Current Management of Acne Vulgaris: Severity-Based Therapy, Combination Treatment, And Antibiotic Stewardship

Abstract

Acne vulgaris is a common chronic inflammatory disorder of the pilosebaceous unit that affects adolescents and adults and may lead to scarring, dyspigmentation, psychosocial distress, and reduced quality of life. Contemporary management is based on acne severity, lesion type, distribution, scarring risk, patient age, pregnancy status, treatment history, and psychosocial burden. First-line therapy for mild-to-moderate acne relies on topical treatment, particularly topical retinoids, benzoyl peroxide, and combination regimens. Topical retinoids normalize follicular keratinization and are useful for both active treatment and maintenance. Benzoyl peroxide has antimicrobial and anti-inflammatory effects and reduces the risk of antibiotic resistance when used with topical or oral antibiotics. Moderate-to-severe inflammatory acne often requires escalation to systemic therapy, most commonly oral tetracycline-class antibiotics combined with non-antibiotic topical agents. Antibiotic monotherapy should be avoided. Hormonal therapy, including combined oral contraceptives and spironolactone, is useful in selected female patients, particularly those with persistent, adult-onset, or hormonally influenced acne. Oral isotretinoin remains the most effective treatment for severe nodular, scarring, refractory, or psychosocially burdensome acne. Adjunctive procedures, including chemical peels, lasers, photodynamic therapy, intralesional corticosteroids, and emerging microbiome-based or drug-delivery approaches, may benefit selected patients but are generally less established than standard pharmacologic regimens. This review summarizes current acne management with emphasis on severity-based escalation, combination therapy, maintenance, adherence, and antibiotic stewardship.