Erfolgreich durch internationale Zusammenarbeit

Dermatology

Cite as: Archiv EuroMedica. 2026. 16; 4. DOI 10.35630/2026/16/Iss.4.35

Received 25 July 2026;
Accepted 24 August 2026;
Published 26 August 2026

SYSTEMIC MANAGEMENT OF MODERATE-TO-SEVERE TRUNCAL ACNE: A NARRATIVE REVIEW COMPARING SARECYCLINE, SPIRONOLACTONE, AND ISOTRETINOIN

Krystian Domeracki1 email orcid, Małgorzata Feret1 orcid,
Filip Chodań1 orcid, Dagmara Laufer1 orcid,
Estera Sośniecka1 orcid, Olga Klimczak1 orcid,
Adam Miler1 orcid

1 Medical University of Silesia, Katowice, Poland

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  krystiandomeracki5@icloud.com

ABSTRACT

Background

Truncal acne is common and may cause psychosocial burden and permanent scarring. Systemic treatment may be required for extensive, moderate to severe, scarring, or treatment resistant disease.

Aim

To critically evaluate the efficacy, safety, patient selection, and clinical limitations of sarecycline, spironolactone, and isotretinoin in truncal acne.

Materials and methods

This narrative review searched PubMed, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov. Publications from January 2016 to June 2026 were prioritized. The final search was conducted on June 20, 2026. Randomized trials, observational studies, guidelines, and relevant reviews were considered. Earlier landmark and mechanistic publications were also included. 59 sources underwent descriptive synthesis.

Results

Sarecycline has the most direct evidence for inflammatory acne of the chest and back, although truncal outcomes were exploratory and superiority over other systemic antibiotics has not been established. Direct evidence for spironolactone in truncal acne is limited mainly to retrospective data in adult women. Broader evidence supports its use as a nonantibiotic systemic option for women with acne. Isotretinoin is an important option for severe, scarring, or treatment resistant acne, but evidence specific to truncal involvement is limited. Its principal concerns are dose dependent mucocutaneous adverse effects and marked teratogenicity. Population studies have not established a consistent increase in inflammatory bowel disease, psychiatric disorders, or suicidal behavior, but individual monitoring remains necessary.

Conclusions

The three treatments have different clinical roles and evidence bases. Available evidence does not support direct comparison or establish the superiority of one treatment over another for truncal acne. Treatment selection should be individualized according to patient characteristics, disease severity, and safety considerations.

Keywords: truncal acne, acne vulgaris, systemic therapy, sarecycline, spironolactone, isotretinoin, antimicrobial stewardship

INTRODUCTION

Acne vulgaris is one of the most common disorders treated by dermatologists, and while it primarily affects adolescents, it also frequently impacts adult and pediatric populations [1]. Historically, clinical studies have focused predominantly on facial acne, leaving truncal acne—which affects the chest and back—relatively underrepresented in the literature. Patients experiencing combined facial and truncal acne often suffer from a compounded psychosocial burden [2]. Individuals with this clinical presentation perceive their condition as a source of considerable emotional stress and social impairment, highlighting the necessity for effective, targeted management strategies [3]. Without proper treatment, active lesions often lead to permanent scarring [4,5].

Epidemiological data demonstrate the occurrence of acne among diverse demographic groups, including male adolescents, young adults, and adult females [6–8]. Across Europe, clinical profiling shows that patients frequently present with mild-to-moderate forms of the disease [9]. Truncal acne is an important clinical manifestation, with survey data highlighting its broad demographic distribution [10,11]. In a referral cohort of 965 patients with acne, involvement of the chest and back was identified in 45% and 61% of patients, respectively [56].

The pathogenesis of acne is multifactorial. Hormonal fluctuations and increased androgenic activity stimulate sebaceous gland activity and sebum production [12-16]. On the trunk, the level of sebum secretion correlates with the development of acne [17], while environmental and lifestyle factors may also influence the course of the disease [18,19]. Excessive sebum production and abnormal differentiation of the follicular epithelium contribute to microcomedone formation and obstruction of the follicular canal [1,4].

