Dermatology
Case by Case: Real-World Management of Acne Vulgaris
The publication of this case study was initiated and funded by Glenmark Pharmaceuticals Ltd. It is for healthcare professionals only.
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Disclosure
Disclaimer
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MA-UKEU-WINL-0004 PP-UK-WIN-0343
Keywords
Short summary
UK prescribing information for WINLEVI® ▼ (clascoterone) can be found here.
Clinical cases were originally presented by Natasha Kapur, Consultant Dermatologist at the Hospital of St John & St Elizabeth, London, UK. Kapur has received payments from AbbVie, Almirall, Biofrontera, Galderma, La Roche-Posay, L’Oréal, LEO Pharma, Incyte Corporation, and Glenmark Pharmaceuticals. These interactive case studies were developed with support from Jessica Jinks, Senior Medical Writer, EMJ, London, UK.
These are patient cases and outcomes may not be reflective of clinical studies or real-life circumstances. This includes reference to agents that may be used off-label or for unlicensed indications. The mention of these agents and their uses is intended solely for educational purposes and should not be considered an endorsement or recommendation for their use outside approved indications. Please always consult guidelines and local prescribing information in your country of practice, as information may vary. Consent has been granted for the use of all images within this presentation. Opinions and guidance included in this presentation are those of the speaker. The real-life cases presented used WINLEVI as part of multi-modal treatment.
Acne vulgaris, anti-androgen therapy, eczema, multimodal treatment, nodulocystic acne, polycystic metabolic ovarian syndrome (PMOS).
These case studies examine different presentations of acne vulgaris, including acne unmasked after oral contraceptive pill cessation, breakthrough nodulocystic acne on an aldosterone antagonist, and acne in the context of severe eczema. They highlight the need for personalised assessment, consideration of hormonal drivers, careful use of anti-androgens, and attention to skin-barrier tolerance when selecting treatments.
Adverse events should be reported. In the UK, reporting forms and information can be found at yellowcard.mhra.gov.uk. In the EU, Healthcare professionals are asked to report any suspected adverse reactions via their national reporting system. Adverse events should also be reported to medical_information@glenmarkpharma.com or call +44 (0) 800 458 0383.
EU prescribing information for clascoterone can be found here.
Always consult local prescribing information in country of practice as information may vary. Adverse Events Reporting information can be found at the bottom of this article. ▼ This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. Details of adverse event reporting are given below.
Case Study 1
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27-year-old woman
Took OCP for years (combined contraception)
Developed acne when she came off the pill
Treated with topical retinoid, antibiotic, and azelaic acid
Factor V Leiden thrombophilia
IUD in situ, removed 1.5 years ago
Footnote:
IUD: intrauterine device; OCP: oral contraceptive pill.
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Before we get started, let’s explore acne pathophysiology.
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The Four Pillars of Acne Pathophysiology
The four pillars of acne pathophysiology.1 Adapted from Del Rosso JQ et al.1
Four pathophysiological pillars underpin acne development:1
1
Excess sebum production
Follicular hyperkeratinisation
2
Colonisation and proliferation of Cutibacterium acnes
3
Inflammation
4
A multimodal approach to acne management is vital to target the four interlinked pathological processes that underpin acne pathophysiology.2
References:
Del Rosso JQ, Kircik L. The primary role of sebum in the pathophysiology of acne vulgaris and its therapeutic relevance in acne management. J Dermatolog Treat. 2024;35(1):2296855. Boreham H. Acne treatment review and present perspectives. EMJ. 2025;10(2):27-35.
How would you manage a patient who does not want to take any tablets, as she had been on an OCP for years for her acne? She is not completely clear with topical retinoids and azelaic acid.
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Case Study 1: Clinical Case Questions
Convince the patient to take an oral treatment
Optimise a topical treatment plan that covers the four components of acne pathophysiology
Prescribe an oral treatment without discussion
Prescribe topical retinoids and azelaic acid only. Continue to prescribe topical retinoids and azelaic acid only.
A
B
C
D
If a patient does not want oral treatment, one needs to optimise topical treatment and discuss the microbiome. One has to make sure that treatments for all four components of the causes of acne are covered in one's treatment plan. Therefore, the plan needs to include azelaic acid, topical retinoids +/- antibiotics, and an androgen receptor blocker (Kapur, personal communication).
OCP: oral contraceptive pill.
Additional investigations: Should this patient be investigated for PMOS?
