Synchronizing Pharmacotherapy in Acne with Review of Clinical Care

Abstract

Acne is a chronic inflammatory skin disease that involves the pathogenesis of four major factors, such as androgen-induced increased sebum secretion, altered keratinization, colonization of Propionibacterium acnes, and inflammation. Several acne mono-treatment and combination treatment regimens are available and prescribed in the Indian market, ranging from retinoids, benzoyl peroxide (BPO), anti-infectives, and other miscellaneous agents. Although standard guidelines and recommendations overview the management of mild, moderate, and severe acne, relevance and positioning of each category of pharmacotherapy available in Indian market are still unexplained. The present article discusses the available topical and oral acne therapies and the challenges associated with the overall management of acne in India and suggestions and recommendations by the Indian dermatologists. The experts opined that among topical therapies, the combination therapies are preferred over monotherapy due to associated lower efficacy, poor tolerability, safety issues, adverse effects, and emerging bacterial resistance. Retinoids are preferred in comedonal acne and as maintenance therapy. In case of poor response, combination therapies BPO-retinoid or retinoid-antibacterials in papulopustular acne and retinoid-BPO or BPO-antibacterials in pustular-nodular acne are recommended. Oral agents are generally recommended for severe acne. Low-dose retinoids are economical and have better patient acceptance. Antibiotics should be prescribed till the inflammation is clinically visible. Antiandrogen therapy should be given to women with high androgen levels and are added to regimen to regularize the menstrual cycle. In late-onset hyperandrogenism, oral corticosteroids should be used. The experts recommended that an early initiation of therapy is directly proportional to effective therapeutic outcomes and prevent complications.

What was known?

Current Indian and Global Acne guidelines give only an overview in acne management based on acne severity.

Introduction

Acne vulgaris is a chronic condition that affects quality of life adversely in about 85% of adolescents and 66.7% of adults.[1,2,3] It starts with the obstruction of pilosebaceous unit, resulting in the formation of comedones (noninflammatory), followed by progression to inflammatory acne that includes papules, pustules, nodules, and cysts.[4] The major causal factors involve altered sebum levels (androgen-driven), changes in keratinization, and bacterial colonization of the pilosebaceous units on the face, neck, chest, and back.[5] It is essential to assess severity of acne as well as the individual patient factors for acne management.[6,7,8] Although standard guidelines and recommendations [Table 1] give an overview on the management of mild, moderate, and severe acne, they do not give the relevance and positioning of each of the categories of pharmacotherapy available in the Indian market. This article discusses the available topical and oral acne therapies and presents the suggestions and recommendations by the dermatologists’ panel across India who held discussions in an order to practically define positioning of different market formulations in acne management, address when to prefer monotherapy or combination therapy with rationality of available combinations, review within class and comparison of strength of different available molecules, and consider formulation innovations along with the role of the adjunctive treatments.

Table 1.

Various guidelines and recommendations for management of acne

Management of Acne using Topical Agents

Monotherapy

Retinoids

Retinoids have a potential role in decreasing sebum production along with in-regulation of desquamation and adhesion of keratinocyte, thus resulting in comedolysis and suppression of new microcomedonal development.[9,10,11,12] They are a preferred choice for scars and postinflammatory hyperpigmentation (PIH) of the skin.[9,13,14] Tretinoin, isotretinoin, adapalene, and tazarotene are considered as the first choice of treatment and maintenance therapy. Topical retinoids are used as monotherapy in noninflammatory acne and in combination with other topical agents in inflammatory and more severe forms of acne.[15,16,17,18,19] However, flaring up of acne during initial weeks of treatment limits its use or warrants combination with other agents [Tables 2 and 3].[20,21]

Table 2.

Various topical and oral pharmaceutical acne preparations available in India

Table 3.

Studies focussing on topical monotherapy for management of acne

Expert opinion

Place of therapy

Micronized topical retinoids are a preferred choice, where adapalene (0.1%) is considered as the first-line therapy. Adapalene gel (0.3%) may have future relevance as maintenance therapy in patients with acne scars. Tretinoin is preferred in the trunk, back, and arm acne for priming before peels and lasers during maintenance phase. However, it should be stopped 2–3 days and 5–6 days before these procedures, respectively. The relevant strengths of tretinoin that are used in India are 0.025% and 0.05% and as micronized formulation (0.1%). Tazarotene, due to poor tolerance, is usually not used in Indian acne management. Isotretinoin is not preferred topically, whereas retinol and retinaldehyde may be used as maintenance therapy due to better tolerance. They can also contribute to antiaging effects and combined with antioxidant Vitamins C and E.

