Acne Vulgaris Management

Medications that exacerbate acne
1. Androgenic steroids (e.g. Danazol, Testosterone
2. Corticosteroids
3. Lithium
4. Oral Contraceptives
5. Isoniazid
6. Phenytoin (Dilantin)
Environment
1. Hot
2. Greasy (fast-food kitchen, garage)
3. Tobacco smoke exposure
Oil based Cosmetics (Acne cosmetica)
1. Cosmetics with Lanolin or petroleum jelly
2. Oil based Shampoos or Sunscreens
Emotional Stress
Physical Pressure (acne mechanica)
1. Tight chinstrap
2. Helmet
Refined Carbohydrates (high Glycemic Index foods)
1. Sweets, Chocolate and pizza do in fact worsen Acne Vulgaris, despite prior dogma
2. fiedler (2017) acta derm venereol 97(1):7-9 +PMID:27136757 [PubMed]
3. mahmood (2014) J Drugs Dermatol 13(4): 428-35 +PMID:24719062 [PubMed]

Acne is not a result of poor hygiene
1. Constant washing does not improve acne
2. Scrubbing dries and irritates skin further

Do not squeeze lesions
1. Forces pus into Dermis
2. Causes inflammation and scarring
Limit washing face to 2-3 times per day
1. Avoid abrasive soaps
2. Gear soap to skin condition
  1. Skin dry: Purpose soap
  2. Skin oily: Dial soap
Change cosmetics from oil-based to water-based products (prevent Acne cosmetica)

See Topical Acne Vulgaris Management (Moderate Acne Vulgaris Management)
See Systemic Acne Vulgaris Management (Severe Acne Vulgaris Management including Cystic Acne)
See Adjunctive Acne Vulgaris Management
Comedones
1. Patients often present already having used Benzoyl Peroxide (OTC)
2. Start with topical Retinoids (e.g. Retin A) at bedtime
Mild Inflammatory Papules and Pustules
1. Start with Benzoyl Peroxide in am AND Topical Retinoids (e.g. Retin A) at bedtime
2. Adapalene with Benzoyl Peroxide (or without if not tolerated) is a preferred first line for mild to moderate acne
  1. Stuart (2021) Br J Dermatol 185(3): 512-25 [PubMed]
Moderate Inflammatory Papules and Pustules
1. Start with Benzoyl Peroxide in am AND Topical Retinoids (e.g. Retin A) at bedtime AND Oral Antibiotics
2. If effective, then maintenance with topical Retinoids with or without Benzoyl Peroxide (and Antibiotics if severe)
3. If ineffective, then advance to Isoretinoin (Accutane)
Moderate to Severe Inflammatory Acne with Nodules
1. Start with Benzoyl Peroxide in am AND Topical Retinoids (e.g. Retin A) at bedtime AND Topical Antibiotic
2. If effective, then maintenance with topical Retinoids (with Benzoyl Peroxide and Antibiotics if severe)
3. If ineffective, then advance to Isoretinoin (Accutane)
Other measures
1. Combined Oral Contraceptives with Spironolactone
  1. See Adjunctive Acne Vulgaris Management
  2. Consider if Menstrual Cycle associated acne or Hyperandrogenism related findings

Skin of Color is more susceptible to scarring, Keloids and Postinflammatory Hyperpigmentation
Be aware of skin and hair products (e.g. cocoa butter, olive oil) that may exacerbate acne
1. Many of these products are used more commonly in Skin of Color communities
Start acne Topical Medications at less irritating, lower concentrations
1. Increase dose slowly to reduce Postinflammatory Hyperpigmentation
2. Retin A 0.025% cream every other day (instead of 0.05% gel daily)
3. Benzoyl Peroxide 2.5% (instead of 5-10%)
4. Azelaic Acid (Azelex, Finacea) may be indicated if Postinflammatory Hyperpigmentation is already present

Acne Vulgaris outbreaks during pregnancy is associated with increased androgen levels in second and third trimesters
1. Worsens in up to ~40% of pregnancies
General Measures
1. Avoid oily cosmetics
2. Perform facial cleansing twice daily
3. Consider reducing dairy intake
4. Avoid high Glycemic Foods
Mild to Moderate Cases: Topicals safe in pregnancy
1. Topical Benzoyl Peroxide 2.5 to 5%
2. Azelaic Acid 15 to 20%
3. Erythromycin Topical 2% (Erygel)
4. Clindamycin Topical 1% (Cleocin-T)
Severe cases
1. Oral Erythromycin
2. Oral Prednisone <20 mg/day for <1 month
3. Pulsed Light Therapy
Avoid Teratogens
1. Avoid topical and oral Retinoids
References
1. Erlandson (2023) Am Fam Physician 107(2): 152-8 [PubMed]