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Clear Thinking: An Update on Acne Treatment in Canadian Practice

  • The Review Course in Family Medicine
  • 4 hours ago
  • 1 min read
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General Treatment Principles

  • Topical therapies are the first-line mainstay for mild acne (monotherapy or adjunct).

  • Systemic medications are often required for more severe cases.

  • Combination therapy (multiple modalities) is generally recommended.

  • Oral isotretinoin is the criterion standard for severe acne and scarring.

  • Antibiotic monotherapy is discouraged due to resistance risk.


Key Topical Therapies

  • Retinoids (e.g., Tretinoin, Adapalene): Comedolytic and anti-inflammatory. Apply nightly with daily sunscreen. Do not combine with Benzoyl Peroxide (BP). Avoid/Contraindicated in pregnancy/pregnancy-planning.

  • Benzoyl Peroxide (BP): Topical antimicrobial, mild comedolytic. Combine with topical antibiotics.

  • Topical Antibiotics (e.g., Clindamycin): Not for monotherapy. Combine with BP to mitigate resistance.

  • Fixed-Dose Combinations: Highly effective (e.g., Adapalene + BP).

  • Topical Clascoterone: Topical antiandrogen. Twice daily monotherapy for age 12+.

  • Azelaic Acid: Comedolytic/anti-inflammatory. Treatment of choice during pregnancy.


Systemic Therapies

  • Systemic Antibiotics: Do not exceed 3-4 months. Examples: Doxycycline, Minocycline. Contraindicated in pregnancy, lactation, and children under 9.

  • Hormonal Therapy (Females):

    • Combined Oral Contraception (COC): Approved for acne in patients seeking contraception. Improvement seen in 3-6 months. Document Blood Pressure and pregnancy status.

    • Oral Spironolactone: Off-label use for women (up to 100–200 mg). Blocks androgen receptors. Risks: menstrual irregularities, breast tenderness. Potassium monitoring is unnecessary unless high-risk comorbidities/medications are present.

  • Oral Isotretinoin: Only approved treatment for severe nodular or refractory acne in Canada. Requires effective contraception due to extreme teratogenicity. Requires baseline and follow-up monitoring (liver enzymes, lipids, pregnancy tests).

  • Intralesional Corticosteroids: Adjuvant for larger lesions, used judiciously for high-risk scarring or rapid relief.


References

 
 
 

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