Alterations in the commensal skin microbiome contribute to inflammation [20]. Cutibacterium acnes products activate the innate immune response and promote the recruitment of inflammatory cells [13]. Disruption of follicular wall integrity and release of follicular contents into the dermis intensify the inflammatory response [1,4].

Variations in cutaneous innate immunity can disrupt the healing process, ultimately leading to permanent atrophic scars [4,21]. The persistence of antibiotic-resistant C. acnes emphasizes the need for rational antibiotic use. Consequently, modern clinical approaches favor targeted therapies that minimize the risk of prolonged antimicrobial resistance [22].

Sarecycline, spironolactone, and isotretinoin were selected because they represent three distinct approaches to systemic acne treatment. Sarecycline provides narrow spectrum antibacterial and anti inflammatory activity, spironolactone provides hormonal modulation, and isotretinoin suppresses sebum production and normalizes follicular keratinization [23-25].

Relevance

Truncal acne may cause substantial psychosocial burden and permanent scarring [2-5,10,11]. Systemic treatment may be required in patients with extensive, moderate to severe, or treatment resistant disease.

Knowledge gap

Evidence specifically addressing truncal acne remains limited because many studies assess facial acne or acne vulgaris without reporting separate outcomes for truncal lesions. Direct evidence is most extensive for sarecycline, whereas the evidence concerning spironolactone and isotretinoin is derived largely from studies of facial acne or acne vulgaris. No studies directly comparing these three treatments in truncal acne were identified.

AIM

The aim of this narrative review is to critically evaluate the available evidence concerning the efficacy, safety, patient selection, and clinical limitations of sarecycline, spironolactone, and isotretinoin in the systemic treatment of moderate to severe truncal acne.

Objectives

  1. To summarize the evidence concerning the efficacy of sarecycline, spironolactone, and isotretinoin in truncal acne and distinguish direct evidence from evidence derived from studies of facial acne or acne vulgaris.
  2. To summarize the reported safety profiles and major clinical limitations of each treatment.
  3. To identify the patient groups for whom each treatment may be appropriate and discuss the implications of antimicrobial stewardship and pregnancy prevention for treatment selection.

MATERIALS AND METHODS

This study was conducted as a narrative review. PubMed, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov were searched for relevant sources. The review focused primarily on literature published from January 2016 to June 2026. The final search was conducted on June 20, 2026. Older publications were included when they provided information on the pathophysiology of acne vulgaris, the mechanisms of the evaluated systemic treatments, or landmark clinical evidence. The review was prepared with reference to the Scale for the Assessment of Narrative Review Articles (SANRA).

PubMed was searched using the following query: ("truncal acne" OR "acne vulgaris" OR "chest acne" OR "back acne") AND ("systemic therapy" OR sarecycline OR spironolactone OR isotretinoin). Embase, the Cochrane Library, and Google Scholar were searched using combinations of the terms "truncal acne", "systemic management", "sarecycline", "spironolactone", "isotretinoin", "clinical trial", and "treatment outcomes". ClinicalTrials.gov was searched using the terms "truncal acne", "acne vulgaris", "sarecycline", "spironolactone", and "isotretinoin".

Eligible sources included randomized controlled trials, prospective and retrospective studies, observational studies, clinical guidelines, and review articles published in English that addressed the systemic treatment of moderate to severe acne. Studies evaluating individualized or reduced dosing regimens were also considered. Experimental studies were included only when they provided information on the mechanisms of action of the evaluated treatments. Because direct evidence concerning truncal acne was limited, studies of facial acne or acne vulgaris that did not report truncal outcomes separately were included as indirect evidence. Non English publications, duplicate records, letters without primary data, conference abstracts without available full text, clinical studies that did not report relevant treatment outcomes, and publications unrelated to acne vulgaris or the evaluated treatments were excluded.

Titles and abstracts were screened, followed by full text assessment of potentially relevant publications. Primary clinical studies were prioritized when evaluating treatment efficacy and safety. Clinical guidelines were used to establish the clinical context and current recommendations, while review articles were used to provide background information and identify additional relevant primary studies. Experimental studies were used only to describe mechanisms of action.