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Yes
No
Unsure
IUD: Intrauterine device; OCP: oral contraceptive pill; PMOS: polyendocrine metabolic ovarian syndrome Słopień R et al. Use of oral contraceptives for management of acne vulgaris and hirsutism in women of reproductive and late reproductive age. Prz Menopauzalny. 2018;17(1):1-4. Lobo RA, Carmina E. The importance of diagnosing the polycystic ovary syndrome. Ann Intern Med. 2000;132(12):989-93. Pastori D et al., “Factor V Leiden Thrombophilia,” Adam MP et al. (eds.), GeneReviews® [Internet] (1999) University of Washington. Available at: https://www.ncbi.nlm.nih.gov/books/NBK1368/. Last accessed: 30 November 2026.
OCP is an effective management tool for acne vulgaris.1 Combined contraception has antiandrogenic properties;1 post-OCP acne can suggest unmasked hyperandrogenism, raising suspicion for PMOS. PMOS assessment is also important for fertility planning after IUD removal and identification of metabolic comorbidities.2 Factor V Leiden thrombophilia precludes oestrogen-containing therapies, impacting acne management.3
Learn more about acne and PMOS in Case Study 3
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Before we move on, let’s take a closer look at the treatment landscape.
Treatment Landscape for Acne Vulgaris:1,2
Physcosocial symptoms1
Sleeplessness due to itching and pain
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Mild
Topical treatments
Retinoids Benzoyl peroxide Antibiotics Antibiotic + benzoyl peroxide (FDC) Retinoid + benzoyl peroxide (FDC) Retinoid + antibiotic (FDC) Clascoterone* Salicylic acid Azelaic acid
*Anti-androgen therapy
Topical treatments, e.g., clascoterone*, and/or:
Moderate-to-severe
Systemic antibiotics
Hormonal agents
Isotretinoin
Doxycycline Limecycline Minocycline
Combined oral contraceptives* Spironolactone* Intralesional corticosteroids
FDC: fixed-dose combination. Reynolds RV et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1-30. European Medicines Agency (EMA). Winlevi - Summary of Product Characteristics. Available at: https://www.ema.europa.eu/en/documents/product-information/winlevi-epar-product-information_en.pdf. Last accessed: 6 May 2026.
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Case Study 1: Clinical Outcome
A personalised treatment plan was created to avoid oral therapies, which covered all four pillars of acne pathophysiology. In this case, clascoterone was added to her current treatment regimen (topical retinoids and azelaic acid). This enabled the patient to gain better control of her acne, and modest improvements were seen in acne lesions at 12 weeks.
Before Treatment
After Treatment
Consent has been granted for the use of all images within this case study.
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24-year-old woman
Severe eczema
Developed hormonal acne around finals at university
Unable to tolerate most topical anti-acne medication due to underlying eczema, except low-dose azelaic acid
The skin barrier is compromised in eczema.1 This means that the skin is less able to tolerate conventional topical treatments like benzoyl peroxide, which are known to damage the skin barrier and microecology.2
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The Challenges of Treating Eczema and Acne
Schmuth M et al. Skin barrier in atopic dermatitis. J Invest Dermatol. 2024;144(5):989-1000.e1. Deng Y et al. Skin barrier dysfunction in acne vulgaris: pathogenesis and therapeutic approaches. Med Sci Monit. 2024;30:e945336. Kang SY et al. Moisturizer in patients with inflammatory skin diseases. Medicina (Kaunas). 2022;58(7):888. National Institute for Health and Care Excellence (NICE). Acne vulgaris: management. 2023. Available at: https://www.nice.org.uk/guidance/ng198/chapter/Recommendations#managing-acne-vulgaris. Last accessed: 11 February 2026.
For individuals with a damaged skin barrier, dermatologists often recommend specific moisturisers that are non-comedogenic, fragrance-free, and hypoallergenic.3 If acne and eczema are present, non-comedogenic water-based moisturisers should be recommended (Kapur, personal communication).4
Healthy skin
Eczematous skin
Created with BioRender.com
How do you manage a patient with severe eczema who develops hormonal acne?
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Case Study 2: Clinical Case Questions
Use topical benzoyl peroxide and strong retinoids immediately at full strength
Stop all eczema treatments to focus only on acne management
Optimise acne treatment with barrier‑friendly options, avoid irritants, and consider systemic or non-irritating topical anti-androgens as needed
Treat acne with high-dose oral isotretinoin without considering eczema status
Schmuth M et al. Skin barrier in atopic dermatitis. J Invest Dermatol. 2024;144(5):989-1000.e1. Deng Y et al. Skin barrier dysfunction in acne vulgaris: pathogenesis and therapeutic approaches. Med Sci Monit. 2024;30:e945336.
In a patient with eczema, one has to be aware that the barrier of their skin is compromised, and so, they are less likely to tolerate conventional topical treatments such as benzoyl peroxide.1,2
What advice about moisturisers would you give a patient with severe eczema who develops hormonal acne?
