What is the recommended treatment for acne vulgaris?

Recommended Treatment for Acne Vulgaris

For acne vulgaris, initiate treatment with a topical retinoid (adapalene, tretinoin, or tazarotene) combined with benzoyl peroxide as first-line therapy, escalating to oral antibiotics plus topical combination therapy for moderate-to-severe disease, and reserving oral isotretinoin for severe, scarring, or treatment-resistant cases. 1, 2, 3

Treatment Algorithm Based on Severity

Mild Acne (Predominantly Comedonal)

• Start with topical retinoid + benzoyl peroxide (2.5-5%) as the foundation of therapy 1, 2, 3
• Topical retinoid options include adapalene (0.1% or 0.3%), tretinoin (0.025-0.1%), or tazarotene (0.05% or 0.1%) 2
• Benzoyl peroxide is strongly recommended because it provides antimicrobial activity without risk of bacterial resistance 1, 3
• Alternative agents for specific situations:
  • Azelaic acid for patients with post-inflammatory hyperpigmentation or darker skin types (Fitzpatrick IV or greater) 1, 2
  • Salicylic acid (0.5-2%) as an over-the-counter option, though clinical evidence is limited 1, 2

Moderate Acne (Mixed Comedonal and Inflammatory)

• Use fixed-dose combination products containing topical retinoid + benzoyl peroxide as first-line 1, 2, 3
• Add topical antibiotics (clindamycin or erythromycin) ONLY in combination with benzoyl peroxide to prevent bacterial resistance 1, 2, 3
• Fixed-combination options include erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, or clindamycin 1%/BP 3.75% 2, 3
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and can be used twice daily 1, 2
• Topical clascoterone (a newer antiandrogen) is conditionally recommended for inflammatory acne 1, 2

Moderate-to-Severe Acne (Extensive Inflammatory Disease)

• Initiate oral antibiotics + topical retinoid + benzoyl peroxide as triple therapy 1, 2, 3
• Doxycycline is the strongly recommended first-choice oral antibiotic with moderate certainty evidence 1, 3
• Minocycline is conditionally recommended as an alternative, though not superior to doxycycline 1
• Sarecycline is conditionally recommended as a newer narrow-spectrum tetracycline option 1
• Limit systemic antibiotic duration to 3-4 months maximum to minimize bacterial resistance 1, 3
• Subantimicrobial doxycycline dosing (20-40 mg daily) has shown efficacy for moderate inflammatory acne 1, 2

Severe Acne (Nodular, Scarring, or Treatment-Resistant)

• Oral isotretinoin is strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne failing standard oral/topical therapy 1, 3, 4
• Intralesional corticosteroid injections should be added for larger papules or nodules at risk of scarring 1, 4
• Oral corticosteroid therapy can provide temporary benefit while initiating standard treatment for severe inflammatory acne 2

Hormonal Therapy for Female Patients

• Combined oral contraceptive pills are conditionally recommended for female patients with hormonal acne patterns 1, 3, 4
• Spironolactone is conditionally recommended as an antiandrogen option for adult females 1, 3, 4
• In meta-analysis, combined oral contraceptives reduced inflammatory lesions by 62% at 6 months compared to 26% with placebo 5

Application Instructions and Practical Considerations

Topical Retinoid Application

• Apply once daily before bedtime to completely dry skin (wait 20-30 minutes after washing) 6
• For sensitive skin, start every other night then advance to nightly application 6
• Use approximately half-inch of product for entire face, spreading thinly until invisible 6
• Avoid corners of nose, mouth, eyes, and open wounds 6
• Apply moisturizer with sunscreen each morning as retinoids cause photosensitivity 2, 6

Benzoyl Peroxide Considerations

• Lower concentrations (2.5%) cause less irritation than higher concentrations while maintaining efficacy 2
• Do NOT apply benzoyl peroxide simultaneously with topical dapsone as it causes orange-brown skin discoloration 1
• Benzoyl peroxide can bleach fabrics and hair 2

Maintenance Therapy

• Continue topical retinoids after clearing to prevent recurrence 2, 3
• Benzoyl peroxide can be continued as maintenance therapy 2, 3
• Re-evaluate treatment efficacy at 6-8 weeks, with many patients seeing improvement by 12 weeks 4, 6

Critical Pitfalls to Avoid

• NEVER use topical antibiotics as monotherapy - this dramatically increases bacterial resistance risk 1, 2, 3
• Do not extend systemic antibiotic use beyond 3-4 months without re-evaluation 1, 3
• Always combine systemic antibiotics with benzoyl peroxide to prevent resistance development 1, 4
• Do not underestimate severity when scarring is present - this warrants more aggressive treatment 2, 3
• Avoid excessive washing or scrubbing, which can worsen acne rather than improve it 6
• Do not discontinue treatment at first signs of improvement - continue until physician instructs otherwise 6

Special Population Considerations

Preadolescents and Children (Age 9-12 years)

• Benzoyl peroxide (starting at 2.5%) is the primary treatment for children under 12 3
• Adapalene 0.1% gel can be considered for predominantly comedonal acne in children ≥9 years 3
• Tetracycline antibiotics (doxycycline, minocycline) are contraindicated under age 8 due to permanent tooth discoloration risk 3, 4

Pregnancy Considerations

• Tretinoin safety in pregnancy is not established; consult physician before use if pregnant or nursing 6
• Azelaic acid is pregnancy category B and safer for pregnant patients 1
• Erythromycin and azithromycin should be reserved for pregnant women who cannot use tetracyclines 1

Back Acne

• Treatment follows the same severity-based approach as facial acne 2
• Adapalene 0.1% gel is available over-the-counter for mild back acne 2

Expected Timeline and Patient Counseling

• Initial adjustment period may include mild discomfort, peeling, or skin blush in first 2-4 weeks 6
• Some patients experience apparent worsening with new papules/pustules at 3-6 weeks - continue treatment through this phase 6
• Noticeable improvement typically occurs by 6-12 weeks of consistent therapy 4, 6
• Emphasize that excessive application does not accelerate results and may increase irritation 6