Update of the EuroGuiDerm evidence-based guideline for the treatment of acne.

<h2 id="background">Background and Methods</h2><ul><li>This consensus-based guideline updates the 2016 EuroGuiDerm acne guideline. Recommendations were graded by strength (Table 1), incorporating efficacy, safety, patient preference, and level of evidence. Three key clinical questions (KQ) were prioritized for this targeted update:<ul><li>KQ1: Isotretinoin vs. systemic antibiotics: indications and optimal duration of systemic antibiotic therapy.</li><li>KQ2: Role of hormonal therapy and spironolactone.</li><li>KQ3: Positioning of new topicals: trifarotene and clascoterone.</li></ul></li><li>Additional updates: benzoyl peroxide (BPO) safety, systemic antibiotic selection, pregnancy considerations, isotretinoin dosing, and hormonal antiandrogenic contraceptives/spironolactone.</li></ul>Table 1: Strength-of-recommendation grading<img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791810285240-581eb91e3359-Strength-of-recommendation.webp" alt="Strength-of-recommendation grading" width="1044" height="242"><h2 id="Induction">Induction Therapy: Summary of Recommendations</h2>Table 2 shows, for each acne severity type, which treatments are graded at each strength (plus female-specific alternatives). For example, topical adapalene + BPO is high-strength for mild-moderate disease, while systemic isotretinoin is the sole high-strength option for both severe categories.Table 2: Recommended treatments by acne type and strength<img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791810441553-6fbaedf474d8-Recommended_treatments_by_acne_type_and_strength.webp" alt="Recommended treatments by acne type and strength" width="2183" height="875">Key notes: Adapalene is preferred over tretinoin/isotretinoin among topical retinoids; trifarotene carries a medium-strength recommendation but lacks head-to-head data. Clindamycin/tretinoin fixed combination (f.c.) was downgraded to medium strength due to antibiotic-resistance concerns. Doxycycline and lymecycline are preferred antibiotics (see General Considerations).<h3 id="Treatment">Treatment of Comedonal Acne</h3><ul><li>Due to lack of direct evidence, strength of recommendation was capped at medium for all options. Topical retinoid = medium; topical azelaic acid/BPO = low.</li><li>Systemic isotretinoin may rarely be considered (off-label) in resistant severe comedonal ("sand-paper") acne. Recommendation approved with only 60% agreement.</li></ul><h3 id="treatment-of-papulopustular-acne">Treatment of Papulopustular Acne</h3><ul><li>Mild-moderate: High-strength options are topical adapalene + BPO (f.c.) or BPO + clindamycin (f.c.).</li><li>Severe papulopustular/moderate nodular: Systemic isotretinoin is the sole high-strength option; systemic antibiotic + topical combinations (adapalene, trifarotene, azelaic acid, adapalene + BPO) are medium strength (Table 3).</li></ul>Table 3: Severe Papulopustular / Moderate Nodular Acne Treatment Recommendations<img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791810585712-1bdc1f2f5f2b-Severe_Papulopustular.webp" alt="Severe Papulopustular / Moderate Nodular Acne Treatment Recommendations" width="2055" height="1067">BPO: Benzoyl peroxide, IPL: Intense Pulsed Light, PDT: Photodynamic Therapy, UV: Ultraviolet, f.c.: fixed combination, top.: topical use, syst.: systemic use<h3 id="treatment-of-severe-nodularconglobate-acne">Treatment of Severe Nodular/Conglobate Acne</h3><ul><li>Systemic isotretinoin remains the only high-strength recommendation (Table 4).</li><li>Medium-strength alternatives: systemic antibiotic + azelaic acid, or + adapalene + BPO (f.c.).</li><li>Systemic corticosteroids can be considered as adjuncts in fulminant/highly inflammatory conglobate disease.</li></ul>Table 4: Severe Nodular / Conglobate Acne Treatment Recommendations<img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791810688852-2ffb13df55c5-Severe_Nodular.webp" alt="Severe Nodular / Conglobate Acne Treatment Recommendations" width="2062" height="917">BPO: Benzoyl peroxide, IPL: Intense Pulsed Light, PDT: Photodynamic Therapy, UV: Ultraviolet, f.c.: fixed combination, top.: topical use, syst.: systemic use<h2 id="General">General Considerations</h2>Choice of type of topical retinoid<ul><li>Adapalene is preferred over tretinoin and isotretinoin. Insufficient head-to-head data exist for trifarotene vs. other retinoids; trifarotene trials focused on truncal acne, showing efficacy vs. placebo.</li></ul>Considerations on the safety of benzoyl peroxide (BPO)<ul><li>Concerns arose regarding benzene degradation of some over-the-counter BPO products at 37–70°C and a theoretical acute myeloid leukaemia (AML) risk. However, two large studies found no increased AML prevalence or risk of lymphoma/leukaemia/other internal cancers among BPO users vs. matched controls. Existing data support BPO safety in acne treatment.</li></ul>Considerations regarding clascoterone<ul><li>Marketing authorization (Winlevi) was submitted to the European Medicines Agency (EMA) in October 2023. The Committee for Medicinal Products for Human Use (CHMP) initially rejected it (April 2025) citing insufficient benefit–risk demonstration in adolescents (12–17y); after re-examination, CHMP issued a positive opinion (25 August 2025), and the European Commission granted EU marketing authorization on 21 October 2025 for acne vulgaris in adults and facial acne in adolescents 12–&lt;18y. As approval postdated the consensus conference and clinical experience was lacking, clascoterone was not yet integrated into the treatment algorithm.