Best Acne Treatment. Possible Contributing Factors for Acne:

• Hormonal
o Signs of androgen excess would include precocious puberty
and hirsutism
o Possible causes of androgen excess would include polycystic
ovary disease, adrenal tumor, ovarian tumor and pituitary
tumor
• Mechanical
o Physical pressure from headbands, violins, chin straps, sports
helmets, guitar straps and orthopedic braces have induced
localized acne; wool and other rough textured fabrics and
occlusive clothing may also be irritants
• Contact
o Oil-based cosmetics, oil-based scalp lubricants, topical tar
products, and hairspray
o Occupational materials such as coal tar, pitch, mineral oil and
petroleum oil
o Ingestion, inhalation or transcutaneous penetration of
halogenated aromatic hydrocarbons, including components in
paint, varnishes, lacquers, fungicides, insecticides, herbicides,
wood preservatives and oils
• Environmental
o Heat and humidity may induce comedones
o Pressure, friction, and excessive scrubbing or washing can
exacerbate existing acne by causing microcomedones to
rupture
o Hair styles low on the forehead/neck may cause excess
sweating, occlusion and make acne worse
• Emotions
o Intense anger or stress can exacerbate acne, causing flares or
increasing mechanical manipulation.
• Drugs (see also Acne Comparison Chart)
o Hormones: androgenic hormones in women, corticosteroids,
corticotrophin (ACTH), oral contraceptives high in progestin
o Topical steroid induced perioral acne
o Bromides, chlorides, halothane, iodides (e.g., Kelp)
o Antiepileptic drugs: gabapentin, phenytoin, phenobarbital & trimethadione  
o Tuberculostatic drugs: ethambutol, isoniazid & thionamide  
o Miscellaneous: cyclosporine, cyanocobalamin, dantrolene, gold
salts, lithium salts, maprotiline, psoralens, quinidine, quinine &
topical coal tar
o Select cancer drugs: cetuximab, erlotinib & gefitinib
• Family history (genetics) often provides prognostic clues

Best Acne Treatment. Diet

• There is anecdotal evidence that certain foods exacerbate acne
• Chocolate – the evidence that chocolate is acnegeic had several
methodological flaws: small sample size; treatment duration and follow-up not long enough to detect changes; and high fat content of control bar may have been acnegenic
• Advice regarding diet should be individualized.

Best Acne Treatment. Isotretinoin (Accutane, Clarus) Highlights

• Official indications: severe nodular and/or inflammatory acne,
acne conglobata & recalcitrant acne.
• Other considerations:
♦ extensive acne involving face and trunk, associated with scarring;
failure to respond to or inability to tolerate systemic antibiotics
and/or hormonal therapy; family history
♦ Significant psychological distress because of acne
• Due to common side effects, avoid concurrent acne topicals, vitamin
A supplements, and follow-up topical retinoids for about 4 months

Best Acne Treatment. Can Diane 35 be used as contraceptive?

• Berlex Canada does not recommend that Diane 35 be prescribed
as contraception alone.  They recommend the use of alternative
contraception while on Diane 35.  However, Diane 35 is indicated
for contraceptive monotherapy in other countries (e.g. Australia).

Best Acne Treatment. What COCs have the official indication for acne tx?

• In Canada, Alesse, Tri-cyclen & Diane 35 have official indications
for acne in the product monograph.
• Yasmin is as efficacious as Tri-cyclen & Diane 35
 for mildmoderate acne, but not officially indicated.
{Yaz in the USA recently got  acne FDA indication}
• All COCs are generally beneficial, likely due to estrogens effect
on sex hormone binding globulin (SHBG) resulting in an
antiandrogenic effect.
  Limited and conflicting evidence does
not support the superiority of one progestin over another.

Best Acne Treatment. COCs: Role in women with acne

• Acne accompanied by mild or moderate hirsutism
• Inadequate response to other acne treatments
• Acne that began or worsened in adulthood
• Premenstrual flares of acne
• Excessive facial oiliness
• Inflammatory acne limited to the “beard area”

Best Acne Treatment. Antibiotics (ABX): Considerations

• Using BP with topical ABX is strongly recommended to reduce
the risk of bacterial resistance!
• Oral ABX are useful for more extensive/severe inflammatory
acne; however, due to bacterial resistance concerns, shorter
“pulse” courses may be preferred over longer-term maintenance
therapy.
• Topical antibiotics are useful as follow-up to an oral ABX course.

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.