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These are activities that use your work data to ensure quality results.
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
While it’s sometimes still perceived as a harmless condition people just grow out of, acne can have a profound impact—affecting social interactions and performance at school and work. Early, appropriate treatment is crucial, and therapeutic advances are improving outcomes and reducing long-term consequences, says Brisbane dermatologist Dr Shobhan Manoharan, Medical Director of Dermatology Clinics Australia and laser training organisation DermEd, and past Director of Training for the Australasian College of Dermatology, Queensland.
Acne begins with occlusion of the pilosebaceous unit, triggering hyperkeratinisation and inflammation. Cutibacterium acnes then flourish, leading to an inflammatory cascade that can last for months to years.
“And the general principle is that the more inflammatory the acne, the more severe the scarring can be,” Dr Manoharan says.
Skin of colour, sensitive skin, and skin affected by inflammatory disorders like eczema or dermatitis can be more prone to scarring, even without severe inflammation.
“So it is important to pick up acne at an early stage, because acne treated early can short circuit this pathway,” he stresses.
When assessing acne, Dr Manoharan recommends considering its nature, severity, the patient’s skin type, previous treatments and the psychosocial impact—which all help determine the best treatment pathway.
Severe inflammatory disease may warrant early specialist involvement, he adds.
Topical retinoids are a cornerstone of treatment, Dr Manoharan says. They exfoliate the skin, normalise keratinisation, reduce comedones, and probably have a positive effect on the skin’s bacterial composition and inflammation.
“So even if we have patients on systemics, having procedural therapy or energy-based devices, we’ll still have them on some topical retinoids because it helps both acne and acne scarring.”
Acne-specific retinoids like adapalene are preferred, he explains. “They tend to be a bit more fat-soluble, or more specific towards the sebaceous units. We still often use tretinoin as well.”
Benzoyl peroxide also remains widely used and is generally well-tolerated. “And it does reduce your bacterial count and reduces inflammation as well.”
It is often combined with oral antibiotics to reduce bacterial resistance, he adds.
Topical antibiotics have become less popular as monotherapy. Current practice favours combining agents such as clindamycin with benzoyl peroxide, often alongside a retinoid.
Several newer topical treatments are also available, including retinoid trifarotene, which is suitable for facial and truncal acne and may be less irritating than some traditional agents, he says.
Clascoterone, a topical androgen receptor inhibitor, was approved in 2024 for topical treatment of acne vulgaris in patients aged 12 years and above. “It’s a very promising form of treatment for hormonal acne,” Dr Manoharan says. He typically uses it as a daytime therapy in conjunction with a topical retinoid at night. “And it doesn’t irritate; it actually hydrates the skin.”
Tetracyclines and erythromycin remain first-line for treating inflammatory acne, but current guidelines generally recommend that patients should not be on continuous therapy for more than 12 weeks, Dr Manoharan says.
“We always combine it with topical retinoids and/or benzoyl peroxide as well to reduce your risk of antibiotic resistance.”
“And if patients are on antibiotics for 8 or 12 weeks, and they’re really not improving, or they’re getting worse or just grumbling along, they probably need to be upgraded. And you’re probably looking at isotretinoin plus or minus your energy-based devices and physical therapies.”
Isotretinoin is the “medical gold standard” for moderate to severe acne, treatment-resistant disease, early scarring or acne occurring in higher-risk skin types, Dr Manoharan says.
It addresses multiple pathways, including sebum production, inflammation, bacterial proliferation and abnormal keratinisation, he explains.
“And it’s been around since the early 80s. It’s been very well studied.”
However, prescribing practices have changed considerably, with lower-dose regimens now commonly used to improve tolerability, support adherence, and mitigate risk of side effects—which need to be closely monitored and managed, he says.
GPs play an important role in monitoring patients, he says, noting dryness and sun sensitivity are common. Less common but more serious concerns include headaches, visual disturbance, muscle aches and mood changes.
“All of these are less of an issue on smaller doses, and all of these are generally reversible,” he says. “But it’s nice to have multiple people guiding patients through their journey here, especially if they’re younger or naive to medical management.”
When mood changes occur, Dr Manoharan generally assesses whether symptoms are new or pre-existing. A break from treatment for one to two weeks followed by dose reduction is often enough to alleviate them, he says.
“Extremely rarely there are patients who have significant mood changes, especially if they do have a background of significant mental health or psychiatric illnesses. These patients are monitored much more closely, and we have a much tighter red flag system.”
Importantly, isotretinoin is highly teratogenic, and women should not fall pregnant while they are taking it. “So we counsel them before treatment. We do a beta-hCG if that’s appropriate, and we follow through and check up on them as they’re going through treatment.”
“And there’s a one-month washout period after stopping treatment as well,” he emphasises.
Spironolactone can be “extraordinarily useful” for women with adult jawline acne—a type of hormonal acne that predominantly affects females, with a pattern on the jawline and chin, Dr Manoharan says. He notes patients with polyendocrine metabolic ovarian syndrome or features suggestive of androgen excess frequently present with this pattern, often alongside treatment resistance or recurrent acne.
Combined oral contraceptives may also be useful, but Dr Manoharan cautions against solely relying on them. Treatment should be escalated if patients fail to respond within a few months, he advises.
Acne care increasingly involves a combination of medical and procedural treatments, Dr Manoharan says.
Blue and red light therapies can reduce inflammation and bacterial burden, while various types of lasers (e.g. vascular, pigment, Q-switch and picosecond) can disrupt the acne process itself, he says.
An important recent development is the 1726 nm laser, marketed in Australia as AviClear, which selectively targets sebaceous glands in a similar manner to isotretinoin, he says.
It can significantly shorten isotretinoin courses, he adds. “Instead of being on it for 12 to 24 months, you’re on it for three to six months because the isotretinoin deals with sebaceous glands from inside, and this is knocking some off from the outside.”
“We either use it on its own, or in combination with other energy-based devices and medical management.”
Scar management is tailored according to type, colour, depth and skin type, he says. Options include chemical peels, subcision, vascular lasers, picosecond lasers, fractional non-ablative lasers, radiofrequency microneedling and ablative laser resurfacing.
“There’s a gamut of technology that we know is safe to be used even while on Isotretinoin treatment, and even while you have active acne,” Dr Manoharan says.
“Most scars can be improved and a significant number of scars can be improved significantly.”
Treatment costs typically range from a few hundred to a few thousand dollars, he says, stressing the importance of early referral.
“Often if scars are treated early, you can use less aggressive, less invasive means, and the costs will be lower as a result as well.”
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