Application

All retinoids are prescribed once a day in the evening or at night. They should be applied after washing face with a mild cleanser (cetyl/stearyl alcohol based) and drying completely. After 10 min, retinoids formulation should be applied on the whole face without rubbing/massaging. If moisturizer is being used, they should be applied immediately after the moisturizer application. Short contact therapy with initial ½ h application, then 1 h, and then overnight application is recommended to decrease irritation and retinoid dermatitis (dryness).

Maintenance therapy

Maintenance therapy is recommended after resolution of all visible lesions to treat microcomedones and to prevent acne flare-up or recurrence. Treatment duration should last until a 6-month acne-free period on maintenance therapy is achieved. Retinoid maintenance treatment may be tapered down to twice/thrice a week, the frequency depending on the tell-tale remnant signs of the primary lesions such as comedones and pigmentation.

Antibacterials

Antibacterials act potentially against Propionibacterium acnes, the most common causal organism in acne, and possess surface-acting capability; hence, they can prevent the formation of inflammatory lesions on the skin surface.[22] Topical antibiotics are recommended for the treatment of mild to moderate acne (inflammatory lesions) [Tables 2 and 3].

Expert opinion

Clindamycin and nadifloxacin are currently preferred in combinations with retinoids or benzoyl peroxide (BPO). Nadifloxacin has potential advantages and comparable efficacy with clindamycin, effect on biofilms, absence of documented resistance, and relative protection from Gram-negative folliculitis (GNF) due to broad-spectrum coverage.[23,24] Erythromycin and clarithromycin are not preferred currently in Indian acne practice. Lincomycin (2%) gel is also available though market is low and not seeming under active promotion. Triclosan is not preferred due to carcinogenic potential, and it may have some role in scabies. In acne pathogens, i.e., P. acnes, Staphylococcus epidermidis, Staphylococcus aureus, methicillin-resistant S. aureus, and Malassezia furfur, M. furfur back acne is treated using itraconazole (twice daily; BID 100 mg for 14 days) after doing hematological and liver function test.

Benzoyl peroxide

BPO is a nonantibiotic antimicrobial agent that allows generation of reactive oxygen species within the follicle and thus elicits bactericidal properties. It is effective for the treatment of inflammatory lesions and provides protection from antibiotic resistance [Tables 2 and 3].[16,23,24,25] Some guidelines suggest systematic approach along with the utilization of BPO mainly in case of inflammatory lesions.[5,9,26]

Expert opinion

BPO (2.5%) is preferred over 5% strength due to comparable efficacy and better tolerance. Plain BPO may be used in newly diagnosed adolescent mild acne and as topical application in patients on systemic isotretinoin. In other cases, combination of BPO with adapalene or antibacterials is used. BPO (5%) with sulfur is reserved for resistant back, arm, and trunk acne. It has been suggested to use it ½ h before bath due to its odor. Coacrylate polymer gels or microencapsulated gels should be preferred for better stability and tolerance.

Combination therapy

Combination therapies are preferred to avoid skin sensitization, antibiotic resistance as well as to enhance the treatment outcomes.[9,24,26,27,28,29,30,31] Multimodal therapy targeting different pathological processes, simultaneously, leads to a better outcome due to synergistic effects.[32] Studies also report that combination therapy plays a role in improving patient adherence due to incorporation of simplified and personalized daily regimen.[32,33] Table 2 enlists various combination therapies available in the market.

Antibacterial-retinoid

The combination therapy of topical retinoid and antibiotic is an essential treatment measure and is contemplated as the first-line therapy for the treatment of moderate to severe acne. Retinoids assist penetration of antibacterials into the pilosebaceous unit (colonization site for P. acnes), hence allowing better efficacy [Table 4].[31,34]

Table 4.

Studies focussing on topical combination therapy for management of acne

Expert opinion

BPO-antibacterials are recommended for pustule-nodular acne, whereas BPO-retinoid/antibacterial-retinoids are prescribed in comedonal papulopustular acne. Antibacterial-retinoids may be prescribed, especially if perceived tolerance with BPO-retinoid combinations is poor, formulation technology (microencapsulation) can determine the choice.

