What is the most appropriate initial treatment for a 21-year-old college student with acute acne and a predominance of comedones and pustules?

Treatment of Acute Acne with Comedones and Pustules

Topical retinoic acid is the most appropriate initial treatment for this 21-year-old college student with acute acne characterized by comedones and pustules. 1

Rationale for Topical Retinoid Therapy

Topical retinoids are the cornerstone of acne treatment for several key reasons:

• They are comedolytic and resolve microcomedone lesions, which are the precursors to visible acne
• They have anti-inflammatory properties
• They enhance any topical acne regimen and allow for maintenance of clearance 1

For this patient with predominantly comedonal acne with pustules but no evidence of chronic scarring, a topical retinoid is ideal as first-line therapy.

Application Instructions for Topical Retinoic Acid

1. Apply once daily before bedtime
2. Wash face with a mild soap and dry gently
3. Wait 20-30 minutes before applying medication (skin must be completely dry to minimize irritation)
4. Apply a small amount (half-inch or less) to fingertip
5. Dab on forehead, chin, and cheeks, then spread over the entire affected area
6. Apply a moisturizer in the morning 2

Expected Timeline and Side Effects

• Patient should be informed that improvement typically takes 6-12 weeks 1, 2
• Initial "purging" phase may occur at 3-6 weeks when new blemishes appear temporarily 2
• Common side effects include mild irritation, redness, dryness, and peeling during the first 2-4 weeks 2
• These side effects can be minimized by:
  • Starting with less frequent application (every other night) if skin is sensitive
  • Using moisturizer
  • Avoiding excessive washing or scrubbing 2

Why Other Options Are Not Appropriate

• Dietary restrictions (chocolates, sugars, milk products): No strong evidence supports dietary restrictions as first-line therapy for acne. The 2016 and 2024 acne guidelines do not recommend dietary modification as initial treatment 1

• Topical acyclovir: This is an antiviral medication used for herpes infections, not for acne vulgaris 1

• Topical hydrocortisone cream: Topical corticosteroids are not recommended for acne treatment and may actually worsen acne through steroid-induced acne (steroid acne) 1

Additional Considerations

• For this patient with acute acne and an upcoming event (wedding in 3 weeks), it's important to set realistic expectations. Complete clearance may not occur before the wedding, as topical retinoids typically take 6-12 weeks for full effect.

• If rapid improvement is needed for the wedding, an intralesional corticosteroid injection could be considered as an adjuvant therapy for larger papules or nodules at risk of scarring 1

• Benzoyl peroxide could be added to the regimen if inflammatory lesions persist, as it has antimicrobial properties and can enhance the effect of topical retinoids 1

• Combination therapy with a topical retinoid and benzoyl peroxide may be more effective than monotherapy and is recommended in the guidelines, but starting with a topical retinoid alone may help minimize initial irritation 1