A total of 59 sources were included in the narrative synthesis. The evidence was grouped by treatment and summarized according to efficacy, safety, patient selection, and clinical limitations. Direct evidence concerning truncal acne was distinguished from evidence derived from studies of facial acne or acne vulgaris. The selection and synthesis of evidence were descriptive and were not conducted according to a systematic review protocol.

RESULTS

Efficacy and Safety of Sarecycline in Truncal Acne

Direct evidence for the use of sarecycline, a narrow-spectrum tetracycline-class antibiotic administered orally at a dose of 1.5 mg/kg/day, in truncal acne is derived from two identically designed, randomized, double-blind, placebo-controlled phase III clinical trials [26,27]. These studies involved patients with moderate-to-severe acne vulgaris. While the primary endpoints focused on facial acne, the evaluation of inflammatory lesions on the chest and back were predefined as additional, exploratory endpoints. Pooled data demonstrated that sarecycline significantly reduced inflammatory lesion counts on both the chest and the back compared with placebo [26,27]. By week 12, Investigator’s Global Assessment (IGA) success for truncal acne was achieved in 33.42% of patients receiving sarecycline versus 20.77% receiving placebo on the chest (p < 0.0001), and in 33.07% versus 21.91% on the back (p < 0.0001). Clinical improvements, marked by significant reductions in inflammatory lesion counts at truncal sites, were observed as early as week 3 [26].

Indirect evidence supporting the overall efficacy of sarecycline is derived from studies evaluating general acne vulgaris without isolating truncal outcomes. In a multicenter, double blind, placebo controlled phase II study of 285 patients aged 12 to 45 years with moderate to severe facial acne, sarecycline at doses of 1.5 and 3.0 mg/kg reduced inflammatory lesion counts at week 12 by 52.7% and 51.8%, respectively, compared with 38.3% for placebo [28]. Because only facial acne was evaluated, these findings represent indirect evidence for truncal acne. In the PROSES real-world observational study, which evaluated general acne populations, 59.3% of patients reported clear or almost clear skin on self-assessment, and 58.9% achieved IGA success after 12 weeks of treatment. Additionally, patient-reported outcomes demonstrated significant mean score reductions across the Acne Symptom and Impact Scale (ASIS), indicating broad improvements in acne-related symptoms and quality of life [29]. Because these findings represent overall acne clearance, they serve as indirect support for its use in patients who may present with truncal involvement.

The safety profile of sarecycline is characterized by its narrow-spectrum mechanism of action, which is specifically designed to target Cutibacterium acnes while minimizing collateral disruption of the normal gastrointestinal microbiome [29]. In phase III studies and long-term open-label extension trials, treatment-emergent adverse events were reported in 25.0–29.3% and 38.9% of patients, respectively [30]. Gastrointestinal adverse events occurred in 6.1–6.6% of patients (with nausea reported in 1.9–4.6%), which is notably lower than the rates frequently reported for broad-spectrum tetracyclines. Vestibular adverse events were uncommon, with no reported cases of vertigo or tinnitus among patients in the pivotal phase III clinical program. Furthermore, phototoxicity was reported in ≤0.8% of treated patients, distinguishing its safety profile from that of other tetracycline-class antibiotics [30].

Based on this profile, sarecycline is an appropriate therapeutic option for patients with moderate-to-severe inflammatory acne, particularly those with combined facial and truncal involvement, or those who have previously experienced gastrointestinal or vestibular intolerance to broad-spectrum tetracyclines. The major clinical limitations of this treatment approach include the lack of direct, head-to-head comparative trials evaluating truncal efficacy against other oral antibiotics, and the fact that its specific efficacy for chest and back lesions was established primarily through exploratory endpoints rather than primary outcome measures.

