Comedone extraction is an office procedure used to disimpact obstructive acne lesions. The obstructing plug can usually be expressed after enlarging the pore with a 25-gauge needle.

Intralesional corticosteroid injection can rapidly (within 48-72 hours) resolve large or recalcitrant inflammatory acne lesions and reduce the risk for scarring. A 30-gauge needle is used to inject 0.05-0.3 mL of a solution containing triamcinolone acetonide through the pore of the lesion. The corticosteroid solution is usually diluted with normal saline or lidocaine to a concentration of 0.63-2.5.

Tetracycline online is favored because of its better tolerability and lower incidence of P acnes resistance. It is initiated at a dose of 1-2 g/d in 2-4 divided doses. Tetracycline should be taken on an empty stomach. Many individuals whose acne is controlled can be weaned off oral antibiotics after 6 months of therapy, and then topical antimicrobial therapy can be continued for maintenance.

Long-term use is considered safe; the most common side effects are gastrointestinal upset and vulvovaginal candidiasis. Gram-negative folliculitis may occur, typically manifested by the sudden appearance of superficial pustular or cystic acne lesions around the nares and flaring out over the cheeks.
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Minocycline (Minocin) and trimethoprim/sulfamethoxazole (TMP/SMX [Bactrim, Septra]) have a place in treating some refractory cases. Minocycline can be particularly valuable for patients with treatment-resistant inflammatory acne. Minocycline, like all tetracyclines, is contraindicated in pregnant women and in children younger than 9 years of age because of potential adverse effects on developing bones and teeth.

TMP/SMX is prescribed at a dose of 1 regular-strength tablet, qd or bid. Hematologic and dermatologic side effects have restricted its use to patients with severe acne refractory to other antibiotics and to those who develop gram-negative folliculitis secondary to long-term antibiotic therapy.

Hormone therapy improves acne by suppressing sebum production. A triphasic oral contraceptive pill containing ethinyl estradiol, 35 g, and norgestimate (Ortho Tri-Cyclen) has been shown to reduce inflammatory acne lesions by 40%.

Topical tretinoin (Retin-A), a vitamin A derivative, promotes the drainage of preexisting comedones and reduces the formation of new ones. The full cosmetic benefit may not be apparent for 6-12 weeks. Tretinoin should be applied lightly every night at bedtime. Skin irritation (dryness, erythema, and peeling) is common. Patients should avoid excessive sun exposure or should use a protective sunscreen.
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Tretinoin (Retin-A) is available in creams (0.025%, 0.05%, 0.1%), gels (0.01%, 0.025%), liquid (0.05%), and a microsphere (Retin-A Micro 0.1%). The liquid is the most irritating. Patients with fair or sensitive skin should begin by using the 0.025% cream every other day and gradually increase to daily use at a higher concentration as tolerated. The microsphere reduces the potential for irritation.
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Adapalene (Differin 0.1% gel), a naphthoic acid derivative with retinoid activity, is comparable to tretinoin, it appears to be less irritating, and it has anti-inflammatory activity. Adapalene is applied as a thin film daily at bedtime. A therapeutic effect is typically seen within 8-12 weeks. Skin irritation occurs in 10-40% of patients. Users should minimize exposure to sunlight.

Tazarotene (Tazorac, 0.05% and 0.1% gel), a synthetic acetylenic retinoid with comedolytic properties, is FDA-approved for topical treatment of mild-to-moderate facial acne. It is applied every evening. Tazarotene is associated with skin irritation. Tazarotene does not offer any significant advantages over tretinoin or adapalene.

Topical antibiotics inhibit the growth and activity of P acnes. Choices include clindamycin (Cleocin-T 1% solution, lotion, or gel), erythromycin (A/T/S 2% gel or solution, Erygel 2% gel, Akne-Mycin 2% ointment, T-Stat 2% solution and pads), sulfacetamide (Klaron 10% lotion), and a 3% erythromycin and 5% benzoyl peroxide gel (Benzamycin). Topical antibiotics are applied twice daily. Skin dryness and irritation are the most common side effects. Antibiotic resistance is possible. Resistance is less likely with the erythromycin and benzoyl peroxide combination, making it an option for patients who have developed resistance to other agents.

Benzoyl peroxide is an antibacterial, agent that may also have mild comedolytic properties. It is available over-the-counter and in prescription formulations (2.5%, 5%, and 10% lotions, creams, and gels). Benzoyl peroxide is typically applied as a thin film, once or twice daily. Mild redness and scaling are common during the first few weeks.
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Azelaic acid (Azelex 20% cream), a dicarboxylic acid with combined antimicrobial and comedolytic properties, is FDA-approved for mild-to-moderate inflammatory acne. It is massaged in twice daily. Mild skin irritation occurs in 5-10% of patients. Because azelaic acid does not cause photosensitivity, it is an alternative comedolytic agent for patients who are reluctant to refrain from activities that involve significant exposure to the sun. Hypopigmentation is a rare adverse reaction.

Proliferation of Propionibacterium acnes is felt to play a pivotal role in the pathogenesis of inflammatory acne lesions.

Clinical evaluation. Acne vulgaris occurs primarily on the face and (to a varying degree) the neck, upper back, chest, and shoulders. Classification is based on the number and predominant type of lesions and on the affected sites. The three distinct types are obstructive acne, inflammatory ache, and acne scars.