At the 2025 New Wave Dermatology meeting in Aventura, Florida, Shanna Miranti, MPAS, PA-C, from Riverchase Dermatology presented key insights on acne treatment strategies, emphasizing the importance of addressing all four pillars of acne pathogenesis simultaneously.
The Four Pillars of Acne Pathogenesis
Miranti highlighted that effective acne management requires targeting four fundamental pathogenic factors:
- Excess sebum production
- Follicular hyperkeratinization
- Inflammation
- Cutibacterium acnes
"What's most important is to make sure that we as providers are treating as many of these 4 pillars as possible," Miranti explained. She compared these pillars to the legs of a table, noting that a comprehensive approach provides the most stable results: "Things do work on a tripod quite well, but of course, the 4 legs or 4 pillars are going to give you the most sturdy balance."
Updated Treatment Guidelines
The American Academy of Dermatology revised their acne guidelines in 2024, updating their previous 2016 recommendations. Key changes include limiting systemic antibiotic use to prevent resistance development and recommending concomitant benzoyl peroxide with antibiotics.
Since 2019, the FDA has approved several new acne medications, expanding the therapeutic arsenal:
- Aklief (trifarotene, a topical photostable retinoid)
- Amzeeq (topical minocycline)
- Arazlo (tazarotene 0.045%, a topical photostable retinoid)
- Seysara (saracycline, oral antibiotic)
- Winlevi (clascoterone, a topical anti-androgen)
- Twyneo (tretinoin 0.1%/ BPO 3%)
- Cabtreo (Clindamycin 1.2%, Adapalene 0.15%, BPO 3.1%)
With these expanded options, Miranti advised against defaulting to generic tretinoin prescriptions without considering the full spectrum of available therapies.
Pillar-Specific Treatment Approaches
Excess Sebum Production
For this pillar, Miranti noted that clascoterone (Winlevi) stands as the only topical therapy that effectively addresses excessive sebum production through its action as an androgen receptor blocker.
"If we can stop the sebum production and block those androgens, we will have a lot less acne in the future," she stated.
Systemic options for controlling sebum include:
- Isotretinoin
- Spironolactone (50 mg QD-BID)
- Oral contraceptive pills
Follicular Hyperkeratinization
Retinoids remain the gold standard for addressing this pillar, with options including:
- Topical: tretinoin, adapalene, tazarotene, and trifarotene
- Other agents: azelaic acid
- Systemic: isotretinoin
Miranti emphasized the importance of counseling patients about potential retinoid-induced irritation and the need for proper moisturization to protect the skin barrier.
Inflammation
Multiple options exist for managing the inflammatory component:
- Topical: retinoids, antibiotics, dapsone, azelaic acid, and clascoterone
- Systemic: isotretinoin, doxycycline, minocycline, sarecycline, spironolactone, and oral contraceptive pills
"The earlier we can stop inflammation, the better we can prevent scarring for our acne patients," Miranti emphasized.
Cutibacterium Acnes
Treatment options include:
- Topical: clindamycin with benzoyl peroxide, minocycline 4%
- Systemic: sarecycline, doxycycline, minocycline, and tetracycline (all to be used alongside benzoyl peroxide)
When to Transition to Systemic Therapy
Miranti outlined specific scenarios warranting a shift from topical to systemic treatments:
- When topical therapy fails to control new active breakouts
- When breakouts follow a hormonal pattern
- During acute situations (stress, sports) causing worsening inflammatory lesions
- When any scarring is present
2025 Treatment Trends
In a separate discussion on 2025 trends, Miranti advocated for simplicity in treatment regimens. "What's truly important when treating acne in 2025 is to keep things simple," she said. "We don't want to create very complex regimens for our patients because, typically, the more medicines that we prescribe for patients, the less they're going to do and the less they will be compliant with."
She recommended starting with once-daily monotherapy when possible and highlighted emerging technologies such as 1726-nanometer acne lasers. Two such lasers have received FDA clearance: AVICLEAR (March 2022) and ACCURE, both targeting sebaceous glands to reduce sebum production and inflammation.
Other notable trends include:
- Early intervention for post-inflammatory hyperpigmentation and scarring
- Setting complete skin clearance as a treatment goal
- Countering misinformation spread through social media platforms like TikTok
Rosacea and Combination Approaches
For patients with both acne and rosacea, Miranti stressed the importance of tailored skincare recommendations that don't compromise the skin barrier. Interestingly, she noted that certain formulations of benzoyl peroxide, traditionally avoided in rosacea patients, have proven effective when properly formulated.
"One interesting overlap is benzoyl peroxide," Miranti said. "For years, I did not believe benzoyl peroxide should ever be used on a rosacea patient until a [benzoyl peroxide] therapy came out and was specifically FDA approved for rosacea a number of years ago."
Isotretinoin remains the only treatment that effectively targets all four pillars of acne pathogenesis, making it the current gold standard for comprehensive acne management. However, with the expanding array of targeted therapies, dermatology providers now have more options to create individualized treatment plans that address multiple pathogenic factors simultaneously.