Efficacy and Safety of Spironolactone in Truncal Acne

Spironolactone is a systemic aldosterone receptor antagonist with antiandrogenic activity that reduces sebum production by competitively inhibiting androgen receptor binding and decreasing androgen synthesis, as presented in Table 1. Clinical studies have demonstrated reductions in sebum excretion during treatment [31,32]. Direct evidence specifically addressing truncal acne is derived from a retrospective case series of 403 adult women treated with spironolactone. At the first follow up, according to CASS scores, 84.0% and 80.2% of patients with available data had reduction or complete clearance of acne on the chest and back, respectively [33].

Although its systemic mechanism of action has led to its widespread use in patients with more extensive disease, the majority of data supporting the use of spironolactone in acne serves as indirect evidence, as it is derived primarily from studies involving adult women with facial acne or general acne vulgaris. For example, in the phase III SAFA trial, self-reported improvement was not significantly different from placebo at week 12 (72.2% vs. 67.9%; OR 1.16, 95% CI 0.70–1.91), but a significant benefit was observed by week 24 (81.9% vs. 63.3%; OR 2.72, 95% CI 1.50–4.93) [24]. Furthermore, systematic reviews have reported clinical success rates ranging from 60% to 85% in adult women treated with oral spironolactone, with clinical success defined as complete clearance or marked improvement [24,32].

Retrospective cohort studies have further shown that treatment outcomes with spironolactone in acne vulgaris are comparable to those achieved with oral tetracycline-class antibiotics, with sustained clinical benefit during long-term follow-up [34]. In long-term observational studies, 96% of patients achieved complete clearance by the end of the follow-up period (over 2 years) [33].

The safety profile of spironolactone has been evaluated extensively in patients treated for acne. Large retrospective studies and cohort analyses have shown that the incidence of hyperkalemia in healthy young women is low (approximately 0.72%) and comparable to that observed in the general healthy population (0.76%), suggesting that routine potassium monitoring is unnecessary in this population in the absence of additional risk factors [35–37]. Reported relative risks were 1.04 for breast cancer, 1.02 for gastric cancer, 0.90 for endometrial cancer, and 1.52 for ovarian cancer, with all confidence intervals including unity [38]. In addition, treatment discontinuation or switching occurred at a similar frequency with spironolactone (14.4%) compared to oral tetracyclines (13.4%), supporting its comparable clinical effectiveness and favorable long-term tolerability [34].

Based on its mechanism of action and available evidence, spironolactone is an appropriate targeted therapy for adult female patients. However, the interpretation of the direct efficacy data for truncal acne is constrained by several major clinical limitations. Primarily, the evidence is limited by the retrospective design of the study evaluating chest and back lesions. Furthermore, the assessment of spironolactone as a monotherapy is confounded by the frequent use of concomitant treatments, and the reliability of the long-term outcomes is limited by the loss of some patients during the follow-up period.

Efficacy and Safety of Isotretinoin in Truncal Acne

Oral isotretinoin remains the most effective systemic therapy for moderate-to-severe acne and is widely used in patients with extensive truncal involvement. Direct evidence supporting its specific use for truncal lesions includes a study involving patients with nodular acne of the face and trunk. In this population, standard or high-dose regimens are commonly prescribed to achieve sustained disease remission. Studies have shown that lower cumulative doses are associated with higher relapse rates, whereas cumulative doses exceeding 220 mg/kg reduce relapse rates to 26.9%, compared to a relapse rate of 47.4% observed in patients receiving lower cumulative doses [25,39].

The remaining studies evaluating isotretinoin in the treatment of general acne vulgaris serve as indirect evidence for its efficacy in truncal acne. In these broader populations, individualized low-dose regimens have demonstrated comparable efficacy to conventional dosing in reducing inflammatory lesions over 24 weeks while improving treatment tolerability [40–42]. Furthermore, successful disease resolution with isotretinoin directly correlates with profound improvements in patient quality of life, as evidenced by significant reductions in Skindex-16 scores, with patients experiencing an average improvement of 22.0 points (a 55.7% improvement) by month 2 [45].

