Acne Vulgaris

Our Approach in Acne Vulgaris

The two most common acne management failures in India are under-treatment of moderate inflammatory acne with topicals alone, and over-prescription of oral antibiotics without a systemic plan. Our acne specialist dermatologist team in Mumbai, India grades severity formally at every visit, selects treatment matched to that grade, and limits antibiotic duration to the evidence-supported window - because antibiotic resistance in Cutibacterium acnes is a growing clinical problem driven directly by prolonged, inappropriate antibiotic prescribing.

1.Acne Grading & Lesion Classification

Treatment is determined by lesion type and severity - not patient frustration level.

• • Comedonal acne (Grade I) - open comedones (blackheads), closed comedones (whiteheads); no inflammatory lesions
  • Mild inflammatory acne (Grade II) - papules and pustules on a background of comedones; limited to one anatomical area
  • Moderate inflammatory acne (Grade III) - multiple papules, pustules, and early nodules; extending across face, chest, or back
  • Severe nodulocystic acne (Grade IV) - deep nodules, cysts, confluent lesions; significant scarring risk; isotretinoin for severe acne is the appropriate treatment
  • Global Acne Grading System (GAGS) - formal scoring for clinical consistency and response monitoring.

2. Topical Therapy - The Backbone of Mild to Moderate Acne

• Retinoids - Tretinoin (0.025–0.05%), Adapalene (0.1–0.3%), Tazarotene; normalise follicular keratinisation; reduce comedone and inflammatory acne; first-line for comedonal and mild inflammatory acne; night use only; photosensitivity counselling
• Benzoyl peroxide - bactericidal; reduces antibiotic resistance when combined with topical antibiotics; 2.5–10% gel or wash; bleaches fabric
• Topical antibiotics - Clindamycin, Erythromycin; never as monotherapy - always combined with BPO to prevent resistance
• Azelaic acid 15–20% - anti-inflammatory, antibacterial, and comedolytic; well-tolerated; safe in pregnancy; reduces post-acne pigmentation
• Adapalene/BPO combination - the most evidence-based topical combination for mild-moderate acne; once-daily fixed-dose formulation
• Topical Ivermectin - emerging for inflammatory acne; particularly useful where Demodex infestation contributes . 

  3. Oral Antibiotics - Time-Limited & Targeted 
  
  

  Oral antibiotics are indicated for moderate inflammatory acne and as adjunct to topical therapy in severe disease before isotretinoin.

• Doxycycline 100mg daily - first-line; 12-week course maximum; GI side effects reduced by taking with food; photosensitivity counselling
• Lymecycline - less photosensitivity than Doxycycline; alternative in photosensitive patients
• Azithromycin pulse therapy - 3 days per week for 12 weeks; useful where daily Doxycycline is poorly tolerated
• Always combine with BPO or topical retinoid - prevents resistance development
• Never prescribe antibiotics beyond 12 weeks without reassessment - escalate to isotretinoin if inadequate response
  

4.Hormonal Therapy for Women

• Combined oral contraceptives (COC) - Ethinylestradiol/Cyproterone acetate (Diane-35); Ethinylestradiol/Drospirenone (Yasmin) - reduce androgen-driven sebum production; effective for moderate acne in women
• Spironolactone 50–200mg daily - anti-androgen; particularly effective for jawline and lower face acne in women; potassium monitoring; not in pregnancy
• Indication: women with premenstrual acne flares, late-onset adult acne, and clinical or biochemical evidence of androgen excess

5. Isotretinoin - The Disease-Modifying Treatment

Isotretinoin for severe acne is the only treatment that produces long-term remission - targeting all four pathogenic factors simultaneously.

• Indications: severe nodulocystic acne, moderate acne unresponsive to two courses of oral antibiotics + topicals, acne causing psychological distress or scarring despite moderate treatment
• Dose: 0.5–1mg/kg/day; cumulative dose target 120–150mg/kg for sustained remission
• Duration: typically 6–9 months at standard dosing
• Monitoring: LFTs and lipids at baseline and monthly; CBC; avoid concurrent tetracyclines (pseudotumour cerebri risk)
• Teratogenicity - absolutely contraindicated in pregnancy; two forms of contraception mandatory in women of childbearing age throughout and for 1 month post-treatment
• Mucocutaneous side effects - dry lips (cheilitis), dry eyes, dry skin, epistaxis - managed with emollients, eye drops, and lip balm; almost universal
• Mood monitoring - depression and suicidality reported; baseline mental health assessment and monitoring throughout; not a contraindication in most cases but requires awareness
  

6. Acne Scar Prevention & Treatment

• Monthly trichoscopy in active disease - tracks yellow dot count (stable follicle reserve), regrowth pattern, and activity markers
• Thyroid function annually - the most common autoimmune comorbidity
• Relapse planning - patients with prior extensive AA are counselled on early re-treatment triggers; JAK inhibitors may need to be continued rather than stopped on achieving response