarring or dyspigmentation.6
FDA Investigator Global Assessment (IGA):12 Ranges from almost clear (Type 1) to severe nodular acne (Type 4)
European clinical classification: 13 Categorizes acne as comedonal, mild-to-moderate papulopustular, severe papulopustular/moderate nodular, or severe nodular/conglobate acne. Severity grading should incorporate lesion count, lesion type, extent, and presence of scarring or dyspigmentation.
Psychosocial Assessment
Acne can have a disproportionate psychological impact that does not always correlate with a patient’s clinical severity. Anxiety, depression, social withdrawal, and impaired self-esteem are common.6 Incorporating validated quality-of-life tools (eg, Dermatology Life Quality Index, Acne Disability Index, or acne-specific QOL scales) can improve clinical decision-making, identify patients needing additional support, and enhance treatment outcomes.6
Differential Diagnosis
Acne vulgaris is usually straightforward to diagnose, but key alternatives include the following.6
Rosacea: adult onset, absence of comedones, flushing and telangiectasia, central facial distribution
Periorificial dermatitis: papulopustular eruption around the mouth or eyes, often associated with topical steroid use
Gram-negative folliculitis: sudden pustular flare following prolonged antibiotic therapy
Syndromic acne: associated with systemic inflammatory or endocrine conditions, like PCOS (polycystic ovarian syndrome)
Drug-Induced Acne
Drug-induced acne is typically monomorphic and may be comedonal or papulopustular. Common triggers include systemic or topical corticosteroids, hormonal agents, lithium, antiepileptics, tuberculostatic drugs, halogens, vitamin B supplements, and certain cosmetics.6 Recognition is critical, as management often requires medication modification rather than escalation of acne therapy.6
Management of Acne Vulgaris
Treatment Goals and Desired Outcomes
Effective management of acne vulgaris begins with establishing clear, patient-centered short- and long-term goals.6 The chronic nature of acne supports early, appropriately aggressive treatment, and maintenance therapy is often required to sustain clinical improvement and prevent relapse.6
Primary treatment goals include reducing the number and severity of lesions, improving visible appearance, limiting disease duration and recurrence, preventing permanent sequelae such as scarring and postinflammatory hyperpigmentation, and minimizing psychological distress.6 Both objective measures (e.g., lesion counts, severity grading) and patient-reported outcomes are important.6
General Approach to Therapy
The microcomedone is the earliest and most important therapeutic target.6 Eliminating follicular occlusion can interrupt the entire acne cascade, so both pharmacologic and nonpharmacologic interventions should be directed toward this goal.6 Optimal management typically involves a combination therapy that addresses all four major pathogenic mechanisms: abnormal keratinization, excess sebum production, Cutibacterium acnes proliferation, and inflammation.6 Skin barrier health should also be supported.6
Treatment selection is individualized and influenced by multiple factors, including disease severity, lesion type, anatomic distribution, presence of scarring or dyspigmentation, patient preferences, cost considerations, skin type, age, adherence, prior treatment response, psychosocial impact, and family history of persistent acne.6
Nonpharmacologic Approaches
Nonpharmacologic strategies play an important role in supporting treatment success and improving tolerability in patients with acne. Patients should be encouraged to use gentle cleansers and avoid harsh scrubbing, which can exacerbate irritation and inflammation.5 The regular use of non-comedogenic moisturizers can help reduce dryness and irritation, particularly when topical therapies such as retinoids or benzoyl peroxide are initiated. Daily application of a broad-spectrum sunscreen is recommended to prevent post-inflammatory dyspigmentation and protect the skin barrier.5 Patients should also be advised to avoid picking or manipulating lesions, as this can worsen inflammation and increase the risk of scarring.5 Additionally, selecting non-comedogenic cosmetics and skincare products can help minimize pore obstruction and support overall treatment effectiveness.5
Induction and Maintenance Strategies
