Treatment of Acne

Acne medications

Medications	Dose	Select adverse effects
Topical retinoids
Tretinoin	Once daily, at bedtime	Local skin irritation, dryness, and flaking; sun sensitivity NOTE: Micronized gel tretinoin 0.05% (Atralin) contains soluble fish proteins, use with caution in patients with known sensitivity or allergy to fish
Adapalene	Once daily, at bedtime	Local skin irritation, dryness, and flaking; sun sensitivity
Tazarotene	Once daily, at bedtime	Contraindicated in pregnancy; local skin irritation, dryness, and flaking; sun sensitivity
Isotretinoin (not available in United States)	Once daily, at bedtime or twice per day	Contraindicated in pregnancy and lactation; local skin irritation, dryness and flaking; sun sensitivity
Topical antimicrobials*
Benzoyl peroxide (BPO)	Twice daily	Local skin irritation; may bleach hair or clothing
Clindamycin	Twice daily Once daily (foam)	Rare risk of pseudomembranous colitis; usually prescribed with BPO to decrease resistance
Erythromycin	Twice daily	Usually prescribed with BPO to decrease resistance
Dapsone	Twice daily
Topical combination products
Benzoyl peroxide 5%/Clindamycin 1%	Twice daily	Local skin irritation; may bleach hair or clothing
Benzoyl peroxide 2.5%/Adapalene 0.1%	Once daily	Local skin irritation; may bleach hair or clothing
Benzoyl peroxide 2.5%/Adapalene 0.3%	Once daily	Local skin irritation; may bleach hair or clothing
Azelaic acid	Twice daily	Local skin irritation
Salicylic acid	Once to three times daily	Local skin irritation; potential for salicylate absorption
Oral antibiotics¶Δ
Tetracycline	500 mg twice daily	Photosensitivity, gastrointestinal distress; contraindicated in pregnancy and young children
Doxycycline	50 to 100 mg twice daily or 100 mg once daily or Delayed release formulation: 100 mg every 12 hours for one day, then 100 mg per day Subantimicrobial dosing: 20 mg twice daily or Delayed release formulation given as 40 mg once daily	Photosensitivity, gastrointestinal distress; contraindicated in pregnancy and young children
Minocycline	50 to 100 mg twice daily or Extended release formulation: 1 mg/kg/day (round to nearest available strength)	Dizziness, drug-induced lupus, skin discoloration; contraindicated in pregnancy and young children
Erythromycin	500 mg twice daily (base)	Gastrointestinal distress
Trimethoprim-sulfamethoxazole	160 mg/800 mg once to twice daily	Stevens-Johnson syndrome, toxic epidermal necrolysis
Azithromycin	Intermittent dosing due to long drug half-life; optimum regimen unknown	Gastrointestinal distress
Hormonal agents¶◊
Combination oral contraceptives (estrogen/progestin)	Once daily	Nausea, breast tenderness, weight gain, thromboembolic events
Spironolactone	25 to 200 mg/day in one or two equally divided doses; doses of 50 to 100 mg/day may be as effective as higher doses and reduce side effects	Contraindicated in pregnancy; menstrual irregularity, breast tenderness, minor gastrointestinal symptoms, orthostatic hypotension, hyperkalemia, dizziness, headaches, fatigue
Oral retinoid§
Oral isotretinoin	0.5 mg/kg/day, increasing to 1 mg/kg/day in one or two equally divided doses; total dose 120 to 150 mg/kg over 20 weeks	Teratogenicity (absolutely contraindicated in pregnancy), mucocutaneous effects, hypertriglyceridemia, others

%: percent; BPO: Benzoyl peroxide (topical).
* Topical sulfacetamide (eg, gels, creams, lotions, other) with and without sulfur are also available but not typically used and have limited data; refer to topic.
¶ Usual oral dose for adult or adolescent.
Δ BPO may be prescribed with oral antibiotics to reduce resistance.
◊ For additional information refer to topic review of hormonal therapy for acne vulgaris.
§ For additional information refer to topic review of oral isotretinoin therapy for acne vulgaris.

References:

1. www.uptodate.com
2. http://www.dermnetnz.org/treatments/isotretinoin.html
3. http://www.nhs.uk/conditions/acne/pages/treatment.aspx
4. http://www.nps.org.au/publications/health-professional/health-news-evidence/2013/oral-antibiotics-for-acne
5. http://emedicine.medscape.com/article/1069804-medication#1