Acne: Drug Therapy

Therapeutic target

Improvement of symptomatology and thus prevention of complications.

Therapy recommendations

  • Mild to moderate acne (A. comedonica (increased closed and open comedones on the face, especially in the nasal region), A. papulopustolosa (increased papules (nodular thickening of the skin) and pustules (pustules) on the face, rarely also on the neck, back or arms):
    • Induction therapy/initial therapy: topical externals/local therapy (synergistic effects of combination therapy of at least two agents).
      • 1st choice: topical retinoid (once or twice daily for 8-12 weeks: e.g., adapalene, ADA) + benzoyl peroxide (BPO); topical retinoid + azelaic acid (15% gel/20% cream).
      • Alternatively: BPO + azelaic acid
      • If inflammatory component is high: topical antibiotic combined with each azelaic acid / BPO / topical retinoid.
    • Maintenance therapy:
  • Moderate to severe acne (A. papulopustulosa nodosa (nodular), A. conglobata (most severe form of acne; there are all efflorescences, some fistula comedones, especially on the back and neck)):
    • Induction therapy (systemic therapy).
      • 1st choice: systemic retinoid: isotretinoin [alternatively: combination of doxycycline and an adapalene/benzolyperoxide gel (1)]
      • If inflammatory component is high: systemic antibiosis (antibiotic therapy).
      • For female patients: Contraceptives (contraceptive) of the antiandrogen type (hormonal antiandrogenic therapy (HAAT))/if necessary, hormonal antiandrogens + systemic antibiosisNote: In women, hormonal antiandrogenic therapy (HAAT) is a reasonable alternative to antibiotic therapy.
    • Maintenance therapy
      • Topical retinoid + BPO or topical retinoid + BPO + azelaic acid.
  • Dosage Notes:
    • Initial therapy of acne vulgaris lasts at least 3 months; maintenance therapy may need to be carried out over a year.
    • For female patients with acne vulgaris, permanent antiandrogenic therapy may be considered.
    • Systemic antibiotic therapy should be extended beyond 3 months only in individual cases.
  • Notes on skin care: oil-in-water emulsions and hydrogels are suitable.

Note: In women, hormonal antiandrogenic therapy (HAAT) is a reasonable alternative to antibiotic therapy. Comedones dissolving substances are fruit acid, glycolic acid, lactic acid and salicylic acid. Further notes

  • The European Medicines Agency (EMA) restricts the prescription of oral contraceptives (“the pill”) containing the active ingredients dienogest and ethinyl estradiol for the treatment of moderate acne because of an unclear risk of venous thromboembolism (vascular disease in which a thrombus (blood clot) forms in a vessel). These are indicated only for patients who have previously failed topical or oral antibiotics and are determined to oral contraception.
  • The Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) advises physicians to avoid daily doses of cyproterone above 10 mg if possible (risk of meningioma formation).
  • In a randomized, double-blind, placebo-controlled study, acne therapy with two capsules of lactoferrin (100 mg each) in combination with vitamin E (11 IU) and zinc (5 mg) for three months resulted in a significant reduction in skin lesions and decrease in comedones.
  • Oral isotretinoin and norethindrone acetate/ethinyl estradiol, topical clindamycin phosphate/benzoyl peroxide, and adapalene/benzoyl peroxide showed significantly better effects on improving health-related quality of life (HRQoL) than placebos.
  • Clascoterone (a novel, topical, local, selective androgen receptor inhibitor (antiandrogen)): 1% topical clascoterone cream applied for 12 weeks proved more effective than treatment with the vehicle.

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following micronutrients (vital substances):

Note: The listed vital substances are not a substitute for drug therapy. Food supplements are intended to supplement the general diet in the particular life situation.