Acne Treatment Recommendations
The first-line treatment for acne vulgaris is a combination of topical retinoid (tretinoin, adapalene, tazarotene, or trifarotene) plus benzoyl peroxide 2.5-5%, with treatment selection based on acne severity. 1
Treatment Algorithm Based on Acne Severity
Mild Acne
- First-line: Topical retinoid + benzoyl peroxide 2.5-5%
- Retinoids are comedolytic, resolve microcomedones, and have anti-inflammatory properties
- Benzoyl peroxide has antimicrobial properties without causing bacterial resistance
- Alternative options:
- Topical clascoterone
- Salicylic acid
- Azelaic acid (particularly beneficial for post-inflammatory hyperpigmentation in darker skin types)
Moderate Acne
- First-line: Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1%)
- If insufficient response: Add systemic antibiotic (preferably doxycycline)
- Low-dose doxycycline (40 mg daily or 20 mg twice daily) is recommended
- Limit treatment duration to 12 weeks when possible to prevent bacterial resistance
Severe or Nodular Acne
- First-line: Systemic antibiotic + topical retinoid + benzoyl peroxide
- If ineffective or scarring present: Oral isotretinoin 0.25-0.4 mg/kg/day for 16-20 weeks 1
- Strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne failing standard treatment
Hormonal Acne
- Consider adding: Hormonal therapy in addition to topical therapy
- FDA-approved combined oral contraceptives (COCs): Ethinyl estradiol/drospirenone, Ethinyl estradiol/norgestimate, Ethinyl estradiol/norethindrone acetate/ferrous fumarate, or Ethinyl estradiol/drospirenone/levomefolate
- Spironolactone (50-100 mg daily) can be safely combined with drospirenone-containing COCs for enhanced anti-androgenic effects
Monitoring and Follow-up
- Initial improvement should be noticeable within 3 weeks
- Reassess efficacy after 6-8 weeks of treatment
- Maximum lesion reduction typically occurs after 8-12 weeks
- For COCs, significant improvement usually seen by the end of cycle 3
Important Considerations and Precautions
Isotretinoin Precautions 2
- Pregnancy risk: Absolute contraindication in pregnancy (Category X)
- Monitoring: Regular assessment for adverse effects including:
- Skeletal effects (hyperostosis, decreased bone mineral density)
- Visual problems (corneal opacities, decreased night vision)
- Gastrointestinal symptoms (abdominal pain, rectal bleeding, severe diarrhea)
- iPledge program: Mandatory registration for patients, pharmacists, and prescribers due to teratogenicity risk 3
Antibiotic Use
- Systemic and topical antibiotics should only be used in combination with benzoyl peroxide and retinoids
- Maximum treatment duration of 12 weeks to prevent bacterial resistance 1, 3
Contraindications for Common Acne Medications
- Doxycycline: Children under 8 years, pregnant or breastfeeding women
- Isotretinoin: Pregnancy, breastfeeding
- Spironolactone: Pregnancy, breastfeeding
- COCs: Women over 35 who smoke (increased cardiovascular risk)
- Note: Drospirenone-containing COCs have slightly higher VTE risk (10 per 10,000 woman-years) compared to levonorgestrel-containing COCs (3-9 per 10,000 woman-years) 1
Lifestyle Modifications
- Reduce consumption of high-glycemic foods
- Consider limiting dairy intake
- These modifications may provide additional benefit alongside pharmacological treatments 1
When to Refer to a Dermatologist
- Moderate to severe acne
- Acne causing psychological distress or scarring
- No improvement after 4-6 weeks of lifestyle changes
- Failure to respond to standard treatment regimens 1
Acne affects approximately 9% of the global population and 85% of adolescents aged 12-24 years, with potential for significant physical and psychological impacts including permanent scarring, anxiety, depression, and reduced quality of life 4. Early, appropriate treatment based on acne severity is essential to prevent these complications and improve outcomes.