Best Acne Treatment. Facts for the Patient

• Stress may exacerbate psychological reaction to acne.
• It can take at least 8 weeks of a prescribed treatment before
the patient sees any improvement.  Acne may even get
worse before it gets better.  Focus on less new lesions.
• Wash the face no more than twice per day with a mild nonalkaline soap / soap-free cleanser & lukewarm water.
Cleaning the skin too often may aggravate acne & cause
flare ups.  Acne is not caused by dirt or surface oil.  
• Use the fingertips or a soft wash cloth to wash the face.
• Picking at acne lesions may cause scarring – NO PICKING.
• There is NO cure for acne.
• There is no evidence to support that chocolate or sugar will
cause acne.  Certain foods may make some patients’ acne
worse and should be avoided.  No specific food/diet has
been proven to worsen or improve acne.
• Acne affects adults as well as children.

Best Acne Treatment. Managing Adverse Effects (Skin)

• Dryness can be managed with non-comedogenic
moisturizers; avoid use of scrubs and astringents.
• If irritation occurs with tretinoin, switch to adapalene.
• If possible, ↓ the strength or contact time (topicals) initially
to prevent further irritation, and gradually ↑ as tolerated.
• For sensitive skin: 2% clindamycin in Complex 15 Lotion or
Cetaphil Cleanser qHS + 2.5% H2O-based BP qAM.

Best Acne Treatment. Initiation Routines to Minimize Irritation

• Less frequent (every 2-3 night) application may be useful
early in therapy; begin with low concentration [2.5%]; avoid
more irritating formulations (e.g. acetone- & alcohol- based
gels) unless skin is oily.
• Alternatively, apply for 15 minutes the 1
st
 evening.  Each
evening the time should be doubled until left on for 4 hours
& subsequently all night.  Once tolerance is achieved, the
strength may be increased to 5%.  
• Alternatively, BP can be applied for 2 hours for 4 nights, 4
hours for 4 nights, and then left on all night.

Best Acne Treatment. Acne Vulgaris Versus Acne Rosacea

• Acne rosacea is a chronic skin eruption with flushing and
dilation of small blood vessels in the face, especially nose
and cheeks.  Its etiology differs significantly from acne
vulgaris and should not be confused given the different
approach to treatment (See Table 2).
• Effective treatments include topical metronidazole, benzoyl
peroxide 5%/erythromycin 3% gel, benzoyl peroxide
5%/clindamycin 1% gel, benzoyl peroxide (BP) alone,
azelaic acid, and sodium sulfacetamide10%/sulfur 5%. Oral
tetracycline was effective by physician assessment, but not
by patient assessment.

Best Acne Treatment. Topical Retinoids: Initiation Considerations

• Apply a thin layer to dry skin 30 minutes after gently cleansing.
Rub in gently.  {For creams and gels, medication should become
invisible within a minute; if not, patient may be using too much.}
• Begin by applying only on every 3 rd night, moving up to every
2nd night and eventually every night if tolerated.
• In some cases, a shorter application time may be useful.
• A non-comedogenic skin moisturizer (various e.g. Complex-15,
Moisturel) may be applied in the morning to manage skin dryness.
• Sunscreen with SPF-15 or greater protection (e.g. Ombrelle) is
important especially with tretinoin and tazarotene.

Best Acne Treatment. General Considerations for Topical Acne Therapies

• If two topicals are being used, apply one qam & the other qhs 
• Multiple agents are useful if from different therapeutic classes  
• Potency:  Solution > Gel > Cream / Lotion  
• Patient skin type:  
• For very oily skin consider a solution or gel 
• For very dry skin choose a cream or a lotion  (or add a moisturizer)