Antibacterial-benzoyl peroxide

The keratolytic action of BPO enhances the antibacterial activity of antibacterials. Further, the bactericidal properties of BPO help in reduction of microbial resistance to the topical antibiotics [Table 4].[24,25,35,36]

Expert opinion

BPO-antibacterial combination may be prescribed in acute inflammatory acne (with large number of pustules) or moderate acne tending to severe acne for early lesion control. It can potentiate action on biofilms and can be given in morning with adapalene at night. It may also be prescribed as topical therapy in patients on systemic isotretinoin and when topical retinoids are not tolerated.

Adapalene (retinoid)-benzoyl peroxide

In mild to moderate acne, adapalene-BPO is the most preferred combination and used as the first-line therapy.[30] The relapses in severe and moderate to severe acne patients can be prevented with the use of adapalene-BPO combination as maintenance therapy (for 6–12 months) subsequent to treatment with oral isotretinoin.[37,38] Combination of BPO with other retinoids is found to be unstable and hence avoided [Table 4].[29]

Expert opinion

Adapalene-BPO is the most preferred combination and used as the initial and first-line therapy in mild-moderate inflammatory acne (mainly comedones with few papules/pustules). This is also preferred in maintenance phase over retinoid monotherapy to tackle intermittent activity and flare-ups.

Miscellaneous Agents

Niacinamide

The inhibitory action of niacinamide on sebocyte secretions results in less sebum production and reduced oiliness of the skin.[39,40] It is beneficial in pustular as well as papular acne due to its anti-inflammatory properties[41] and is also a choice of treatment in cases with antimicrobial resistance [Tables 2 and 5].[42,43]

Table 5.

Studies focussing on the role of miscellaneous agents in management of acne

Expert opinion

For active treatment, niacinamide (4%) in dermato-cosmetic mattifying creams are used for daytime use and retinoids/BPO/anti-infective combinations are used at night time. During maintenance therapy, combination with adapalene is preferred for daytime use. It is also used in the cases of PIH for skin lightening and for patients with oily skin.

Dapsone

Dapsone is used in acne due to its antibacterial and anti-inflammatory activity. Its low cost makes it affordable and available to acne patients in developing countries.[44,45,46] Topical gel of dapsone (5%) is usually used to treat inflammatory and noninflammatory acne lesions.[47]

Expert opinion

Dapsone is used more of an elimination molecule due to intolerance or inadequate response to BPO/retinoids in inflammatory acne (effect seen only after 6 weeks). However, it has efficient action in scalp folliculitis and acne inversa (given twice a day with adapalene-BPO at night time).

Azelaic acid

Azelaic acid inhibits protein synthesis of the P. acnes species without bacterial resistance.[48,49] Its bacteriostatic, anti-inflammatory, antioxidant, and antikeratinizing properties enhance its antiacne potential.[50] Its combination with clindamycin 1% gel, BPO 4% gel, and tretinoin 0.025% cream is an effective acne treatment regimen.[30,51]

Expert opinion

It is effective but its use is limited due to unpredictable irritation and it has been suggested to consider liposomal preparation. Initially, 10% strength is given which is then scaled up to approximately 20%. However, it is not recommended in fixed-dose combinations. It is preferred as a morning application in acne with pigmentation along with retinoid combination in the evening.

Zinc

Zinc in combination with or without nicotinamide has been recommended as a budding alternate acne treatment with reduced adverse effects (AEs) of antibiotics. It has anti-inflammatory activity and inhibits the P. acnes lipases and free fatty acids, thereby reducing the P. acnes counts.[52] Furthermore, it is found to possess antiandrogenic activity which enables in suppression of sebum levels.[53] Its combination with antibiotics facilitates antibiotic absorption as well.[52,54]

Expert opinion

Role of zinc is not established. Its salts with pyrrolidone carboxylic acid and gluconate may be used in the combination dermato-cosmetic products with niacinamide and soothing agents.

Hydroxy acids

Glycolic acid (alpha hydroxy acid) and salicylic acid (beta hydroxy acid) are used as chemical peels for facial resurfacing. They mainly act by stimulating reepithelialization and skin rejuvenation.[3,44] However, they are not recommended as the first-line treatment for acne due to safety issues.[44,55]

Expert opinion

Glycolic acid is used as a cream with 6% and 12% concentration. It may also be used in highly comedonal acne and in the presence of pigmentation. Salicylic acid (2%) may have a role as supportive therapy in acne maintenance. Keratolytic action below 3% is uncertain, and it may actually be keratoplastic. It is mostly used as face wash.

