What is the treatment algorithm for acne?

Treatment Algorithm for Acne

The treatment of acne should follow a severity-based approach, with topical retinoids and benzoyl peroxide forming the foundation of therapy for mild acne, while moderate to severe acne requires combination therapy with systemic agents. 1

Assessment and Classification

• Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide treatment selection 1
• Evaluate impact on quality of life, satisfaction with appearance, and presence of scarring, as these factors may warrant more aggressive treatment 2
• For patients with signs of hyperandrogenism, endocrine testing is warranted, including free and total testosterone, DHEA-S, androstenedione, luteinizing hormone, and follicle-stimulating hormone 2

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoids (tretinoin, adapalene 3, tazarotene) + benzoyl peroxide 4 1
• Alternative options:
  • Azelaic acid for patients with post-inflammatory dyspigmentation 1
  • Topical dapsone 5% gel, particularly effective for inflammatory acne in adult females 1

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, but always in combination with benzoyl peroxide to prevent bacterial resistance 1
• Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) enhance treatment compliance 5

Moderate-to-Severe Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 1
• Preferred oral antibiotics: doxycycline and minocycline 1
• Limit systemic antibiotics to 3-4 months to prevent bacterial resistance 1
• Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy in patients with moderate inflammatory acne 5

Severe, Nodular, or Recalcitrant Acne

• Isotretinoin is indicated for severe, recalcitrant nodular acne 6
• Oral corticosteroid therapy can provide temporary benefit in patients with severe inflammatory acne while starting standard acne treatment 5

Hormonal Therapy Options

• For female patients with hormonal acne or signs of hyperandrogenism:
  • Combined oral contraceptives with FDA approval for acne 7
  • Spironolactone (50-100 mg daily) as first-choice oral anti-androgen therapy 2, 7
  • Potassium monitoring is of low usefulness in patients without risk factors for hyperkalemia 7

Maintenance Therapy

• Topical retinoids are essential for maintenance after clearing to prevent recurrence 1
• Benzoyl peroxide can be continued as maintenance therapy 5

Special Considerations

• Treatment for back acne follows the same severity-based approach as facial acne 1
• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children with acne 5
• Intralesional corticosteroids may be effective for larger acne papules or nodules at risk of scarring 2

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 1
• Underestimating severity when scarring is present 1
• Extended use of systemic antibiotics beyond 3-4 months 1
• Failing to consider underlying endocrine disorders in patients with signs of hyperandrogenism 2
• Not using benzoyl peroxide concurrently with antibiotics to prevent resistance 2

Topical Therapy Details

• Benzoyl peroxide: Available in 2.5-5% concentrations, with lower concentrations causing less irritation; no bacterial resistance has been reported 1
• Topical retinoids: Include tretinoin (0.025-0.1%), adapalene (0.1%, 0.3%), tazarotene (0.05%, 0.1%), and trifarotene 1
• Some tretinoin formulations should be applied in the evening due to photolability and should not be used with benzoyl peroxide 1
• Azelaic acid: Mildly effective as a comedolytic, antibacterial, and anti-inflammatory agent; particularly useful for patients with post-inflammatory hyperpigmentation 1