Acne management follows an induction–maintenance model.6,14 During the induction phase, combination therapy is used to suppress active lesions and achieve control.6,14 Once improvement is established, treatment should be simplified and transitioned to maintenance therapy to prevent relapse.6,14 Because microcomedones can mature over approximately 8 weeks, therapy must be continued beyond this period to adequately assess efficacy.6,14
Lesions often recur for years, and microcomedones may reappear rapidly after treatment discontinuation.6,14 As a result, maintenance therapy is essential and may be required for months to years, depending on patient age and disease course.6,14
Topical and Systemic Therapy
Topical therapy is the foundation of treatment for mild to moderate acne and remains an essential component of most regimens.6,14 Because topical agents act only where applied, they should be used over the entire affected area rather than as spot treatments to prevent new lesion formation.6 Initial irritation is common and may impair adherence, and this can often be mitigated by starting with lower strengths, gradually increasing frequency, or selecting more moisturizing formulations.6,14
Patients with moderate to severe acne or disease unresponsive to topical therapy alone typically require systemic therapy in combination with topical agents.6,14 Treatment escalation should be guided by severity, risk of scarring, and psychosocial burden. Therapy is directed at disease control rather than cure, and regimens should be adjusted over time to balance efficacy, tolerability, and adherence.6,14
Acne treatments are recommended using a graded evidence-based framework, with strong recommendations for topical retinoids, benzoyl peroxide, combination topical therapy, doxycycline, and isotretinoin, and conditional recommendations for hormonal agents and select alternative therapies.
The tables below provide information about acne treatments. Table 2 details topical treatments, Table 3 antibiotic therapies, and Table 4 hormonal therapies.
Table 2
Topical Acne Treatments5,6,15-18
| Treatment | Examples | Typical Dosing | Common Side Effects | Key Clinical Notes |
| Benzoyl peroxide | OTC washes, gels | Apply once daily, increase to twice daily as tolerated | Dryness, irritation, peeling, and bleaching of fabrics | Antimicrobial; no resistance; use alone or in combination |
| Topical retinoids | Adapalene, tretinoin, tazarotene, trifarotene | Apply once daily (evening); start every other night if sensitive | Dryness, erythema, peeling, irritation (“retinoid dermatitis”) | Cornerstone therapy; comedolytic and anti- inflammatory |
| Topical antibiotics | Clindamycin, erythromycin, dapsone, minocycline | Apply once or twice daily, depending on formulation | Local irritation; rare systemic absorption effects | Do not use as monotherapy; combine with BP to reduce resistance |
| Fixed-dose topical combinations | Retinoid+BP, Antibiotic+BP, Retinoid+antibiotic | Apply once daily (some twice daily, depending on product) | Similar to individual components (irritation, dryness) | Improves adherence; reduces resistance |
| Clascoterone (topical antiandrogen) | Clascoterone 1% cream | Apply twice daily | Mild erythema, pruritus, local irritation | Topical antiandrogen; useful alternative in selected patients |
| Salicylic acid | 0.5–2% topical products | Apply once to twice daily | Mild irritation, dryness | OTC; mild comedolytic; less effective than retinoids |
| Azelaic acid | 15–20% topical | Apply twice daily | Burning, stinging, mild irritation | Useful for sensitive skin and post- inflammatory dyspigmentation |
Table 3
Antibiotic Treatment Recommendations for Acne5,6,19-21
| Treatment | Typical Dosing | Common Side Effects | Key Clinical Notes |
| Doxycycline | 50–100 mg once or twice daily | GI upset, photosensitivity, esophagitis | First-line systemic antibiotic; take with water and remain upright |
| Minocycline | 50–100 mg twice daily (IR); ER formulations vary | Dizziness, vertigo, hyperpigmentation, rare drug-induced lupus or hepatitis | Consider rare but serious adverse effects |
| Sarecycline | Weight-based dosing (typically 60–150 mg once daily) | Nausea, mild GI upset | Narrow-spectrum tetracycline; reduced impact on gut microbiota; cost may limit use |
| Systemic antibiotics (general use) | Varies by agent; typically 3–4 months duration | Class-dependent; includes GI upset and resistance risk | Limit duration (≤3–4 months); always combine with topical therapy (BP ± retinoid) to reduce resistance |