The safety profile of isotretinoin has been extensively evaluated in clinical trials, systematic reviews, and large observational studies. Mucocutaneous adverse events, particularly xerosis and cheilitis, are the most common treatment-related complications and occur more frequently with standard or high-dose regimens than with lower daily doses; for instance, cheilitis occurs in 64.7% of patients on low-dose regimens compared to 93.8% on conventional dosing, and xerosis in 5.9% versus 31.3%, respectively [40–42]. Laboratory abnormalities are generally uncommon, mild, and transient. Meta-analyses have reported clinically significant triglyceride elevations in approximately 4–5% of patients, while elevations in liver transaminases occur in fewer than 2% of cases [46]. More severe laboratory abnormalities have been reported in fewer than 1% and 0.5% of patients, respectively [47], suggesting that frequent routine laboratory monitoring may have limited clinical utility in otherwise healthy individuals [46,47]. Epidemiological studies have found no significant increase in the risk of inflammatory bowel disease [48,49] or psychiatric disorders and suicidal behavior during isotretinoin treatment [50–53].

Isotretinoin is the treatment of choice for patients with severe, nodular, or treatment-resistant acne, including those with prominent truncal involvement. However, its use is accompanied by major clinical limitations. Primarily, isotretinoin remains a highly teratogenic medication. While pregnancy prevention programs have substantially reduced fetal exposure, unintended pregnancies continue to occur (rates of 0.02–0.1% in Europe, and 0.33–0.65% in the US), with birth defects reported in 20–35% of exposed fetuses and neurocognitive disorders in up to 60% of affected children [54,55]. Another clinical limitation is the relative scarcity of direct clinical trial data isolating truncal outcomes, requiring clinicians to extrapolate efficacy primarily from indirect evidence in acne vulgaris.

The mechanisms of action, target populations, potential clinical advantages, limitations, and safety considerations of sarecycline, spironolactone, and isotretinoin are summarized in Table 1.

Table 1. Summary of systemic therapies used in the management of truncal acne

FeatureSarecyclineSpironolactoneIsotretinoin
Mechanism of ActionNarrow spectrum tetracycline class antibiotic with antibacterial and anti inflammatory activity [23].Aldosterone receptor antagonist with antiandrogenic activity that reduces sebum excretion [31,32].Systemic retinoid that suppresses sebaceous gland activity and sebum production and affects follicular keratinization and inflammation [1,25].
Target GroupPatients with moderate to severe inflammatory acne, including involvement of the chest and back [26].Adult women with acne for whom a nonantibiotic systemic treatment is appropriate [33,34].Patients with severe, scarring, or treatment resistant acne [1,57,58].
AdvantagesProvides the most direct evidence among the three therapies for improvement of inflammatory lesions on the chest and back [26].Provides a nonantibiotic systemic option for adult women and avoids additional antibiotic exposure [24,32,33].May provide prolonged disease control in severe or treatment resistant acne [25,39].
Disadvantages and LimitationsTruncal outcomes were exploratory, and superiority over other systemic antibiotics has not been established. Treatment duration should follow antimicrobial stewardship principles [22,26,57,58].Direct evidence for truncal acne is limited to retrospective data in adult women. Applicability to other patient groups remains uncertain [24,32,33].Evidence specific to truncal acne is limited because most studies do not report chest and back outcomes separately. Findings concerning dosage and relapse are therefore only indirectly applicable [25,39-42].
Safety ProfileGastrointestinal adverse events occurred in 6.1% to 6.6% of patients. Vestibular adverse events were uncommon, and phototoxicity was reported in no more than 0.8% of treated patients [30].Menstrual irregularities, breast tenderness, dizziness, and other adverse effects may occur [32]. Hyperkalemia is uncommon in healthy women aged 18 to 45 years without additional risk factors, but the risk is higher in older patients and cannot be generalized across all patient groups [35-37].Dose dependent mucocutaneous adverse effects are common [40-42]. Clinically significant laboratory abnormalities are uncommon, but the available evidence does not justify eliminating patient specific monitoring [46,47]. Population studies have not established a consistent increase in inflammatory bowel disease, psychiatric disorders, or suicidal behavior, but individual monitoring remains necessary [48-53]. Isotretinoin is highly teratogenic, and pregnancy prevention is mandatory for patients of reproductive potential [54,55].

