What is the treatment algorithm for acne vulgaris?

Treatment Algorithm for Acne Vulgaris

The treatment of acne vulgaris should follow a severity-based approach with topical retinoids and benzoyl peroxide as the cornerstone of therapy for all acne types, with additional agents selected based on acne severity and patient characteristics. 1, 2

Assessment and Classification

• Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide treatment selection 1, 2
• Evaluate impact on quality of life, satisfaction with appearance, and presence of scarring, as these factors may warrant more aggressive treatment 1, 2

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoid (tretinoin, adapalene, tazarotene) + benzoyl peroxide (BP) 1, 2
• Topical retinoids are essential as they are comedolytic, resolve microcomedones, and have anti-inflammatory properties 1, 3
• Benzoyl peroxide (2.5-5%) kills C. acnes with no reported bacterial resistance 1, 4
• Adapalene 0.1% gel is available over-the-counter for mild acne 4

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
• Alternative options include:
  • Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin or erythromycin) 1, 4
  • Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) may enhance treatment compliance 1
  • Topical dapsone 5% gel is particularly effective for inflammatory lesions, especially in adult females 1, 4

Moderate-to-Severe Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline and minocycline are more effective than tetracycline for systemic antibiotic therapy 1, 4
• Limit systemic antibiotic use to 3-4 months to minimize bacterial resistance 2, 4
• For females with hormonal component: Consider combined oral contraceptives and/or spironolactone 1, 2

Severe, Recalcitrant Acne

• Isotretinoin is the treatment of choice for severe, nodular acne or acne that fails standard treatment 1, 5
• Patients with psychosocial burden or scarring should be considered candidates for isotretinoin 1
• Monitoring requirements include LFTs and lipids; pregnancy prevention is mandatory for persons of pregnancy potential 1

Special Considerations

Adjunctive Treatments

• Intralesional corticosteroids for larger acne papules or nodules at risk of scarring 1
• For back acne: Follow the same severity-based approach as facial acne 4

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 2, 3
• Apply tretinoin once daily before bedtime after washing with a mild soap and allowing skin to dry for 20-30 minutes 3

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 2, 6
• Underestimating severity when scarring is present 2
• Extended use of systemic antibiotics beyond 3-4 months 2
• Stopping treatment once acne clears; maintenance therapy is essential to prevent relapse 2, 4
• Excessive application of topical treatments; use only the recommended amount to avoid irritation 3
• Failing to consider the psychological impact of acne, especially with scarring 2

Proper Application of Topical Treatments

• For tretinoin: Apply a pea-sized amount to cover the entire affected area after washing with a mild soap and allowing skin to dry for 20-30 minutes 3
• Avoid applying near corners of the nose, mouth, eyes, and open wounds 3
• Expect some discomfort or peeling during early days of treatment (2-4 weeks) as skin adjusts to tretinoin 3
• Continue treatment even if new blemishes appear at 3-6 weeks; improvement typically occurs after 6-12 weeks of therapy 3

Evidence-Based Treatment Outcomes

• Topical retinoids combined with benzoyl peroxide show superior efficacy for mild-to-moderate acne compared to monotherapy 7
• Oral isotretinoin at cumulative dose ≥120 mg/kg per course shows highest efficacy for moderate-to-severe acne 7
• Combination therapy with benzoyl peroxide, topical retinoid, and oral tetracycline demonstrates significant improvement for moderate-to-severe acne 7