Table 4
Hormonal Treatment Recommendations for Acne5,6,22
| Treatment | Typical Dosing | Common Side Effects | Key Clinical Notes |
| Combined oral contraceptives (COCs) | One tablet daily (varies by formulation; typically ethinyl estradiol + progestin) | Nausea, breast tenderness, breakthrough bleeding, risk of venous thromboembolism (VTE) | FDA-approved options available; useful in hormonally driven acne; consider patient preferences and contraindications |
| Spironolactone | 50–200 mg daily (often started at 25–50 mg and titrated) | Menstrual irregularities, breast tenderness, dizziness, and rare hyperkalemia | Antiandrogen; potassium monitoring generally not required in healthy patients; contraindicated in pregnancy |
| Intralesional corticosteroids | Small-volume injection (e.g., triamcinolone 2.5–10 mg/mL) directly into the lesion | Local skin atrophy, hypopigmentation | Adjunct for large inflammatory papules or nodules; provides rapid reduction in inflammation |
Oral Isotretinoin: Safety and Monitoring Considerations
Oral isotretinoin is the most effective therapy for severe or refractory acne; however, its use requires careful monitoring due to the potential for significant adverse effects and safety concerns. The most critical risk associated with isotretinoin is its high teratogenicity, making it strictly contraindicated in pregnancy and necessitating rigorous pregnancy prevention measures for patients of childbearing potential.23 In the United States, isotretinoin prescribing is regulated through the iPLEDGE program, a mandatory risk management system that requires registration of prescribers, pharmacies, and patients, as well as monthly pregnancy testing and verification prior to dispensing.23
Laboratory monitoring is an essential component of isotretinoin therapy. Baseline and periodic assessments of liver function tests (LFTs) and a lipid panel are recommended, with monitoring frequency tailored to individual patient risk factors and clinical judgment.24 Common adverse effects include mucocutaneous symptoms such as dry skin, cheilitis, and epistaxis, while more serious risks include hypertriglyceridemia and hepatotoxicity. Additionally, there have been reports of mood changes and depression in patients receiving isotretinoin.24 Although a causal relationship remains uncertain, clinicians should remain vigilant and monitor patients for emerging psychiatric symptoms throughout treatment.
Stepwise Treatment Approach to Acne Vulgaris6,14
(AAD-Informed Framework)
Management of acne should follow a structured, severity-based approach that incorporates lesion type, risk of scarring, and patient-specific factors.
Mild Acne (comedonal or mild inflammatory)
First-line:
Topical retinoid ± benzoyl peroxide (BP)
Alternative/adjunct:
Azelaic acid or salicylic acid (OTC options)
Key principle: Target microcomedones early
Moderate Acne (inflammatory papules/pustules)
First-line:
Combination topical therapy (retinoid + BP ± topical antibiotic)
Second-line:
Add oral antibiotic (e.g., doxycycline) + continue topical retinoid/BP
Key principle: Avoid topical or oral antibiotic monotherapy
Severe Acne (nodular, cystic, or scarring)
First-line:
Oral isotretinoin OR
Oral antibiotic + combination topical therapy
Second-line:
Escalate to isotretinoin if inadequate response
Key principle: Early aggressive treatment to prevent scarring
Maintenance Therapy (all severities)
Topical retinoid ± BP
Continue long-term to prevent relapse
Cost and Access Considerations in Acne Management
Cost and access to therapy are important determinants of treatment adherence and clinical outcomes in acne management. While many effective treatments are available, out-of-pocket costs, insurance coverage limitations, and formulary restrictions can significantly influence therapy selection. Lower-cost options, such as generic topical retinoids, benzoyl peroxide, and oral antibiotics like doxycycline, are widely accessible and often serve as first-line therapies. In contrast, newer or branded agents, including topical clascoterone, sarecycline, and certain fixed-dose combination products, may be associated with higher costs and limited insurance coverage, which can reduce patient access and long-term adherence. Oral isotretinoin, although highly effective, requires participation in the iPLEDGE program and frequent laboratory monitoring, which may add indirect costs and logistical barriers for patients.24
