Acne Treatment Options: From Drugstore to Prescription, Explained

There are more proven acne treatments than most people realize, and they sort roughly by severity. Mild acne usually starts with topicals such as benzoyl peroxide, adapalene or a combination product. Moderate acne often adds a prescription topical, a short course of an oral antibiotic, or hormonal therapy for women. Severe, scarring or stubborn acne is where isotretinoin comes in. That ladder comes straight from the 2024 American Academy of Dermatology (AAD) guideline and the UK’s NICE acne guideline (NG198). Below I map every option, what the evidence says, and where to read more.

How do doctors decide which acne treatment to use?

Mostly by severity, scarring risk and how much the acne is affecting your life. NICE gives a handy rule of thumb. It counts acne as mild to moderate with any number of blackheads and whiteheads, up to 34 inflammatory spots and up to 2 nodules, and as moderate to severe with 35 or more inflammatory spots or 3 or more nodules (NICE NG198). If you’re not sure which type of spot you have, my guide to the types of acne walks through it.

The AAD guideline was built from a systematic review using the GRADE method, and it ended up with 18 evidence-based recommendations and 5 “good practice” statements (Reynolds et al., JAAD 2024). Each recommendation is labelled “strong” or “conditional.” A conditional rating isn’t a thumbs-down. As one of the guideline authors told Healio, “a conditional recommendation does not mean they should not be used.” It usually means the evidence was thinner, or cost and side effects make the trade-off more personal.

What does the 2024 AAD guideline recommend?

Here’s the whole map in one table. The strong and conditional ratings are from the guideline’s published abstract and the AAD’s own highlights page.

The guideline’s good-practice statements matter just as much as the list: combine topical treatments that work in different ways, limit oral antibiotic use, pair any oral antibiotic with benzoyl peroxide and other topicals, and consider steroid injections for large, painful individual lumps (AAD guideline highlights).

What can you try from the drugstore first?

Three proven ingredients are sold without a prescription in the US: benzoyl peroxide, salicylic acid and adapalene 0.1% (sold as Differin) (AAD).

• Benzoyl peroxide kills acne bacteria and, importantly, doesn’t breed resistance the way antibiotics can (Grada and Bunick, Cutis 2025). It’s strongly recommended.
• Adapalene is a retinoid that unclogs pores and helps prevent new spots. My how to start adapalene guide covers the irritation phase.
• Salicylic acid is gentler and mostly helps clogged pores. The AAD rated the evidence for it as low, hence a conditional recommendation (MDedge).

Combining works better than going solo. In a large network meta-analysis of 40 trials and 18,089 people, benzoyl peroxide plus adapalene was ranked the most effective topical option. In participant-reported improvement, 54% improved on that pairing versus 35% on benzoyl peroxide alone, though more people stopped using it (25% versus 16%) (Stuart et al., BJD 2021). The authors rated overall confidence in the evidence as low, which is worth keeping in mind. For a starter plan, see my simple acne routine or the teen routine on a budget. If you’re weighing the two classic ingredients, read salicylic acid vs benzoyl peroxide.

Which prescription creams and gels are options?

When OTC products aren’t enough, prescription topicals add more firepower:

• Stronger retinoids such as tretinoin, tazarotene and trifarotene. MDedge’s summary of the guideline reports that people using topical retinoids were more likely to improve at 12 weeks (risk ratio 1.57) (MDedge). My retinol vs retinoids explainer untangles the names.
• Topical antibiotics, mainly clindamycin. They work, but the guidelines agree they shouldn’t be used on their own because of resistance (NICE).
• Fixed-dose combinations that put two or three ingredients in one tube, such as clindamycin plus benzoyl peroxide, adapalene plus benzoyl peroxide, or a triple gel of clindamycin, adapalene and benzoyl peroxide. NICE lists three fixed combinations as first-line options for mild to moderate acne: adapalene with benzoyl peroxide, tretinoin with clindamycin, and benzoyl peroxide with clindamycin, each used for 12 weeks (NICE NG198).
• Azelaic acid, useful when dark marks are also a problem, and a reasonable option in pregnancy (AAD).
• Clascoterone, a cream that blocks androgen hormones in the skin. MDedge reports the evidence was rated high, but the recommendation was conditional largely because of cost (MDedge).

When are oral antibiotics used?

For moderate to severe inflamed acne, a tetracycline-class antibiotic is a common next step. The AAD gave doxycycline a strong recommendation, while minocycline and sarecycline got conditional ones (Reynolds et al.). Part of the reason is safety: minocycline carries rare but serious side effects, including dizziness-type problems, autoimmune hepatitis and drug-induced lupus (Healio).

The rules around antibiotics are about limiting resistance. NICE says not to use an oral antibiotic on its own, not to combine a topical and an oral antibiotic, to review at 3 months, and not to go beyond 6 months (NICE NG198). The AAD says to pair oral antibiotics with benzoyl peroxide (AAD). Oral antibiotics can treat moderate-to-severe pimples but not nodular acne, according to the AAD’s patient guide.

What about hormonal treatments?

For women, two hormonal options are recommended conditionally by the AAD: combined oral contraceptives and spironolactone (Reynolds et al.). Some pills are FDA-approved for acne, and the AAD says improvement typically shows up within 2 to 3 months (AAD). I dig into the pill in birth control for acne, and the anti-androgen tablet in spironolactone for acne. Both are relevant if your pattern looks like adult hormonal acne. Spironolactone can cause serious birth defects, so it’s not an option during pregnancy (AAD).

When is isotretinoin the right call?

Isotretinoin (formerly sold as Accutane) is the heavy hitter. The AAD says it “often results in prolonged clearance of acne, which can be permanent for some patients” (AAD). The AAD strongly recommends it for severe acne, acne causing psychosocial burden or scarring, and acne that has failed standard treatment (Healio). NICE reserves it for severe forms such as nodulo-cystic acne or acne with a risk of permanent scarring, after standard treatment has been tried (NICE NG198).

It comes with real requirements. It can cause severe birth defects, so in the US everyone taking it is enrolled in the iPLEDGE safety program, and people who can get pregnant need contraception and pregnancy tests (FDA-approved label). A course typically lasts four to five months (AAD). If you’ve got deep, painful cystic acne, it’s worth asking about sooner rather than later, since scarring is permanent.

Do procedures like lasers, peels and injections help?

Procedures are add-ons, not replacements. The AAD says lasers and lights can reduce acne but “rarely can these treatments alone clear acne,” and most people need a series of sessions (AAD). A Cochrane review of 71 trials found that “high-quality evidence on the use of light therapies for people with acne is lacking” (Barbaric et al., Cochrane 2016). None of the 2024 AAD guideline’s recommendations in favor of a treatment involve lights, lasers or peels, and its one recommendation against was adding pneumatic broadband light to adapalene 0.3% gel (AAD highlights).

Two procedures have clearer roles. A steroid injection into a single large, painful nodule is endorsed as good practice (AAD highlights). And once active acne is under control, procedures come into their own for scars. See acne scar treatments and chemical peels for acne.

How long should you give a treatment before switching?

Longer than feels comfortable. The AAD says it takes at least 6 to 8 weeks before breakouts start to thin out (AAD), and NICE builds its plan around a 12-week course followed by a review (NICE NG198). If a first-line option fails, NICE suggests trying a different one; if two full courses fail, it suggests considering referral to a dermatologist. After clearing, NICE suggests maintenance, for example adapalene with benzoyl peroxide, because acne tends to come back. My how long acne treatments take page has realistic timelines, and retinoid purging explains the early flare some people get.

Frequently asked questions