Herbal Agents

Since ancient times, the herbal therapies such as Yarrow (Achillea millefolium), Aloe vera (Aloe barbadensis), Burdock (Arctium lappa), Wormwood (Artemisia absinthium), Neem (Azadirachta indica), Barberry (Berberis vulgaris), False unicorn (Chamaelirium luteum), and Goldthread (Coptis chinensis) are being used for the treatment of acne.[56,57] These agents are found to have anti-inflammatory, moisturizing, and soothing properties.[22]

Expert opinion

For herbal preparations, substantiating data are poor; A. vera as a soothing agent may have some acceptance. Sulfur is used for back acne ½ h before bath, but it is not prescribed for facial acne.

Other Suggestions/Recommendations by Experts

Postinflammatory hyperpigmentation

PIH, also known as acne hyperpigmented macule, is an acquired hypermelanosis that occurs due to inflammation or injury to the cutaneous and can affect all types of skin. It mainly affects the skin color of patients and is widespread in people with darker skin. Basically, PIH is observed in the areas of acne papules, pustules, and nodules. Moreover, the intensity of PIH is based on the severity of inflammation and the type of skin.[59,60]

Expert opinion on postinflammatory hyperpigmentation

Sunscreen and removal of triggering factors should be implemented in all patients. Hydroquinone (2/4%) or triple-agent therapy (hydroquinone/tretinoin/fluocinolone), kojic acid and Vitamin C, azelaic acid, topical retinoids (adapalene/tretinoin/tazarotene) are used as the first-line therapy. Chemical peels (glycolic acid, salicylic acid) are recommended as the second-line therapy while laser therapy can be considered as the third-line therapy. These therapies are used along with regular antiacne treatment. The duration of treatment is variable; most patients respond 6–8 weeks after the therapy. Although skin lighting is an additional advantage with azelaic acid and topical retinoids, tolerability (irritation and dryness) limits their use; concerns more with Indian skin.

Face wash

Face washes used with retinoids should be a mild cleanser. Cetyl, stearyl alcohol should be used for mild cleansing property without exfoliative/acidic component. BPO cleansers and foams may be used in truncal acne. For acne maintenance, salicylic acid (2%) is the most preferred, whereas glycolic acid (1%) can be used as an exfoliator, but it may increase irritation. A 2-min contact time for face wash is advised.

Application do's and don’ts

Azelaic acid, glycolic acid, retinoids, plain BPO, and BPO-retinoid combination should be applied on full face, whereas antibacterials and their combination with BPO should be applied on lesions. Massaging and rubbing are not recommended. Gels are preferred over creams. Creams may be used in very dry weather (winter) or in case of skin dryness in response to retinoids. Moisturizer (noncomedogenic, nongreasy, nonsticky, and nonfragrant) should be applied after face wash on dry face, twice daily, whereas antidandruff shampoo has been recommended to be used twice weekly. Some miscellaneous points discussed by experts are presented in Figure 1.

Figure 1.

Miscellaneous recommendation(s) by experts

Management of Acne using Oral Agents

Isotretinoin (retinoid)

Currently, isotretinoin is the only oral retinoid available in India for the treatment of acne. Isotretinoin targets the four major factors involved in the mechanism of acne owing to the following effects, viz., stabilizing the follicular desquamation, suppressing the sebum production, preventing the P. acnes growth, and allowing anti-inflammatory action [Tables 2 and 6].[7,19,60]

Table 6.

Studies focussing on oral therapy for management of acne

Expert opinion

Although the literature recommendation is for severe nodular acne, in real-life practice, isotretinoin is used earlier in the treatment of acne (moderate-severe). A cumulative dose of 120–150 mg/kg isotretinoin is the best treatment regimen for moderate to severe acne. If patients relapse (0.5–1 mg/kg) after achieving target cumulative dose (120–150 mg/kg), repeat cycle should be given at a double dose (1–2 mg/kg). Overall, low-dose regimens (0.3–0.4 mg/kg) are economical and have better patient acceptance. Due to early response or improvement after starting isotretinoin, patients may not come back for follow-up and stop therapy on their own leading to relapses as cumulative required dose is not reached.

