What are the recommended treatments for acne?

Recommended Treatments for Acne

For acne treatment, begin with a topical retinoid (adapalene, tretinoin, or tazarotene) combined with benzoyl peroxide 2.5-5% as first-line therapy for mild to moderate disease, escalating to add oral antibiotics (doxycycline or minocycline) for moderate-to-severe inflammatory acne, always with concurrent benzoyl peroxide to prevent resistance. 1, 2

Treatment Algorithm Based on Severity

Mild Acne

• Start with topical retinoid + benzoyl peroxide as first-line therapy 1, 2
• Topical retinoid options include adapalene 0.1-0.3% (available over-the-counter at 0.1%), tretinoin 0.025-0.1%, or tazarotene 0.05-0.1% 1, 2, 3
• Benzoyl peroxide 2.5-5% provides antimicrobial activity without bacterial resistance; lower concentrations cause less irritation 1, 2
• Alternative agents for specific situations: azelaic acid for post-inflammatory hyperpigmentation, salicylic acid 0.5-2% as over-the-counter option (though evidence is limited) 1, 2

Moderate Acne

• Use fixed-dose combination products: topical retinoid + benzoyl peroxide OR topical antibiotic + benzoyl peroxide 1, 2
• Add topical antibiotics (clindamycin 1% or erythromycin 3%) for inflammatory lesions, but never as monotherapy due to resistance risk 1, 2
• Fixed combinations include clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5% to enhance compliance 1, 2
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females (no G6PD testing required for topical use) 2
• Clascoterone (topical antiandrogen) is a newer option with high-certainty evidence, though conditionally recommended 1, 2

Moderate-to-Severe Inflammatory Acne

• Triple therapy is first-line: oral antibiotic + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline 100 mg once daily (strongly recommended) or minocycline 100 mg once daily (conditionally recommended) are preferred oral antibiotics 1, 2
• Sarecycline is a newer narrow-spectrum tetracycline option (conditionally recommended with high-certainty evidence) 1
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1, 2
• Always use benzoyl peroxide concurrently with any antibiotic (topical or oral) to prevent resistance development 1, 2

Severe, Recalcitrant, or Scarring Acne

• Isotretinoin is recommended for severe acne, treatment-resistant acne, or acne causing psychosocial burden or scarring 1, 2
• Daily dosing is preferred over intermittent dosing 1
• Monitor only liver function tests and lipids; CBC monitoring is not needed in healthy patients 1
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease with isotretinoin 1
• Pregnancy prevention is mandatory for persons of childbearing potential 1, 4
• Potential musculoskeletal effects: bone mineral density changes were minimal in most patients, though some showed decreases; long-term effects of multiple courses are unknown 4

Hormonal Therapy for Female Patients

• Combined oral contraceptives (COCs) are effective for inflammatory acne in females (conditionally recommended with moderate evidence) 1, 2
• Spironolactone is useful for females with hormonal acne or those unable to tolerate oral antibiotics (conditionally recommended with moderate evidence) 1, 2
• Potassium monitoring is not needed in healthy patients; consider testing only for those with risk factors for hyperkalemia (older age, medical comorbidities, medications) 1, 2

Adjunctive Treatments

• Intralesional corticosteroid injections for larger papules or nodules at risk of scarring or for rapid improvement in inflammation and pain 1, 2
• Use lower concentration and volume to minimize adverse effects (atrophy, hypopigmentation) 1

Maintenance Therapy

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence 2, 3
• Benzoyl peroxide can also be continued as maintenance 2

Special Populations and Considerations

Back Acne

• Treatment follows the same severity-based approach as facial acne 5
• Adapalene 0.1% gel is available over-the-counter for mild back acne 5
• Benzoyl peroxide can bleach clothing and bedding; wear old or white clothing when applying to back 5

Pediatric Patients (≥12 years)

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children 2
• Isotretinoin use in ages 12-17 should be given careful consideration, especially with known metabolic or structural bone disease 4
• Pediatric patients on isotretinoin had increased incidence of back pain, arthralgia, and myalgia compared to adults 4

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2
• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk 1, 2
• Do not underestimate severity when scarring is present; these patients should be considered candidates for isotretinoin 1, 2
• Do not stop treatment once acne clears; maintenance therapy with topical retinoids is essential to prevent relapse 2, 3, 5
• Topical retinoids cause photosensitivity; daily sunscreen use is mandatory 2, 3
• Some tretinoin formulations should not be used with benzoyl peroxide simultaneously due to oxidation and inactivation 2, 3

Multimodal Approach Rationale

• Combining multiple mechanisms of action is essential: retinoids address comedones and normalize keratinization, benzoyl peroxide provides antimicrobial activity, and antibiotics reduce inflammation 1, 2
• Fixed-dose combination products enhance compliance compared to multiple separate products 1, 2