Cost-related nonadherence is a well-recognized issue in dermatologic care, with patients sometimes using medications inconsistently, delaying refills, or discontinuing therapy prematurely due to financial constraints.25 To mitigate these challenges, clinicians and pharmacists should consider prescribing cost-effective alternatives when appropriate, utilizing generic formulations, and being familiar with patient assistance programs or manufacturer savings cards.25 Additionally, simplifying regimens, such as selecting combination products when affordable or reducing the number of prescribed agents, may improve adherence while balancing cost considerations. Shared decision-making that incorporates financial factors is essential to ensure that selected therapies are both clinically appropriate and sustainable for the patient.25
Patient Education and Counseling
Successful long-term outcomes depend heavily on patient education and adherence. Patients should understand the chronic nature of acne, the rationale for combination and maintenance therapy, expected timelines for improvement, and the psychosocial benefits of sustained disease control. Selecting tolerable regimens that fit the patient’s lifestyle and emphasizing the preventive role of maintenance therapy can significantly improve adherence and the likelihood of long-term remission.6,14
Some practical points for patient counseling are detailed below.
Use a pea-sized amount of topical retinoid for the entire face
Initial worsening (“retinoid purge”) is common and temporary
Benzoyl peroxide can bleach fabrics (clothing, towels, pillowcases)
Take doxycycline with a full glass of water and remain upright for ≥30 minutes
Apply topicals to the entire affected area, not as spot treatment
Improvement typically requires 6–8 weeks of consistent use
Shared Decision-Making in Acne Management
Treatment selection should incorporate patient preferences, lifestyle, and treatment goals.
Example 1: Adolescent with Mild Acne
Preference: Avoid prescriptions
Plan: OTC adapalene + BP wash
Counseling: Set expectations for gradual improvement
Example 2: Adult Female with Hormonal Acne
Preference: Long-term control, avoid antibiotics
Plan: Spironolactone ± topical retinoid
Discussion: Risks, contraception, and monitoring
Example 3: Patient with Severe Acne and Scarring Risk
Concern: Permanent scarring
Plan: Early isotretinoin referral
Discussion: Safety monitoring, iPLEDGE requirements
Interprofessional Roles in Acne Management
Effective acne management requires coordinated care among members of the healthcare team, with each professional contributing to accurate diagnosis, appropriate treatment selection, patient education, and ongoing monitoring. Physicians and advanced practice providers are responsible for establishing the diagnosis, assessing disease severity, and initiating evidence-based therapy. They also determine when treatment escalation is necessary and monitor patients for complications, treatment response, and the need for referral, particularly in cases of severe or refractory disease.
Primary care physicians may collaborate with the pharmacist to optimize pharmacotherapy by assisting with medication selection, ensuring appropriate combinations are used, and minimizing the risk of adverse effects and drug interactions. Pharmacists are also well positioned to recommend appropriate over-the-counter therapies for mild acne and to identify situations warranting referral to a prescriber.
Frequently Asked Questions (FAQ): Acne Management6
When should systemic therapy be used for acne?
Systemic therapy is generally indicated for moderate-to-severe inflammatory acne, extensive truncal involvement, acne associated with scarring or significant dyspigmentation, or disease that does not adequately respond to topical therapy alone. Oral antibiotics (e.g., doxycycline or minocycline) and hormonal therapies (e.g., combined oral contraceptives or spironolactone) are typically used in combination with topical agents such as benzoyl peroxide and retinoids. Oral isotretinoin is reserved for severe acne or treatment-resistant moderate acne.
How is acne therapy selected?
Treatment selection is individualized based on acne morphology (comedonal vs inflammatory), severity, anatomic distribution, risk of scarring, and patient-specific factors.
