What are the treatment options for acne in adults and kids?

Acne Treatment in Adults and Children

For adults and adolescents with acne, start with combination topical therapy using benzoyl peroxide plus a topical retinoid for mild disease, escalate to oral antibiotics (doxycycline) combined with topical agents for moderate inflammatory acne (limited to 3-4 months maximum), and use isotretinoin for severe, scarring, or treatment-resistant cases. 1, 2, 3

Treatment Algorithm by Severity

Mild Acne (Primarily Comedonal)

• Topical retinoids (adapalene, tretinoin, or tazarotene) are the cornerstone of treatment and should be used as monotherapy or in combination with benzoyl peroxide. 1, 3
• Benzoyl peroxide 2.5-5% can be used alone or combined with topical retinoids for enhanced efficacy. 1, 4
• Azelaic acid is particularly useful for post-inflammatory hyperpigmentation that commonly accompanies acne lesions. 1, 5
• Never use topical antibiotics (clindamycin or erythromycin) as monotherapy due to rapid development of bacterial resistance. 1, 2, 3

Moderate Acne (Mixed Comedonal and Inflammatory)

• Combination topical therapy is strongly recommended: benzoyl peroxide + topical retinoid, or fixed-dose combinations of benzoyl peroxide + topical antibiotic (clindamycin or erythromycin). 1, 3
• If inadequate response after 6-8 weeks of topical therapy, add oral antibiotics. 3
• Doxycycline 100 mg once daily is the preferred oral antibiotic for patients ≥9 years of age. 2, 3
• Minocycline or sarecycline are alternative oral antibiotics if doxycycline is not tolerated. 3
• Critical: Limit systemic antibiotic duration to 3-4 months maximum to prevent bacterial resistance, and always combine with benzoyl peroxide. 1, 2, 3

Severe or Scarring Acne

• Isotretinoin 0.5-1 mg/kg/day for 15-20 weeks is the gold standard and should be strongly considered for any patient with scarring or significant psychosocial burden, regardless of lesion count. 2
• Baseline liver function tests and lipid panels are required, with at least one repeat during treatment. 2
• Isotretinoin must be taken with food to optimize bioavailability. 6
• The presence of scarring automatically indicates need for aggressive treatment with isotretinoin regardless of total lesion count. 2

Adjunctive Therapies for Large Cystic Lesions

• Intralesional triamcinolone acetonide 10 mg/mL can flatten individual large, painful cystic nodules within 48-72 hours and prevent scarring. 2, 3

Hormonal Therapy Options (Female Patients Only)

• Combined oral contraceptives or spironolactone should be considered for women with hormonal components to their acne, including acne flares with menstrual cycle or clinical signs of hyperandrogenism. 1, 2
• Hormonal testing (free and total testosterone, DHEA-S, androstenedione, LH, FSH) may be warranted in women with severe acne, hirsutism, or irregular menses to evaluate for PCOS or other endocrine disorders. 1

Maintenance Therapy After Clearance

• Topical retinoid monotherapy (adapalene 0.1-0.3% gel or tretinoin 0.025-0.1% cream/gel) should be continued indefinitely after achieving clearance to prevent recurrence. 2, 3
• This maintenance approach applies after successful treatment with either oral antibiotics or isotretinoin. 2

Special Considerations for Children Under 12 Years

Treatment Options for Young Children

• Benzoyl peroxide is the first-line topical agent for children under 9 years due to its antimicrobial properties and lack of resistance development. 7
• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children. 1
• Tetracycline antibiotics (doxycycline, minocycline) are absolutely contraindicated in children under 8 years due to risk of permanent tooth discoloration. 7
• Standard topical retinoids are not FDA-approved for children under 9-12 years of age, though they may be used off-label with caution. 7

Monitoring in Pediatric Patients

• Assess treatment response after 4-6 weeks. 7
• Monitor carefully for scarring, which would indicate need for more aggressive therapy. 7
• Isotretinoin can be used in adolescents ages 12-17 years for severe recalcitrant nodular acne, but requires careful consideration due to potential effects on bone density. 6

Critical Pitfalls to Avoid

Antibiotic Stewardship

• Never extend oral antibiotics beyond 3-4 months, as this dramatically increases resistance risk. 2, 3
• Never use topical or oral antibiotics without concurrent benzoyl peroxide, as resistance develops rapidly without it. 1, 2, 3
• Benzoyl peroxide is essential for preventing bacterial resistance when combined with antibiotics. 1, 4

Patient Counseling

• Doxycycline causes significant photosensitivity; patients must be counseled about strict sun protection and daily sunscreen use. 2
• Isotretinoin is highly teratogenic and requires enrollment in the iPledge risk management program for all patients, prescribers, and pharmacists. 8
• Topical retinoids commonly cause initial irritation and dryness; starting with lower concentrations or every-other-night application can improve tolerability. 5

Treatment Timeline

• Re-evaluate topical therapy efficacy after 6-8 weeks. 3
• Re-evaluate systemic antibiotic therapy at 3-4 months to minimize bacterial resistance. 3
• Most acne treatments require 8-12 weeks to show significant improvement; set realistic patient expectations. 8