Table 1

Overview of acne pharmacotherapy*

TREATMENT	ROLE	COMMENTS	USE
Topicals: applied to entire affected area13
BP
Water-based 2.5%, 4%, 5%, 8%, 10% Other (alcohol-based, acetone-based, lotion, soap, washes)	Mild to moderate acne; monotherapy or in combination regimens; prevents bacterial resistance7,12,13	Water-based formulations (eg, creams) are less drying or irritating; initial worsening for 2–4 wk; improvement < 3 mo	Start with lower strength (2.5%–5%) or less frequent nighttime application; increase strength or frequency if tolerated; water-based BP preferred for dry skin
Retinoids
TRE 0.01%, 0.025%, 0.05%, 0.1% Adapalene 0.1% cream; 0.3% gel Tazarotene 0.05%, 0.1% cream, gel	Mild to moderate acne, especially comedonal; maintenance therapy (can step down to less frequent use)	Some guidelines suggest as first-line13; irritating and drying (adapalene might be better tolerated); initial worsening for 2–4 wk; improvement < 3 mo	Apply minimal amount to cover area; start with lower strength tretinoin 0.01%–0.025% or adapalene 0.1% applied every 2–3 nights; gradually increase frequency or strength; AEs subside over time
Topical antibiotics
CLI 1% solution ERY 2% gel	Mild to moderate inflammatory acne	Use in combination with BP to minimize resistance concerns	Apply twice daily; avoid long-term use if possible; step down to BP or retinoid only
Combination topical gels
Benzamycin (BP 5% and ERY 3%) BenzaClin, Clindoxyl (BP 5% and CLI 1%) Stievamycin (TRE and ERY 4%)	Mild to moderate inflammatory acne when more intensive therapy is desired	More effective than monotherapy; response might be seen in 2–3 wk; optimal results in 8–10 wk; convenient but more expensive	Apply 1–2 times daily (begin with nighttime administration); after response, step down to maintenance with BP or retinoid
Orals
Oral antibiotics
Tetracycline 250-mg capsule Doxycycline 100-mg capsule MIN 50- or 100-mg capsule ERY 250 mg, 333 mg, 500 mg	Moderate to severe inflammatory acne if topical agents are not effective or practical; use with BP	Little or no difference in efficacy14; MIN has AE concerns (eg, rare lupuslike reaction) and is expensive15	To minimize resistance, use for 2–4 mo then step down to topical agents; dosing: doxycycline 100 mg daily (see CFPlus for other dosing)
Hormonal contraceptives
Tri-Cyclen, Alesse, Aviane, Yasmin (have acne indication) Diane-35, Cyestra-35 (acne but no contraception indication)	First-line in women if also desired for contraception; antiandrogen effect; useful in combination with other therapies	Acne might worsen early in cycle; allow 3–6 mo for response; any COC might be beneficial owing to estrogen’s effect on sex hormone binding globulin, but some might make acne worse16,17	Generally used in typical cyclic fashion; daily for 21 d, followed by 7-d hormone-free interval
Spironolactone
25- or 100-mg tablets	Adult or late onset acne in women; hirsutism	Antiandrogen effect; 2–3 mo for optimal response	Usual dose is 50–100 mg/d
Isotretinoin (Accutane, Clarus)
10- or 40-mg capsules (10-mg capsules relatively expensive)	For more severe acne (eg, nodulocystic, scarring)	Very effective, but must balance with AEs, contraindications, side effect management, and follow-up; teratogenic in pregnancy	Low dose for 1 mo; increase (or decrease) as tolerated; optimal cumulative dose: 120–150 mg/kg/course; see monograph for pregnancy testing and contraception requirements

AE—adverse effect, BP—benzoyl peroxide, CLI—clindamycin, COC—combination oral contraceptive, ERY—erythromycin, MIN—minocycline, TRE—tretinoin.
↵* Table is adapted from the RxFiles Acne Pharmacotherapy Comparison Chart18 and the Dalhousie CME Academic Detailing Service Acne Review 2008.19