Predominantly comedonal acne is usually managed with topical retinoids ± benzoyl peroxide.
Inflammatory acne with papules and pustules often requires combination topical therapy and may warrant systemic agents.
Nodular or scarring acne and acne refractory to standard therapies may require isotretinoin.
Should topical therapies still be used when systemic agents are started?
Yes. Combination therapy is the standard of care. Topical retinoids and benzoyl peroxide help prevent new lesion formation, reduce antibiotic resistance, and maintain remission after discontinuation of systemic agents.
What are the most common adverse effects of topical acne treatments?
Topical retinoids and benzoyl peroxide commonly cause dryness, erythema, peeling, and irritation, particularly during initiation. Benzoyl peroxide may also cause allergic contact dermatitis, characterized by itching, swelling, and eczematous changes.
What adverse effects should be monitored with oral antibiotics?
Tetracycline derivatives may cause gastrointestinal irritation, erosive esophagitis if taken without adequate water, and photosensitivity (more common with doxycycline). Long-term use increases the risk of antimicrobial resistance. Rare but serious adverse effects include drug-induced hepatitis, lupus-like syndromes (minocycline), and pseudotumor cerebri.
How long should oral antibiotics be used for acne?
Oral antibiotics should be used for the shortest effective duration, typically 3–4 months, and always in combination with topical benzoyl peroxide or retinoids to reduce the risk of resistance.
When should isotretinoin be considered?
Isotretinoin should be considered for severe nodular acne, acne causing scarring, or moderate acne unresponsive to adequate topical and systemic therapy. Early referral may be appropriate when the psychosocial burden is high.
What counseling points are important for patients starting acne therapy?
Patients should be counseled on expected timelines for improvement (often 6–8 weeks), the importance of adherence, sun protection, gentle skin care, and early recognition of adverse effects to improve tolerability and outcomes.
Summary
Acne vulgaris is a chronic, multifactorial inflammatory condition that requires thoughtful assessment and sustained management to achieve optimal outcomes. Accurate diagnosis is based on recognition of characteristic lesion types, distribution, and severity, with attention to psychosocial burden, potential triggers, and differential diagnoses. Disease expression is influenced by hormonal, genetic, environmental, and lifestyle factors, underscoring the need for individualized care.
Management strategies should prioritize early intervention, combination therapy targeting multiple pathogenic mechanisms, and realistic goal setting focused on disease control rather than cure. Treatment selection is guided by severity, lesion morphology, risk of scarring, patient preferences, and prior response to therapy. An induction-and-maintenance approach is essential because microcomedones and clinical lesions frequently recur after treatment discontinuation.
Interprofessional collaboration plays a critical role in optimizing acne care. Comprehensive patient education regarding treatment expectations, adherence, and long-term maintenance is fundamental to reducing relapse, preventing complications, and improving quality of life for individuals living with acne.
References
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BENZOYL PEROXIDE ACNE MEDICATION- benzoyl peroxide gel. Prescribing Information. NuCare Pharmaceuticals, Inc. Updated July 17, 2024. Accessed March 18, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b55acec6-5a4d-08b7-e053-2995a90a0f74
ADAPALENE- adaplane 0.1% gel. Prescribing Information. Acne Free, LLC. Updated July 24, 2025. Accessed March 18, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0dc574e0-397a-7bc8-e063-6394a90a27e2
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MINOCYCLINE HYDROCHLORIDE capsule. Prescribing Information. Actavis Pharma, Inc. Updated June 30, 2025. Accessed March 18, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a5fc4d50-50b2-46e0-b722-4c6b2ec47d06
SEYSARA- sarecycline hydrochloride tablet, coated. Prescribing Information. Almirall, LLC. Updated June 5, 2024. Accessed March 18, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b200957c-3004-4988-be97-9fd619a83649
SPIRONOLACTONE- spironolactone tablet, film coated. Prescribing Information. Abbreviated New Drug Application. Updated August 26, 2025. Accessed March 18, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e61269b2-823a-49e8-b55f-ef0b8b1dbcde
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