Combination Therapy Guides Acne Management Across Severity Levels

Kord Honda, MD, a dermatologist and dermatopathologist at University Hospitals Cleveland Medical Center and professor of dermatology at Case Western Reserve University School of Medicine in Ohio, recently outlined a stepwise approach to acne management in recognition of Acne Awareness Month coming to a close in June. Honda described first-line topical therapies, hormonal considerations, and options for severe disease, along with emerging and declining treatment trends.

Topical Retinoids Anchor First-Line Treatment

Honda said the most important step is treating the initiating factor in acne, with topical retinoids serving as the base treatment for most patients. He starts many patients on over-the-counter adapalene (Differin), topical tretinoin, or topical tazarotene. Benzoyl peroxide is often added as a wash, gel, or cream, and topical antibiotics may be introduced for patients with an inflammatory component.

"The most important thing is to try to treat the initiating factor in acne, so really the base treatment for a lot of acne is going to be topical retinoids," Honda said.

Application Timing and Whole-Face Coverage

Honda cautioned that benzoyl peroxide can bleach clothing and pillowcases, and he prefers a wash formulation for easier removal. He advises patients to wait 30 minutes after washing with benzoyl peroxide before applying tretinoin or a topical antibiotic. Treatment should cover the entire face rather than function as spot therapy, since preventing new lesions works better than treating existing ones. Honda said results take about 2 months to appear, and patients should not abandon a regimen before then.

"It's not spot treatment. You want to treat the whole face and not just individual pimples as they pop up, because we have a much better track record of preventing new pimples than treating the pimples that are already there," Honda said.

Hormonal and Severe Acne Require Additional Options

For girls and women, Honda recommends asking about a hormonal component, since hormonal acne may not always respond to topicals alone. Oral contraceptives or spironolactone, which addresses the male hormone contributing to acne, are additional options. For severe cases, Honda described isotretinoin as highly effective, though it requires patient registration through the iPledge system due to potential side effects, including birth anomalies in pregnancy.

"Isotretinoin is quite effective, but it does carry more side effects," Honda said.

Emerging Options and Declining Interest in Red Light Therapy

Honda noted topical androgen inhibitors, a relatively new drug class, may help address oil production contributing to acne for select patients. He said microbiome-targeted therapy could prove helpful down the road, though nothing is currently FDA-approved specifically for it. Interest in red light therapy has also declined; Honda said patients asked about it more often approximately 5 years ago than they do now.

"If we can control the microbiome of the skin, that may prove to be helpful down the road, but nothing's currently newly FDA-approved for that treatment," Honda said.

According to Honda, most patients can be managed with a scale of these products, titrated according to severity at presentation.

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