What is the management algorithm for acne?

Acne Management Algorithm

For optimal acne management, follow a severity-based treatment approach starting with topical retinoids plus benzoyl peroxide for mild acne, adding topical antibiotics for moderate acne, and incorporating systemic therapy for severe cases. 1

Classification and Initial Assessment

• Acne Severity Classification:
  • Mild: Few papules/pustules, no nodules
  • Moderate: Multiple papules/pustules, few nodules
  • Severe: Numerous papules/pustules, many nodules, scarring

Treatment Algorithm by Severity

Mild Acne

1. First-line: Topical retinoid (adapalene 0.1%) + benzoyl peroxide 2.5-5% 1
   • Apply retinoid once daily in the evening
   • Apply benzoyl peroxide in the morning
   • Wait 20-30 minutes after washing face before applying medications 2

Moderate Acne

1. First-line: Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%) 1
   • Consider fixed-dose combinations (e.g., clindamycin-benzoyl peroxide) for better compliance 3
2. If insufficient response: Add systemic antibiotic (doxycycline) 1
   • Limit antibiotic use to maximum 12 weeks to prevent bacterial resistance 1, 4

Severe Acne

1. First-line: Systemic antibiotic + topical retinoid + benzoyl peroxide 1
2. If ineffective or scarring: Isotretinoin 0.25-0.4 mg/kg/day 1
   • Requires iPledge registration due to teratogenicity risk 4
   • Monitor liver function tests and lipids
   • Consider psychosocial impact

Hormonal Acne (Women)

1. First-line: Combined oral contraceptives (COCs) with anti-androgenic progestins 1
   • Particularly for women with signs of hyperandrogenism
   • Contraindications: History of VTE, smoking in women >35 years, migraine with aura, active liver disease, breast cancer
2. Alternative/Add-on: Spironolactone 100-150 mg daily 1
   • Particularly effective when combined with COCs

Application Techniques

Topical Retinoids

• Apply a thin film to the entire face once daily in the evening 1
• Wait 20-30 minutes after washing face with mild soap 2
• Start with lower concentration (0.1%) for sensitive skin 1
• Apply approximately half-inch of medication for the entire face 2
• Avoid corners of nose, mouth, eyes, and open wounds 2

Common Pitfalls to Avoid

1. Overuse of products: Using more than recommended amount increases irritation without improving results 2
2. Excessive washing: Frequent washing and harsh scrubbing can worsen acne 2
3. Expecting immediate results: Improvement typically takes 6-12 weeks 2
4. Discontinuing too early: Continue treatment even after initial improvement 2
5. Prolonged antibiotic use: Increases risk of bacterial resistance 1

Maintenance Therapy

• Continue topical retinoid after clearance to prevent recurrence 1
• Consider lower concentration or reduced frequency if irritation occurs

Special Considerations

• Sensitive skin: Start with lower concentration retinoids (adapalene 0.1%) and gradually increase frequency 1
• Darker skin tones: Consider combining adapalene with ingredients addressing hyperpigmentation (niacinamide, azelaic acid) 1
• Pregnancy: Retinoids contraindicated; consult physician for alternatives 2
• Expected side effects: Erythema, scaling, dryness, stinging/burning in first 2-4 weeks of treatment 2

Combination Therapy Rationale

• Topical retinoids normalize follicular desquamation 5
• Antibiotics inhibit C. acnes growth and reduce inflammation 5
• Benzoyl peroxide reduces bacterial resistance 4
• Combination therapy targets multiple pathogenic factors simultaneously, improving efficacy and reducing irritation 5, 3