Best Acne Treatment. Pharmacological Overview

• Benzoyl Peroxide (BP) is used as 1
st
 line monotherapy for mildmoderate acne.
o BP produces powerful anaerobic antibacterial activity due to slow
release of oxygen and comedolysis.
o BP is also a useful  adjunct to topical retinoids, antibiotics (ABX)
topical/oral
, combination oral contraceptives (COCs) & spironolactone.
• Topical retinoids (e.g. tretinoin, adapalene) are important in acne
treatment.
  They affect the desquamation process, reducing the
number of microcomedones & comedones.
o Used for mild-moderate comedonal acne (inflammatory or noninflammatory) or as adjunct with BP, ABX, COCs &
spironolactone.
• Topical ABX are best used in combination with topical retinoids
or BP (↓ potential for antimicrobial resistance).
• Systemic ABX (tetracyclines, erythromycin, & trimethoprim) are
indicated for moderate-severe acne. Due to resistance concerns
monotherapy should be avoided and therapy courses limited where
possible to short durations or “pulses” of 8-12 weeks.
• COCs may be considered over antibiotics for females with
moderate-severe acne.  Spironolactone has been used for adult
women with moderate-severe acne when COCs are
contraindicated or other treatments fail.
• Isotretinoin monotherapy is the most effective therapy for
moderate-severe inflammatory acne; care must be taken to ensure
potential serious adverse events are avoided/recognized.
o Isotretinoin causes a high rate of birth defects in the
developing fetus of pregnant woman.
o Depression & suicide have been reported in people taking
isotretinoin; direct correlation not established.
• Other OTC agents: salicylic acid, sulphur, resorcinol, glycolic acid
& tea tree oil (limited data; all less efficacious than BP).

{Tea tree oil 5%: 1 trial showed effectiveness but slow onset.}

Best Acne Treatment. Key Messages, Tips and Pearls

1) Acne drug therapies require consistent use for
several weeks before optimal results are seen.
2) Topical therapies need to be applied to the entire
affected area, not just specific lesions.
3) Benzoyl Peroxide (BP) is a very effective and
relatively inexpensive acne therapy.  Strengths
greater than 5% are no more effective but more
irritating than strengths ≤ 5%.
4) Topical retinoids are an effective first line option
for comedonal acne.
a. Tretinoin  (e.g. Retin-A, Stieva-A, Vitamin A Acid):
i. 0.025-0.05% products are most useful; lower
concentrations do not work; higher
concentrations are seldom tolerated
b. Adapalene (Differin) may be preferred if:
i. less skin irritation is important
ii. part of a combination regimen where morning
application of agent causing minimal sun
sensitivity is important (e.g. BP+ABX at night,
retinoid in am)
5) Topical antibiotic monotherapy should be avoided.
Addition of BP to antibiotic regimens is strongly
recommended to reduce bacterial resistance.
(Combo products useful: Benzamycin, BenzaClin / Clindoxyl)
6) Oral antibiotics should be used for shorter
“pulses” of therapy (e.g. 8-16 weeks) to reduce the
development of bacterial resistance.
7) Any combination oral contraceptive (COC) may
result in improvement in acne.
8) Oral isotretinoin (Accutane, Clarus) is the most
effective therapeutic option for severe acne.
Physicians should be familiar with cost effective
dosing strategies, pregnancy precautions, required
monitoring and side effect management.
9) Acne can cause significant stress, psychosocial
concerns to the patient.  Early intervention is
recommended when presentation or family history
suggests a severe course is likely.
10) Identification of sensitive skin issues is important
so that steps can be taken to reduce drug related
irritation {e.g. patients with non-oily skin, previous
eczema or a history of sensitivity}.
______________________________________________________

Acknowledgements:  Contributors & Reviewers:  Dr. D. Lichtenwald (Saskatoon-Derm), Dr. J. Taylor (C. of 
Pharmacy, U. of S.), Dr. R. McKay (Regina-Derm), Dr. T. Laubscher (SHR-FM),Dr. M. Evans (CCFP, U. of T., 
Toronto) & RxFiles Advisory Committee.  Prepared by: M. Jin PharmDc Candidate; L. Regier BSP, BA,  B. Jensen BSP 
DISCLAIMER: The content of this newsletter represents the research, experience and opinions of the authors and not those of the Board or Administration of Saskatoon 
Health Region (SHR). Neither the authors nor Saskatoon Health Region nor any other party who has been involved in the preparation or publication of this work warrants or 
represents that the information contained herein is accurate or complete, and they are not responsible for any errors or omissions or for the result obtained from the use of such 
information. Any use of the newsletter will imply acknowledgment of this disclaimer and release any responsibility of SHR, its employees, servants or agents. Readers are 
encouraged to confirm the information contained herein with other sources.