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Use rich, oily creams to repair the skin barrier, even if they may clog pores
Non‑comedogenic, water‑based moisturisers are ideal
Avoid moisturisers completely to prevent worsening acne
Only use exfoliating moisturisers with salicylic acid daily
Reference:
National Institute for Health and Care Excellence (NICE). Acne vulgaris: management. 2023. Available at: https://www.nice.org.uk/guidance/ng198/chapter/Recommendations#managing-acne-vulgaris. Last accessed: 11 February 2026.
Non‑comedogenic, water‑based moisturisers help maintain the skin barrier in eczema without aggravating acne.1 Avoiding moisturisers or using heavy/oily creams may worsen acne, while exfoliating or acid-containing products can irritate eczema (Kapur, personal communication).
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Case Study 2: Clinical Outcomes
A personalised treatment plan was created to manage breakthrough hormonal acne while protecting the eczema‑prone skin. Improvement in acne control was observed after 3 months of clascoterone therapy, alongside advice on using non‑comedogenic moisturisers to support the skin barrier.
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17-year-old man with a long-standing history of acne vulgaris
Initially, he was given oral lymecycline and topical clindamycin/tretinoin combination
3 months later, only a small improvement has been seen
Topical clascoterone was added and the antibiotics were stopped
The patient is currently on clascoterone and topical clindamycin/tretinoin combination.
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Acne Vulgaris and Hormones
Acne is driven in part by androgens, which increase sebaceous gland size and sebum production, promoting follicular occlusion and inflammation.1 Dihydrotestosterone acts locally in the pilosebaceous unit via the androgen receptor, amplifying these processes.1
Del Rosso JQ, Kircik L. The primary role of sebum in the pathophysiology of acne vulgaris and its therapeutic relevance in acne management. J Dermatolog Treat. 2024;35(1):2296855.
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How Do Anti-Androgen Therapies Work in Acne?
Anti-androgens are used along with other acne Treatments (topical or systemic, currently depending on the severity of the acne manifestations).1
AR: androgen receptor; DHT: dihydrotestosterone; Hsp: heat shock protein. Carmina E et al. Female adult acne and androgen excess: a report from the Multidisciplinary Androgen Excess and PCOS Committee. J Endocr Soc. 2022;6(3):bvac003. Erratum in: J Endocr Soc. 2023;7(3):bvad006. Reynolds RV et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1-30. Sanchez C, Keri J. Androgen receptor inhibitors in the treatment of acne vulgaris: efficacy and safety profiles of clascoterone 1% cream. Clin Cosmet Investig Dermatol. 2022;15:1357-66. Del Rosso JQ, Kircik L. The primary role of sebum in the pathophysiology of acne vulgaris and its therapeutic relevance in acne management. J Dermatolog Treat. 2024;35(1):2296855.
Spironolactone Blocks androgen action Reduces androgen production Combined oral contraceptives Lowers circulating androgens Lowers free testosterone
Systemic anti-androgen therapies can induce feminisation, including gynaecomastia in males, meaning that the treatment is not always suitable for adolescent male patients.3
Clascoterone Locally blocks androgen signalling in sebaceous glands In vitro studies suggest that clascoterone binds with high affinity to the androgen receptor in sebocytes, inhibiting downstream sebum production3
= No systemic anti-androgen effect
This makes it particularly useful in adolescent males where androgen-driven disease is prominent and systemic hormonal therapy is not appropriate.4
Acne and Mental Health: A Two-Way Relationship
There is a close bidirectional link between mental stress and acne.1 Acne is known to have substantial negative effects on quality of life and can be emotionally distressing for adolescents, a period when self-image is especially important.1 Concerns about acne-related appearance are also associated with significant mental health challenges, including anxiety and depression.2
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Effective treatment can improve the psychological wellbeing of people with acne.1 Individuals with acne may benefit not only from medical therapies to manage their symptoms, but also from timely psychological support to help prevent the development of mental health disorders.1
Costa CS et al. Systemic pharmacological treatments for acne: an overview of systematic reviews (Proto-col). Cochrane Database Syst Rev. 2021;2021(11):CD014917. Smith H et al. Identifying the impacts of acne and the use of questionnaires to detect these impacts: a systematic literature review. Am J Clin Dermatol. 2021;22(2):159-71.
How do you manage a 17-year-old male with persistent inflammatory acne who has shown only partial improvement after 3 months of oral lymecycline with topical clindamycin/tretinoin?
