What is the best treatment approach for a 16-year-old patient with worsening acne on her bilateral cheeks, despite using clindamycin wash twice daily?

Treatment Approach for 16-Year-Old with Worsening Acne

For a 16-year-old with worsening acne on bilateral cheeks despite using clindamycin wash twice daily, the recommended treatment is to add a topical retinoid (adapalene 0.1%) and benzoyl peroxide 2.5-5% to the current regimen, as clindamycin monotherapy is insufficient and may lead to bacterial resistance. 1

Current Assessment

• 16-year-old with worsening acne on bilateral cheeks
• Currently using clindamycin wash twice daily
• Practices good hygiene (face washing twice daily, regular sheet washing)
• Acne appears to be progressing despite current treatment

Why Current Treatment Is Failing

• Clindamycin monotherapy is not recommended for acne treatment due to:
  • Potential for bacterial resistance development
  • Limited efficacy against multiple acne pathogenic factors 1, 2
• Clindamycin wash may have reduced contact time with skin compared to leave-on formulations 3

Recommended Treatment Plan

Step 1: Optimize Topical Therapy

• Continue gentle face washing twice daily
• Add topical retinoid: Adapalene 0.1% gel or cream once daily (evening)
  • Addresses comedone formation
  • Has anti-inflammatory properties
  • Better tolerated than other retinoids for beginners 1
• Add benzoyl peroxide 2.5-5% gel or wash (morning)
  • Prevents bacterial resistance to clindamycin
  • Has keratolytic and anti-inflammatory properties 1, 2

Step 2: Consider Fixed-Combination Products

• If patient prefers fewer products, consider switching to a fixed-combination product:
  • Clindamycin 1%/benzoyl peroxide 5% gel applied twice daily 2, 4
  • OR Clindamycin 1.2%/adapalene 0.15%/benzoyl peroxide 3.1% gel once daily for more severe cases 5

Step 3: Assess Response After 6-8 Weeks

• If inadequate improvement, consider:
  • Adding oral antibiotic (doxycycline 50-100mg twice daily) for 12 weeks maximum 1
  • For females: hormonal therapy options (combined oral contraceptives or spironolactone)

Practical Considerations

Application Instructions

• Apply thin film of medications to entire face, not just affected areas
• Start retinoid every other night for 2 weeks before increasing to nightly use
• Use non-comedogenic moisturizer if dryness occurs
• Apply sunscreen daily (SPF 30+) as retinoids increase sun sensitivity

Lifestyle Modifications

• Continue regular sheet washing (2-3 times weekly)
• Consider low-glycemic diet
• Reduce dairy consumption, particularly skim milk
• Use oil-free, non-comedogenic cosmetics and hair products 1

Common Pitfalls to Avoid

1. Monotherapy with topical antibiotics: Using clindamycin alone promotes bacterial resistance and has limited efficacy 1, 2
2. Inconsistent application: Emphasize importance of daily adherence to regimen
3. Premature discontinuation: Warn patient that full improvement may take 8-12 weeks
4. Excessive washing/scrubbing: Can worsen irritation and inflammation
5. Spot treatment only: Medications should be applied to entire face to treat visible and developing lesions

The American Academy of Dermatology guidelines strongly support this multi-mechanistic approach targeting different acne pathways simultaneously for moderate acne, which is more effective than continuing with clindamycin monotherapy 1.