Acne treatments are tailored to each patient according to severity, as shown in the Table. Clinicians must always bear in mind that acne can fluctuate from time to time; therefore, taking an accurate patient history and developing a flexible treatment plan that accommodates fluctuations in acne severity are an important part of management.
Patients often expect advice regarding skincare and the choice of skincare can be paramount to the success of treatment. There are many inexpensive skincare ranges that offer acne cleansers and moisturisers that aim to be gentle to the skin and not be occlusive. The use of an appropriate cleanser and moisturiser can also minimise the irritancy of many topical acne treatments as well as dry skin often associated with oral isotretinoin use.
Patients may also expect advice on diet and, as mentioned previously, it is important to dispel acne myths and consider offering patients an acne educational resource such as the All About Acne website (www.acne.org.au).
When seeing a patient for the first time, be mindful that they may have already been to a chemist or beautician for advice. They may have fixed ideas about what is causing their acne and, even in patients with mild disease, acne can have significant psychological impact that does not necessarily correlate with their acne severity.14
Acne cleansers can be beneficial for all types of acne and are available at pharmacies and supermarkets. Cleansers usually contain salicylic acid, glycolic acid, azelaic acid or benzoyl peroxide. Cleansing twice daily is ideal to remove excess sebum, keratinous debris, make up and pollution. Micellar water can also be used on sensitive skin. Non-prescription leave-on acne treatments can be used once or twice a day and may contain benzoyl peroxide, salicylic acid, glycolic acid or azelaic acid.
Benzoyl peroxide reduces pilosebaceous duct colonisation by C. acnes, as well as decreasing sebum and comedone formation. Gradual introduction and starting with a low concentration are recommended to minimise potential skin irritation. It is the active ingredient in acne facial washes or leave-on creams and has also been incorporated into the fixed-dose combination prescription products clindamycin phosphate/benzoyl peroxide and adapalene/benzoyl peroxide combinations.
Alpha hydroxy acids such as glycolic acid (and others such as lactic, citric and mandelic acid) and the beta hydroxy acid, salicylic acid, decrease altered follicular keratinisation in blocked oil glands and improve skin appearance by exfoliation.
Azelaic acid works by inhibiting C. acnes growth and improving abnormal pilosebaceous follicular keratinisation. It has fewer irritant side-effects compared with benzoyl peroxide.
Prescription first-line therapy for mild acne usually consists of a topical fixed dose combination. The combination products tend to be more effective, work faster and target more areas of acne pathogenesis than monotherapy. They are applied at night to a cool dry face and are not used as spot treatments. Patients should be followed up eight to 12 weeks after starting treatment to assess its effectiveness and determine whether a change should be made. Therapies include:
- clindamycin phosphate 1% plus benzoyl peroxide 5% (not listed on the PBS)
- adapalene 0.1% or 0.3% plus benzoyl peroxide 2.5%, note that there are two strengths (currently listed on the PBS)
- clindamycin phosphate 1% plus tretinoin 0.025%, the newest combination (not listed on the PBS).