Macrocomedonal flare-up is observed in 20%–30% cases during isotretinoin treatment and should be handled with patient counseling and using a low-dose isotretinoin or addition of pulse dose of azithromycin. It lasts for almost 4–5 weeks and usually does not require tapering or stopping the drug (continuing the same dose). Flare-ups may also be managed with an initial short course of oral corticosteroids. Association of isotretinoin with depression and suicidal tendency is controversial and not proved; however, cautious use is advised in vulnerable population. Concomitant use of laser therapy and isotretinoin in Indian patients may be acceptable.

Antibiotics

Oral antibiotics are generally preferred in moderate to severe inflammatory acne.[9] They are found to possess antimicrobial as well anti-inflammatory properties.[7,24,61] Likewise topical antibiotics, oral antibiotics should also be given in combination with other agents to minimalize the bacterial resistance and enhance treatment outcomes. Generally, they are prescribed in combination with topical retinoids or BPO [Tables 2 and 6].[60,61]

Expert opinion

The management of acne should focus on the treatment of inflammation which supports the use of oral antibiotics in acne. Antibiotics should be used till the inflammation is visible. Afterward, the patients should be managed with isotretinoin.

Mild acne/Grade I should be treated with topical agents such as BPO and retinoids. A 3-month low-dose oral antibiotic treatment (to reduce microbial resistance) can be given to patients if they do not respond to topical agents. Combination of isotretinoin at a higher dose (20–30 mg) and doxycycline is contraindicated (due to risk of pseudotumor cerebri, hair fall, and benign intracranial hypertension). Combination of isotretinoin and azithromycin is preferred in case of Grade III or IV or severe papulopustular acne.

Minocycline seems to far best in terms of least resistance and efficacy; however, reliable evidence does not support its superiority or benefits in acne-resistant to other therapies. Moreover, dose ambiguity, unpredictable safety (risk of phototoxic vestibulotoxic, autoimmune, and hypersensitive reactions), and inconsistent safety benefits of minocycline modified-release (MR) formulations do not substantiate the minocycline use as the first-line drug in acne treatment.

Minocycline and doxycycline are seen to have comparable efficacy. Although gastric intolerance is higher for doxycycline, this can be reduced with enteric-coated or double-scored tablets or using staggered dosing. Low dose doxycycline (subantimicrobial dose 40 mg MR) has been used in treatment of acne and found to prevent development of resistant strains.

Lymecycline is a new drug with low antimicrobial resistance and can show significant benefits in acne treatment. However, it is not used as the first line of therapy due to price and availability issues. Levofloxacin can be used as an anti-acne oral antibacterial due to lowest resistance; however, its anti-inflammatory action is not established.

In case of pregnant women, azithromycin alone is prescribed with or without topical agents. A 3-day course (Friday, Saturday, and Sunday) per week for 6–8 weeks is the best azithromycin regimen (due to 96 h half-life of azithromycin).

Pulse clarithromycin therapy (250 mg twice daily) for 7 days (repeated after a gap of 10 days) has been used in isolated case reports in patients with moderate to severe acne that are ineffective to doxycycline, minocycline, and erythromycin treatment regimen.[62]

BPO in combination with oral antibiotics is a beneficial therapy as it reduces the dependence on systemic agents and further prevents the development of P. acnes resistance.[61,63]

Antiandrogen therapy

Androgens play a key role in the development of acne vulgaris through the induction of sebum production.[5] Therefore, antiandrogenic therapies can be useful for the management of female patients with moderate to severe acne. The contraceptive hormones have a role in reducing the androgen-induced sebum production. It enhances the production of sex hormone-binding globulin, thereby decreasing the free testosterone (biologically active) levels in women. Contraceptives are preferred in the treatment of hormone-related acne; progestins are particularly recommended despite their no androgen activity [Tables 2 and 6].[64,65,66]

Expert opinion

Females <14 years or >35 years should be treated with antiandrogens after an opinion of endocrinologist/gynecologist. Oral contraceptives (OCs) are must in women with high androgens and are added to regimen to regularize the menstrual cycle. Women with polycystic ovary syndrome, premenstrual flares, and other clinical signs should be prescribed with antiandrogen therapy (mainly cyproterone) in combination with OCs. Spironolactone is not used in acne because of less role/low evidence of sebocytes in acne. However, in patients with high androgens or with late-onset acne (above 40 years of age), spironolactone can be prescribed as monotherapy in low dose. OC and spironolactone should be tapered down in terms of dose to avoid hair fall. Flutamide is not used because of the associated AEs.

