Differentiating and Treating Acneiform Conditions

About 60% of visits for skin conditions are made to primary care providers, so it is important to understand the differences between the most common forms of acneiform conditions and how to treat each of them.

During her session at Practical Updates in Primary Care 2021, Kim O’Connor, MD, discussed differentiating between acne vulgaris, acne rosacea, and periorificial dermatitis and outlined the treatment options. Dr O’Connor is an associate professor of medicine in the Division of General Internal Medicine at the University of Washington School of Medicine in Seattle, Washington.

Differentiating Acneiform Conditions

Consider the age of presentation, distribution of skin findings, and clinical manifestations, Dr O’Connor said.

Acne vulgaris usually starts in adolescence; most commonly distributes on the face, shoulders, and torso; and includes multiple clinical manifestations.


Acne vulgaris


Acne rosacea usually presents in patients aged 30 to 50 years, most commonly distributes on the face, and is a chronic condition.

Acne rosacea


Periorificial dermatitis usually presents in women aged 18 to 40 years, commonly presents around the mouth or eyes, and has various clinical manifestations.


Periorificial dermatitis


Choosing Therapies

Consider the delivery vehicle, not just the medication, Dr O’Connor said. For instance, gels are drying vehicles because of the high alcohol content and are recommended for the face, scalp, and hairy areas. Lotions also dry the condition but are used for oozing lesions and hairy areas only. Creams are more lubricating than lotions but have some drying effects and are used on cosmetic and intertriginous areas. Creams vanish into the skin, and occlusion increases potency. Ointments are lubricating and occlusive, are most potent, and are recommended for dry, thick, hyperkeratotic lesions. Finally, foams, mousse, or shampoo regimens are only recommended for use on the scalp.

Topical retinoids are considered first-line therapies. Over-the-counter benzoyl peroxide, sulfacetamide-sulfa, and tea tree oil can also be used. Prescription dapsone gel and azelaic acid are also recommended—the latter is the best option for women who are pregnant, Dr O’Connor said.

Topical and Oral Therapies

Topical retinoids are the most common treatment option for acneiform conditions but should be avoided in women who are pregnant. Dr O’Connor went on to explain that tretinoin, adapalene, and tazarotene are the most effective. Tretinoin is the least expensive and has the most potencies. Adapalene may have the fewest adverse events and is now available over the counter in a 0.1% gel. Tazarotene may be the most potent but is the least tolerated.

It is important to remind your patients that treatment may take several months to see benefit, Dr O’Connor said.

For inflammatory acne, add a topical antibiotic—clindamycin is recommended—to the retinoid therapy and benzoyl peroxide to reduce antibiotic resistance. Switch to an oral antibiotic when severe acne is present or when topical antibiotics show no response after several months.

For acne rosacea, counsel patients about avoiding sun exposure, gentle skin cleansing, frequent moisturizer use, and avoid irritating topical products and triggers.

For periorificial dermatitis, steroids can improve symptoms, but as soon as steroids are stopped, a flare often occurs. Therefore, stop or taper the topical steroids and start topical and/or oral treatments while tapering off steroids. Topical calcineurin inhibitors are the most efficacious, but topical or oral antibiotics are also efficacious, Dr O’Connor concluded.

—Amanda Balbi


O’Connor K. Acne, rosacea, and other acneiform conditions. Talk presented at: Practical Updates in Primary Care 2021 Virtual Series; May 13-15, 2021; Virtual