Acne Treatment: One Dermatologist's Approach -

Michael H. Berkson, M.D.

With the exception of Isotretinoin/Accutane, in certain cases, there still is no reliable cure for acne. However, there are excellent treatment options which should markedly improve the skin of nearly all who have acne.

The treatment of acne can sometimes be complex and difficult. In all but the mildest of cases, seeking care from a health care provider who has experience in the management of acne is highly recommended. Dermatologists have the most in depth training and experience in the treatment of skin conditions in general, and acne in particular, and are thus ideally suited to guide the treatment of acne patients. Furthermore, most dermatologists genuinely enjoy treating acne because they recognize that successful treatment has such a positive effect on people’s lives and they get to see the tangible results of their efforts, which is truly gratifying.

To follow is a discussion of the treatment plans that I have personally found most helpful and applicable to the various forms and severity of acne that I see in practice. I present these in general terms as every person is different and there is no cookbook approach. The overarching principle is simple and that is to use the least amount of medicine in the safest way possible to achieve maximal, sustained control of the breakouts. Some of the other goals are to prevent/limit physical and psychological scarring, limit time on antibiotics when possible, use benzoyl peroxide whenever using antibiotics to help reduce the emergence of bacterial resistance, use spironolactone in women whenever applicable, and to not hesitate to use Isotretinoin/Accutane when indicated, unless there is a good reason to avoid it.

Below are the medications and one procedure that I most frequently recommend for the treatment of acne. Together these account for about 90% of what I do and prescribe:

Topical Retinoids ( adapalene/Differin, tretinoin/Retin-A and tazarotene/Tazorac)

Benzoyl Peroxide ( BPO)

Antibiotics ( topical or oral)+ Benzoyl peroxide

Spironolactone ( women only)

Isotretinoin ( Accutane)

Intralesional Steroid (Cortisone) Injections

Treatment Plans:

Mild Acne- mainly comedones- whiteheads and blackheads:

Benzoyl peroxide ( BPO) leave on product or wash available over the counter ( OTC) once or twice daily

Adapalene 0.1% gel (Differin) (OTC) once daily

Salicylic acid wash or leave on product ( OTC) once or twice daily

Tretinoin (Retin-A)

Azelaic acid (Finacea or Azelex )

Mild Acne- comedones+ few inflammatory papules/pustules:

Adapalene 0.1% gel (Differin) +Benzoyl peroxide leave on product or wash each once daily (OTC)

Benzoyl peroxide (BPO) wash if acne is on the trunk (OTC)

Tretinoin ( Retin-A)

Topical dapsone ( Aczone)

Azelaic acid ( Finacea or Azelex)

Mild-Moderate Acne- comedones+moderate number of papules/pustules:

Adapalene/benzoyl peroxide combination ( Epiduo or Epiduo Forte) once daily alone or with topical clindamycin each once daily

Tretinoin ( Retin-A), adapalene 0.3%( Differin), or tazarotene ( Tazorac) once daily

Clindamycin/benzoyl peroxide combination (Duac Benzaclin) once or twice daily

Topical dapsone ( Aczone)

Moderate Acne- numerous papules/pustules and possibly some small nodules:

Topical retinoid (usually adapalene or tretinoin) +clindamycin/BPO combination ( Duac or Benzaclin) each once daily

Epiduo/Epiduo Forte+ topical clindamycin each once daily

Oral antibiotic(usually doxycycline or minocycline )+ Epiduo/ Epiduo Forte+ BPO wash if truncal involvement

Spironolactone ( for women, especially if obvious hormonal triggers)

Isotretinoin if persists or recurs despite oral antibiotics and/or spironolactone

Intralesional steroid injections for select inflamed nodules

Moderate-Severe Acne- numerous papules+ moderate number of nodules, possibly with evident scarring:

Oral antibiotic ( usually minocycline)+ Epiduo/Epiduo Forte+ BPO wash if truncal involvement

Spironolactone ( for women, especially if obvious hormonal triggers)

Isotretinoin ( Accutane)

Intralesional steroid injections for select inflamed nodules

Severe Acne- numerous nodules, often with significant scarring:

Cool down period using oral antibiotic (usually minocycline)+ Epiduo/Epiduo Forte+ BPO wash if truncal involvement, followed by isotretinoin (Accutane)

Oral steroids( if very severe) followed by isotretinoin

Persistent (despite oral antibiotics and/or spironolactone), but less severe acne:

Isotretinoin

The next article discusses over the counter and alternative treatments for acne.

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