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Case Study 3: Clinical Case Questions
Continue topical clindamycin/tretinoin and add topical clascoterone as a targeted anti-androgen therapy, with gentle adjuncts such as azelaic acid if needed
Stop all active treatments and use strong benzoyl peroxide and retinoids alone
Move directly to oral isotretinoin without trying further topical options
Continue oral lymecycline long term and intensify topical antibiotics, with gentle adjuncts such as azelaic acid if needed
In adolescent males, acne is often driven by local androgen signalling within the pilosebaceous unit. Adding topical clascoterone targets this hormonal pathway via skin-selective androgen receptor antagonism, providing a logical escalation when antibiotics alone have been insufficient. Maintaining a topical retinoid continues to address comedogenesis, while gentle agents such as azelaic acid can support inflammation control and tolerability (Kapur, personal communication).
How is this hormonal acne different from inflammatory acne?
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Hormonal acne typically appears in a U-shaped or perioral distribution, while inflammatory acne more commonly affects the T-zone
Hormonal acne mainly affects teenagers, while inflammatory acne is seen only in adults
Hormonal acne is the result of diet alone, while inflammatory acne is unrelated to lifestyle
Hormonal acne clears without treatment, while inflammatory acne always requires antibiotics
Inflammatory acne is often concentrated in the T-zone and can spread, whereas hormonal acne usually presents in a U-distribution (jawline) or perioral (Kapur, personal communication).
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Case Study 3: Clinical Outcomes
After adding topical clascoterone, the patient showed a modest but clinically meaningful reduction in inflammatory lesions, allowing cessation of oral lymecycline without rebound worsening. He reported greater satisfaction with his skin, with a noticeable improvement in confidence and mood.
Case Study 4
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52-year-old woman with a long-standing history of nodular cystic acne
Tried various treatments: antibiotics, OCP, and spironolactone
Long-standing treatment with spironolactone, azelaic acid, clindamycin, and tretinoin
Clear of acne for 12 months
Flare occurred and so increased dose of spironolactone from 100 mg to 125 mg
Flare currently unresolved
Flares and Tapering Systemic Therapies
Even long-term responders to anti-androgen therapy can develop flare-ups due to hormonal fluctuations, changes in adherence, or natural disease progression (Kapur, personal communication). Effective management requires individualised, multi-modal therapy with ongoing monitoring of safety and patient-centred outcomes.1,2 Topical androgen receptor antagonists like clascoterone can provide meaningful improvement by reducing acne lesions and allow tapering of systemic therapy.3,4
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National Institute for Health and Care Excellence (NICE). Acne vulgaris: management. 2023. Available at: https://www.nice.org.uk/guidance/ng198/chapter/Recommendations#managing-acne-vulgaris.Last accessed: 11 February 2026. Boreham H. Acne treatment review and present perspectives. EMJ. 2025;10(2):27-35. European Medicines Agency (EMA). Winlevi - Summary of Product Characteristics. Available at: https://www.ema.europa.eu/en/documents/product-information/winlevi-epar-product-information_en.pdf. Last accessed: 6 May 2026. Del Rosso JQ, Kircik L. The primary role of sebum in the pathophysiology of acne vulgaris and its therapeutic relevance in acne management. J Dermatolog Treat. 2024;35(1):2296855.
How do you manage a patient with severe inflammatory acne that has progressed into hormonal nodulocystic acne who has a breakthrough on oral spironolactone?
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Case Study 4: Clinical Case Question
Start a combined oral contraceptive and stop spironolactone
Increase the dose of spironolactone and add topical clascoterone; once clear, reduce spironolactone
Continue the same spironolactone dose and add oral antibiotics long term
Immediately start oral isotretinoin without pregnancy counselling or monitoring
For a 52-year-old with breakthrough nodulocystic acne, optimise anti-androgen therapy, consider increasing spironolactone and adding topical clascoterone, then taper spironolactone once cleared (Kapur, personal communication). Topical clascoterone has shown efficacy by reducing acne lesions and is commonly used alongside systemic therapy.1 Oral isotretinoin remains an alternative for severe/scarring disease (pregnancy prevention usually not relevant if truly post-menopausal), but requires baseline and ongoing labs (lipids/liver function tests), counselling, and vigilance for adverse effects.2
Sanchez C, Keri J. Androgen receptor inhibitors in the treatment of acne vulgaris: efficacy and safety profiles of clascoterone 1% cream. Clin Cosmet Investig Dermatol. 2022;15:1357-66. National Institute for Health and Care Excellence (NICE). Acne vulgaris: management. 2023. Available at: https://www.nice.org.uk/guidance/ng198. Last accessed: 6 February 2025.
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At Week 12, a modest improvement in acne was seen, enabling her to taper the dose of spironolactone back down to 100 mg.
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