Table 2.

Summary of treatment recommendations from the European acne guidelines

Type of acne	First-line treatment	Second-line treatment	Third-line treatment	Hormonal alternatives for women
Comedonal acne	Topical retinoids, adapalene is preferred to tretinoin	Benzoyl peroxide (BPO) or azelaic acid	–	Not recommended
Mild to moderate papulopustular acne	BPO + adapalene (f.c.) or BPO + clindamycin (f.c.)	BPO or azelaic acid or systemic antibiotic + adapalene	Isotretinoin or tretinoin + topical erythromycin (f.c.); or systemic antibiotics + BPO; or systemic antibiotics + azelaic acid; systemic antibiotics + adapalene + BPO (f.c.)	Not recommended
Severe papulopustular acne and mild nodular acne	Systemic isotretinoin	Systemic antibiotics + adapalene; systemic antibiotics + azelaic acid; or systemic antibiotics + BPO + adapalene (f.c.)	Systemic antibiotics + BPO	Hormonal antiandrogens + topical treatment or systemic antibiotics (topical treatment is preferred)
Severe nodular acne and conglobate acne	Systemic isotretinoin	Systemic antibiotics + azelaic acid	Systemic antibiotics + BPO; or systemic antibiotics + adapalene; or systemic antibiotics + BPO + adapalene (f.c.)	Hormonal antiandrogens + systemic antibiotics (consider as third line treatment)

Abbreviation: f.c., fixed combination.