Acne Treatment Should Evolve With Patients Across the Lifespan

During her presentation at the Masterclass in Dermatology NP/PA Institute, “Systemic Approaches to Acne,” Hannah Rodriguez, MPAS, PA-C, of Pennsylvania Dermatology Group, highlighted how acne treatment should account for changes in disease presentation, hormonal influences, management needs, and psychosocial burden across a patient’s lifespan.

Rodriguez reviewed systemic approaches to acne treatment from infantile disease through adolescence, adulthood, and perimenopause, emphasizing an escalation strategy that considers more than lesion count alone.

Acne has a multifactorial pathogenesis involving follicular hyperkeratinization, Cutibacterium acnes colonization, sebum production, inflammation, neuroendocrine mechanisms, and genetic and nongenetic risk factors.

Its clinical presentation changes with age. Infantile acne is associated with maternal and neonatal adrenal androgens stimulating sebaceous glands and commonly presents with comedones and inflammatory papules. During adolescence, rising adrenal and gonadal androgens contribute to sebaceous gland enlargement, with microcomedones emerging on the forehead and nose. Acne reaches peak prevalence and severity during the teenage years, affecting approximately 35% to 40%.

Adult acne is conventionally defined as disease presenting or persisting beyond age 25. Hormonal acne may be associated with the menstrual cycle, polycystic ovary syndrome, or stress and often concentrates along the jawline and lower face. During perimenopause, declining estrogen can unmask relative androgen effects, contributing to deep, tender lesions along the jawline and chin.

Across age groups, first-line treatments include benzoyl peroxide (BP), topical retinoids, and topical antibiotics, with antibiotics never used as monotherapy. Additional options include clascoterone, salicylic acid, and azelaic acid.

Rodriguez emphasized pairing retinoid and antibiotic therapy with BP to limit resistance. Systemic antibiotics should similarly serve as “a bridge, not a destination,” paired with BP and generally limited to 3 to 4 months.

Hormonal treatments, including oral contraceptive pills and spironolactone, can expand treatment options for adult and older-adolescent patients, although spironolactone remains off label.

Treatment decisions also require family planning considerations. Tazarotene is contraindicated during pregnancy, while topical minocycline is not recommended during pregnancy or lactation. Nonretinoid options are preferred during pregnancy.

For patients with more severe disease, Rodriguez stressed that decisions surrounding isotretinoin should incorporate the broader effects of acne. “Isotretinoin candidacy is about severity, scarring, and psychosocial burden together—not lesion count alone,” she noted.

Rodriguez also emphasized the importance of maintaining a patient-centered perspective throughout treatment: “Don’t forget to have empathy; remember what it was like to have acne, then treat accordingly.”

Reference

Rodriguez H. Systemic approaches to acne. Presented at: Masterclasses in Dermatology NP/PA Institute; September 26–27, 2026; New York City, NY.