Personalizing Acne Regimens: Balancing Efficacy, Tolerability, and Adherence

Hilary Baldwin, MD, clinical associate professor of dermatology at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey, led an engaging discussion during the recent Dermatology Times Case-Based Roundtable event, “Refining Acne Management: Case-Based Approaches to Personalizing Topical Treatment,” held in New York City. The session explored practical strategies for tailoring acne therapy using both established and emerging topical agents.

“This isn’t about right or wrong,” Baldwin told the group at the outset. “It’s whatever you do in your practice. Prescription data only tells us so much. It doesn’t tell us how we combine things, what comes first, or how we add therapies.”

Throughout the evening, Baldwin and her peers reviewed 3 cases that highlighted clinical reasoning, patient psychology, and the evolving role of agents such as tretinoin, clascoterone cream 1% (Winlevi; Sun Pharmaceutical Industries), and tazarotene lotion 0.045% (Arazlo; Ortho Dermatologics) in acne management.

Case 1: Teen Girl With Comedonal Acne

The first case involved a 15-year-old woman presenting with multiple comedones across her forehead. The patient had been using a salicylic acid cleanser intermittently, experienced irritation, and wore makeup during volleyball practice, often failing to wash her face afterward. Her father noted the emotional impact—she avoided team photos due to embarrassment.

Panelists discussed the challenges of adherence in teenagers and debated whether to begin with a simple topical regimen or an aggressive multimodal approach. “I tend to start kind of easy,” one clinician said, noting that routine adherence varies by patient personality and motivation. Others argued that visible distress warranted early combination therapy.

Baldwin emphasized patient education as a cornerstone of success. “Education on how to use products is more important than just prescribing them,” she said. “I have a typed-out AM/PM routine for all my patients. It’s not enough to hand them a tube and hope for the best.”

The group agreed that this case represented a straightforward indication for a topical retinoid—specifically, tretinoin—in combination with a benzoyl peroxide (BPO) cleanser. Baldwin noted that while guidelines may recommend retinoid plus antimicrobial therapy, clinical reality often requires tailoring. “The AAD guidelines say start with a retinoid and benzoyl peroxide or clindamycin, but no one really sits down and reads them before treating a patient. We all just know what works,” she said.

Consensus emerged around tretinoin 0.025% or 0.05%, applied to the face, coupled with a BPO wash used several times weekly to manage follicular occlusion. Moisturizers and gentle cleansers (such as CeraVe or La Roche-Posay) were preferred to mitigate dryness.

Panelists also discussed clascoterone cream (Winlevi; Sun Pharma) as a potential add-on, particularly for adolescent women with signs of androgenic activity or persistent oiliness. However, given the comedonal predominance and age, most agreed to start with retinoid plus BPO before escalating therapy.

“Acne medicine doesn’t get rid of the pimples you have—it stops the ones that are forming,” Baldwin reminded the group. “It takes a month to see that you’re getting better, but you’re actually improving from day one.”

Case 2: Swimmer With Truncal and Facial Acne

The second case focused on a 17-year-old competitive swimmer with moderate to severe acne affecting both face and trunk. Continuous chlorine exposure had caused dryness, and prior attempts with BPO wash led to irritation. Baldwin noted the psychosocial dimension of the case, as the patient’s acne was visibly impacting confidence during competitions.

Several clinicians favored initiating oral antibiotics for rapid anti-inflammatory control. “Start with sarecycline or minocycline first,” one participant said. “It clears inflammatory lesions really well and fast.” Baldwin agreed, highlighting the pharmacologic advantages of sarecycline (Seysara; Almirall). “There’s a lot of bells and whistles about Seysara—it’s legit once-a-day, with phase 3 data behind it. Narrower spectrum, less GI upset, no photosensitivity,” she said.

The panel also discussed combining systemic therapy with topical maintenance to improve long-term outcomes. Tazarotene lotion (Arazlo; Ortho Dermatologics) was highlighted for its tolerability and truncal data, while clascoterone cream was praised for its moisturizing qualities and androgen blockade without systemic exposure.

Baldwin advocated early integration of clascoterone: “It’s a foundational treatment upon which to build the acne regimen. It takes three months to work, so it should be started at the beginning, not as an afterthought.”

Ultimately, the group’s final regimen incorporated doxycycline or sarecycline for short-term control, with Tazarotene lotion for retinoid activity and clascoterone cream for sebum suppression. “You combine agents with different mechanisms of action—kill bacteria, unclog pores, reduce sebum,” Baldwin summarized.

Case 3: Woman With Hormonal and Postinflammatory Changes

The third case described a 26-year-old Black woman, a flight attendant with predominantly lower facial acne and postinflammatory hyperpigmentation (PIH). She reported irritation with tretinoin and inconsistent use, stopping therapy when flares occurred.

Panelists immediately recognized a hormonal component and the need for gentle, pigment-conscious care. “I also tell patients who can’t use their retinoids every night that I want them to be consistently inconsistent,” Baldwin explained. “Use it every other day instead of four days in a row and then stopping for a week.”

Because of her skin sensitivity and risk of hyperpigmentation, clinicians selected Clindamycin (1.2%), Adapalene (0.15%), and Benzoyl peroxide (3.1%) (Cabtreo; Ortho Dermatologics) for its convenience and efficacy, along with broad-spectrum sunscreen and a topical lightening agent.

Baldwin acknowledged the growing role of adjunctive depigmenting agents in acne-related PIH: “The nice thing about the new topical brighteners like Melad3 or Radian Tone is that they’re affordable, around $30 to $40, and they work without bleaching normal skin.”

Practice Pearls

The roundtable reinforced the importance of personalized acne management, integrating patient behavior, skin type, and psychosocial context with pharmacologic data. Baldwin summarized the session succinctly: “Managing acne isn’t about finding the magic molecule, it’s about matching the right drug, in the right form, for the right patient.”

Key takeaways included:

• Retinoids remain foundational; Arazlo offers improved tolerability and spreadability.
• Clascoterone serves as a unique topical antiandrogen effective in both sexes and suitable for truncal use.
• Combination therapy (eg, Cabtreo) can streamline regimens and boost adherence, particularly in young adults.
• Education and expectation management are as critical as the prescription itself.

As Baldwin noted, “Acne therapy is a marathon, not a sprint. Setting realistic expectations, especially for adolescents and their parents, determines success as much as any drug we choose.”