Miscellaneous agents

Oral corticosteroids

Oral corticosteroids are used in cases with late-onset hyperandrogenism (up to 6 months).[67,68] In case of severe acne, low-dose oral corticosteroids along with low-dose isotretinoin are used.[69,70] Oral corticosteroids are generally used as a 2–3-week course (0.5–1.0 mg/kg/day methylprednisolone) without tapering down. Low dose of isotretinoin (0.25 mg/kg/day) in combination with oral corticosteroids should be used for 2–3 weeks after which oral corticosteroids should be stopped (over the next 6 weeks), followed by continued isotretinoin at a dose of 0.25 mg/kg/day depending on the condition of the patient.[71]

Expert opinion

Oral corticosteroids should be used in late-onset hyperandrogenism (up to 6 months). They should be used as a 2–3-week course (20 mg prednisolone or 16 mg methylprednisolone) without tapering down. Low dose of isotretinoin (10–20 mg) in combination with oral corticosteroids should be used for 2–3 weeks after which oral corticosteroids should be stopped followed by continued isotretinoin at a dose of 20 mg. Prednisolone is recommended for premenstrual flares and dexamethasone in cases with congenital adrenal hyperplasia.

Diet

The diet with high glycemic content (milk/dairy product) plays a crucial role in the development of acne and relates to longer duration/persistence of acne.[72] The underlying reasons may be due to the presence of hormone/bioactive molecule in the skimmed milk or insulinotropic effect of milk protein which elevates the serum level of insulin and insulin-like growth factor-1.[73] Further, hyperglycemic diet causes reduction in the levels of adiponectin, which results in upregulation of pro-inflammatory cytokines and downregulation of anti-inflammatory cytokines.[74,75,76,77] It is also responsible for the rise in oxidative stress and decline in serum level of antimicrobial peptide, both of which results in triggering the comedogenesis and eliciting the inflammation.[78,79,80] Zinc can be used as an add-on therapy due to its sebosuppressive activity.[81] Omega fatty acids are used as individualized treatment option due to anti-inflammatory or antioxidant effects.[82]

Specific Acne Allied Disorders

Acne inversa

Acne inversa (also called hidradenitis suppurativa) is a chronic inflammatory disorder of the regions of apocrine gland (axillary and anogenital).[83] Antibiotics, antiandrogen, and retinoids are useful only in exacerbations of the disease or as the perioperative treatment.[84]

Acne exocriee

Some acne patients develop the habit of picking their skin (neurotic or psychogenic problem) known as acne excoriee.[85] It can be managed with serotonin reuptake inhibitor antidepressant, a cognitive behavioral method that may provide benefits to such patients.[86]

Gram-negative folliculitis

GNF is caused due to intercession and substitution of Gram-positive flora of acne affected skin by Gram-negative bacteria. The patients with acne or rosacea who are on prolonged treatment with systemic antibiotics may develop GNF. It is generally noticeable in patients after 3–6 months of ineffective prolonged therapy with oral antiacne antibiotics. Oral isotretinoin (0.5–1 mg/kg daily for 4–5 months) is the most effective cure for GNF in acne or rosacea.[87]

Conclusion

The four well-known pathogenic factors responsible for acne are generally managed by topical as well as oral therapies. Although topical therapy is the mainstay as well as the first-line treatment prescribed for patients suffering from noninflammatory comedones to moderate inflammatory acne, oral therapies are preferred in cases with severe nodular acne. An early initiation of therapy is directly proportional to effective therapeutic outcomes. However, the complexity of the disease as well as interpatient differences warrants combination of various agents to be followed. There is a need to develop a daytime applicable dermato-cosmetic product for both, active acne and maintenance therapy, with mattifying effects. Incorporation of cosmetic daily regimen would result in affluent application of product and improved patient adherence which would further make the clinicians and patients overlook the cost involved in combined therapies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

What is new?

First Indian Expert Opinion based on clinical evidence and clinical expertise which provides a practical module for in clinic use addressing;

• Place and positioning along with the rationality of all available topical and oral acne therapies in India.

• Provides insights on combination vs monotherapy their class, strength comparison along with formulation innovations.

• Particularized role of adjunctive therapies (face wash, moisturizer and miscellaneous topical therapy) along with their do's and don’ts in acne management.