DISCUSSION

The principal finding of this review is that the evidence supporting the use of sarecycline, spironolactone, and isotretinoin for truncal acne differs substantially in its extent, quality, and direct applicability. These medications are used in different clinical settings and have been investigated in heterogeneous populations using different outcome measures. Therefore, direct comparison and ranking of the three medications in terms of efficacy and safety are not possible.

The most direct evidence for truncal acne is available for sarecycline. A pooled analysis of two phase III placebo controlled trials demonstrated the efficacy of sarecycline in treating acne of the chest and back [26]. However, truncal acne outcomes were exploratory endpoints in these trials. These findings support the efficacy of sarecycline for inflammatory truncal acne but do not replace studies specifically designed to evaluate this anatomical location. The available results also do not demonstrate that sarecycline is superior to other systemic antibiotics. As sarecycline is a systemic antibiotic, its use should consider the necessary duration of treatment and the principles of responsible antimicrobial use [22,57,58].

The evidence supporting spironolactone for truncal acne is less certain. Direct evidence is provided by a retrospective study of adult women in which acne of the chest and back was assessed separately [33]. Other studies primarily evaluated facial acne or acne in adult women without a separate assessment of truncal involvement [24,31,32,34]. In the SAFA trial, the benefit of spironolactone according to the Acne QoL score was small but statistically significant at week 12 and became more pronounced by week 24 [24]. This finding indicates a gradual development of the clinical effect. However, the SAFA results do not constitute direct evidence of efficacy in truncal acne.

Spironolactone may be considered a nonantibiotic treatment option for acne in adult women, particularly when prolonged antibiotic use should be limited [24,32,33]. Nevertheless, the retrospective design of the direct evidence concerning truncal acne, the possible use of concomitant therapies, and incomplete follow up limit the strength of the conclusions [33]. Similar rates of treatment switching between spironolactone and tetracyclines reflect treatment persistence but do not demonstrate equivalent clinical efficacy [34]. Evidence showing a low incidence of hyperkalemia relates predominantly to healthy young women without additional risk factors and cannot automatically be extrapolated to other patient groups [35-37].

Isotretinoin is primarily considered for severe, scarring, or treatment resistant acne [1,57,58]. However, the isotretinoin studies included in this review mainly concern acne vulgaris without a separate assessment of chest and back involvement [25,39,40-42]. Consequently, findings concerning cumulative dosage, relapse rates, and different treatment regimens are only indirectly applicable to truncal acne. Studies evaluating the combination of isotretinoin with laser therapy and elastographic assessment of scars also do not permit a separate determination of the medication’s efficacy in active truncal acne [43,44].

The interpretation of isotretinoin data must account for dose dependent cutaneous and mucosal adverse effects [40-42]. The included studies did not identify convincing evidence of an increased population level risk of inflammatory bowel disease [48,49]. Similar findings were reported for psychiatric disorders and suicidal behavior [50-53]. These data do not exclude individual risk or eliminate the need to monitor the patient’s condition. Isotretinoin is highly teratogenic. Therefore, pregnancy prevention is mandatory for patients of reproductive potential [54,55].

The clinical roles of the three medications differ. Sarecycline is a systemic antibacterial treatment option for inflammatory acne [26]. Spironolactone is a nonantibiotic option for adult women [24,33]. Isotretinoin is primarily considered for severe, scarring, or treatment resistant disease [1,57,58]. Treatment selection should consider disease severity and extent, the presence of nodules and scarring, the patient’s sex and reproductive status, previous treatment outcomes, contraindications, and tolerability [59]. However, these criteria do not constitute an algorithm supported by comparative studies. The available evidence helps define the potential clinical role of each medication but does not establish the superiority of any medication for truncal acne.

Directions for future research

Prospective studies specifically designed for patients with truncal acne are required. Involvement of the chest and back should be evaluated separately from facial acne. Standardized measures are needed for disease severity, inflammatory and noninflammatory lesion counts, affected surface area, scarring, quality of life, time to response, and relapse rates.