</li></ul>Choice of type of systemic antibiotic<ul><li>Doxycycline and lymecycline are preferred over minocycline and tetracycline. Azithromycin: EMA committee (2025) recommended against its use in acne, citing insufficient efficacy evidence and an unfavourable benefit–risk ratio regarding antimicrobial resistance.</li></ul>Recommended Treatment Duration with Systemic AntibioticsTable 5 shows the recommendations for systemic antibiotic duration.Table 5: Systemic antibiotic duration recommendation<img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791810792671-e9c5bd4266ab-Systemic_antibiotic.webp" alt="Systemic antibiotic duration recommendation" width="2232" height="315"><h2 id="Treatment">Treatment During Pregnancy</h2>Table 6 lists the acne treatment options in pregnancy.Table 6: Acne treatment options in pregnancy<img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791810881819-9a37659339d2-Acne_treatment.webp" alt="Acne treatment options in pregnancy" width="2217" height="321"><ul><li>Erythromycin, though excluded from the general population due to high resistance rates, remains an option in pregnancy where alternatives are limited.</li><li>Systemic corticosteroids may be considered for highly inflammatory conglobate acne. Systemic isotretinoin is strongly contraindicated in pregnancy and in women trying to conceive owing to high teratogenic risk; effective contraception is mandatory.</li></ul><h2 id="Considerations">Considerations on Isotretinoin and Dosage</h2>Table 7 presents the isotretinoin dosing considerations.Table 7: Isotretinoin dosing recommendations<img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791810967772-b35581fd03fb-Isotretinoin_dosing.webp" alt="Isotretinoin dosing recommendations" width="2358" height="341"><ul><li>No evidence-based cumulative dose threshold for relapse prevention/retrial could be established.</li><li>Clinical practice generally continues therapy ≥6 months with ≥1–2 months lesion-free before discontinuation. Given inter-brand pharmacokinetic variability, the same product should be used throughout treatment.</li><li>An initial acne "flare-up" is commonly observed after isotretinoin initiation. In fulminant conglobate acne, isotretinoin + systemic glucocorticoid (prednisone 0.5–1 mg/kg/day for 4–5 weeks) may be considered.</li></ul>Risk of Antibiotic Resistance<ul><li>Systemic antibiotics should generally be capped at 3 months.</li><li>Prolonged topical/systemic antibiotic courses increase resistance risk in Cutibacterium acnes, staphylococci and the broader skin/mucosal microbiome, with potential spread from commensal to pathogenic species. Even sub-minimum-inhibitory-concentration (sub-MIC) antibiotic exposure can select for high-level resistance; a single broad-spectrum agent may co-select multi-drug resistance.</li></ul>Use of Hormonal Antiandrogenic Contraceptives or Other Combined Hormonal Contraceptives<ul><li>Combined oral contraceptives (COCs) contain oestrogen (usually ethinyl estradiol [EE], or newer 17β-estradiol/oestradiol valerate/estetrol) plus a progestin.</li><li>Early-generation (1st–3rd) progestins are testosterone-derived and may worsen acne via androgenic activity; newer-generation progestins have antiandrogenic/anti-mineralocorticoid properties, reducing acne/hirsutism but carrying higher venous thromboembolism (VTE) risk.</li><li>Hormonal antiandrogenic contraceptives/COCs can be considered as adjunctive therapy in moderate–severe papulopustular, nodular or conglobate acne in females, particularly when contraception is also desired or acne relates to hormonal/androgen excess; not recommended for comedonal/mild-moderate papulopustular acne unless contraception or gynaecological indications are primary.</li></ul>Use of Spironolactone<ul><li>Spironolactone (antiandrogenic; off-label for acne in Europe) is included based on emerging efficacy evidence, particularly beneficial in hormonally-driven acne (e.g., polycystic ovary syndrome [PCOS]-associated).</li><li>Dosing: start 50 mg/day, increasing to 100 mg/day after 4 weeks if tolerated (monitor for breast tenderness, fatigue, headache, dizziness/hypotension).</li></ul>Effect onset is gradual; continued improvement observed over 6 months in trials. No routine laboratory monitoring required in healthy patients &lt;45 years; individual factors may warrant exceptions.<h2 data-section="conclusion" id="Disclaimer">Disclaimer</h2>This scientific information content is facilitated by Mega Lifesciences and is intended for healthcare professionals for their reading and update. Although care has been taken in compiling and checking the information, the facilitator is not responsible, or in any way liable for any errors, omissions or inaccuracies in this content whether arising from negligence or otherwise, however, or for any consequences arising therefrom.

2db4985c0d73 DERMATOLOGY UPDATE ISSUE 5 2026

<ul><li><a href="#background">Background and Methods</a></li><li><a href="#Induction">Induction Therapy: Summary of Recommendations</a></li><li><a href="#General">General Considerations</a></li><li><a href="#Treatment">Treatment During Pregnancy</a></li><li><a href="#Considerations">Considerations on Isotretinoin and Dosage</a></li><li><a href="#Disclaimer">Disclaimer</a></li></ul>

Update of the EuroGuiDerm evidence-based guideline for the treatment of acne.

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