Pharmacotherapeutic strategies for the treatment of severe juvenile acne

Introduction: Severe juvenile acne vulgaris is a chronic inflammatory disorder that can impair quality of life and lead to permanent scarring during adolescence. Advances in understanding acne pathophysiology have shifted treatment toward early intervention, antimicrobial stewardship, and individualized systemic strategies. Areas covered: This narrative review summarizes current evidence on pharmacotherapy for severe juvenile acne, focusing on systemic treatments. PubMed, Embase, Google Scholar, Cochrane Library, and ClinicalTrials.gov database were searchede from inception to March 2026. Key pathogenic mechanisms,, including sebaceous hyperactivity, follicular hyperkeratinization, Cutibacterium acnes, dysbiosis, immune-inflammatory activation, and hormonal influences, are reviewed. Expert opinion: Severe juvenile acne should not be dismissed as a physiologic feature of adolescence, because delayed or inadequate treatment may cause major physical and psychological sequelae. Oral isotretinoin remains the gold standard for severe nodulocystic, scarring, or treatment-resistant acne. Timely specialist assessment is essential to avoid unnecessary delay when licensed criteria are met, while ensuring compliance with product information, regulatory requirements, and risk-minimization measures. Prolonged systemic antibiotic use should be limited through benzoyl peroxide combinations and shorter courses. Future strategies will likely become more individualized, microbiome-conscious, and inflammation-targeted, aiming to prevent scarring and psychosocial burden as well as achieve lesion clearance.