Comparative studies should account for differences in the clinical indications for these medications. Scientifically justified comparisons include sarecycline with other systemic antibiotics, spironolactone with antibiotic therapy in adult women, and different isotretinoin regimens in severe or scarring acne. Comparing all three medications within a single population may be methodologically inappropriate because they are used in different clinical settings.

Longer follow up is needed to assess the durability of response, relapse rates, the need for repeated treatment, and long term safety. Separate studies are required in adolescents, adult women, men, and patients at high risk of scarring. The primary research priority remains the acquisition of direct clinical evidence for truncal acne using standardized outcome measures.

Limitations

This narrative review has several limitations. The methodological quality and risk of bias of the included studies were not formally assessed. Consequently, the review does not provide a systematic comparison or formal ranking of the three treatments.

Direct evidence for truncal acne is limited and differs substantially among the evaluated therapies. For sarecycline, outcomes for acne of the chest and back were reported in two placebo controlled phase III trials, but these were exploratory outcomes. Direct evidence for spironolactone is limited to a retrospective study in women, while most other studies concern facial acne or acne in adult women without separate truncal outcomes. For isotretinoin, one study included patients with nodular acne of the face and trunk, but much of the remaining evidence concerns acne vulgaris without separate analysis of truncal involvement.

Differences in study design, patient populations, disease severity, treatment regimens, concomitant therapies, outcome measures, and follow up duration prevent reliable comparison of the findings. No direct trials comparing sarecycline, spironolactone, and isotretinoin using standardized truncal acne outcomes were identified. Therefore, the available evidence does not permit conclusions about the comparative efficacy, comparative safety, or superiority of any of these treatments.

CONCLUSIONS

The evidence supporting systemic treatment of moderate to severe truncal acne differs substantially among sarecycline, spironolactone, and isotretinoin. Sarecycline has the most direct trial evidence for inflammatory acne of the chest and back, although truncal outcomes were exploratory and superiority over other systemic antibiotics has not been established. Evidence for spironolactone in truncal acne is limited mainly to retrospective data, while broader evidence from studies of acne in adult women supports its use as a nonantibiotic option for adult women. Evidence for isotretinoin is largely extrapolated from studies of acne vulgaris without separate assessment of truncal lesions. It remains clinically relevant for severe, scarring, or treatment resistant disease.

Treatment selection should consider disease severity and extent, the presence of nodules or scarring, sex, reproductive status, previous treatment outcomes, contraindications, and tolerability. The principal limitations include the need to limit the duration of systemic antibiotic therapy and follow antimicrobial stewardship principles when prescribing sarecycline, the limited direct evidence and patient specific risk of hyperkalemia with spironolactone, and the dose dependent mucocutaneous adverse effects and marked teratogenicity of isotretinoin. Pregnancy prevention is mandatory during isotretinoin treatment in patients of reproductive potential. The available evidence does not permit direct ranking of these three medications or establish the superiority of any one treatment for truncal acne. Further prospective studies using standardized and separately reported outcomes for chest and back acne are required.

DISCLOSURE

Author contributions

Conceptualization and methodology: Krystian Domeracki, Małgorzata Feret. Investigation and data collection: Krystian Domeracki, Filip Chodań, Olga Klimczak, Dagmara Laufer. Formal analysis: Krystian Domeracki, Małgorzata Feret, Adam Miler. Writing, original draft preparation: Krystian Domeracki, Olga Klimczak, Dagmara Laufer, Estera Sośniecka. Writing, review and editing: Krystian Domeracki, Małgorzata Feret, Filip Chodań, Adam Miler, Estera Sośniecka. Supervision: Krystian Domeracki.

All authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflicts of interest.

AI use

Artificial intelligence tools, including ChatGPT and other OpenAI systems, were used to support language refinement, structural improvement, and the development of certain sections of the manuscript. All content produced with the assistance of artificial intelligence was thoroughly reviewed and verified by the authors.

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