What is the appropriate first-line therapy for an adolescent patient with new onset acne?

From the Guidelines

The appropriate first-line therapy for an adolescent patient with new onset acne is a topical retinoid, such as tretinoin 0.05% cream, due to its comedolytic, anti-inflammatory, and ability to normalize follicular keratinization properties. According to the most recent guidelines of care for the management of acne vulgaris 1, strong recommendations are made for topical retinoids, as well as for benzoyl peroxide and topical antibiotics. The guidelines suggest that topical retinoids are important in addressing the development and maintenance of acne and are recommended as monotherapy in primarily comedonal acne, or in combination with topical or oral antimicrobials in patients with mixed or primarily inflammatory acne lesions.

Some key points to consider when prescribing topical retinoids include:

• They should be applied at night after gentle cleansing and complete drying of the skin
• Patients should be advised to use a non-comedogenic moisturizer and sunscreen daily, as retinoids can cause dryness and photosensitivity
• The regimen should be continued for at least 8-12 weeks before assessing efficacy, as improvement is gradual
• For moderate inflammatory acne, adding a topical antibiotic like clindamycin 1% in the morning regimen may be beneficial
• If there is minimal improvement after 12 weeks or if the acne is more severe with nodules or cysts, referral to a dermatologist for consideration of oral antibiotics or isotretinoin may be necessary, as oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy 1.

It's worth noting that while other options, such as doxycycline capsules or erythromycin tablets, may be effective for acne treatment, they are not typically recommended as first-line therapy for adolescents with new onset acne, due to concerns about antibiotic resistance and side effects 1.

From the FDA Drug Label

To get the best results with tretinoin therapy, it is necessary to use it properly. Apply tretinoin once daily before bedtime, or as directed by your physician Your physician may advise, especially if your skin is sensitive, that you start your therapy by applying tretinoin every other night.

The appropriate first-line therapy for an adolescent patient with new onset acne is Tretinoin 0.05 % cream 2.

From the Research

First-Line Therapy for Acne

The appropriate first-line therapy for an adolescent patient with new onset acne can be determined based on the severity and type of lesions.

• For mild acne, topical treatments are generally recommended, with options including:
  • Benzoyl peroxide
  • Azelaic acid
  • Antibacterials for inflammatory lesions
  • Topical retinoids, such as tretinoin, for noninflamed lesions
• According to a study published in 2019 3, tretinoin 0.05% lotion was found to be effective and well-tolerated in preadolescent subjects with moderate-to-severe acne.
• Another study from 2003 4 suggests that for moderately severe acne, oral antibacterials such as tetracyclines or erythromycin may be considered, but these are not typically first-line treatments for mild to moderate acne.
• A 2019 study 5 evaluated the efficacy and tolerability of tretinoin 0.05% lotion in women with moderate or severe acne, categorized by age, and found it to be effective in achieving treatment success and reducing inflammatory and noninflammatory lesions.
• Additional studies from 2011 6 and 2008 7 support the use of topical retinoids, such as tretinoin gel, for the treatment of acne in young adolescents, highlighting their efficacy and tolerability.

Treatment Options

Based on the provided evidence, the most appropriate first-line therapy for an adolescent patient with new onset acne would be:

• Tretinoin 0.05% cream (option c), as it is a topical retinoid that has been shown to be effective and well-tolerated in adolescents with acne 3, 5, 6, 7.