What are the recommended treatments for acne?

Recommended Treatments for Acne

For mild acne, start with a topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% applied once daily; for moderate-to-severe inflammatory acne, add oral doxycycline 100 mg daily for a maximum of 3-4 months while continuing the topical regimen. 1, 2

Treatment Algorithm by Severity

Mild Acne (Comedonal or Minimal Inflammatory Lesions)

• First-line therapy: Topical retinoid + benzoyl peroxide 1, 2

  • Topical retinoids work through comedolytic and anti-inflammatory mechanisms and normalize follicular keratinization 1, 3
  • Options include adapalene (0.1% available over-the-counter, 0.3% prescription), tretinoin (0.025-0.1%), or tazarotene (0.05-0.1%) 1, 3
  • Benzoyl peroxide (2.5-5%) provides antimicrobial activity without bacterial resistance and mild comedolytic effects 1, 2

• Alternative options for specific situations:

  • Azelaic acid 15-20% for patients with post-inflammatory hyperpigmentation 1, 2
  • Salicylic acid 0.5-2% as an over-the-counter comedolytic agent (though evidence is limited) 1

Moderate Acne (Mixed Comedonal and Inflammatory)

• First-line therapy: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2

• Add topical antibiotics (clindamycin 1% or erythromycin 3%) for inflammatory lesions, but always combined with benzoyl peroxide—never as monotherapy 1, 2

  • Fixed-combination products enhance compliance: clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5% 1, 2
  • Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 2

Moderate-to-Severe Inflammatory Acne

• First-line therapy: Oral antibiotics + topical retinoid + benzoyl peroxide (triple therapy) 1, 2

• Oral antibiotic selection:

  • Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1, 2
  • Minocycline 100 mg once daily (conditionally recommended with moderate evidence) 1, 2
  • Sarecycline (conditionally recommended with high-certainty evidence) 1
  • Limit systemic antibiotics to 3-4 months maximum to prevent bacterial resistance 1, 2

• Critical requirement: Always use oral antibiotics with concurrent benzoyl peroxide and topical retinoid to prevent resistance development 1, 2

Severe, Recalcitrant, or Scarring Acne

• Isotretinoin is recommended for severe acne, acne failing standard therapy, 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 not needed in healthy patients) 1
  • Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 1
  • Pregnancy prevention is mandatory for persons of childbearing potential 1

Hormonal Therapy for Female Patients

• Combined oral contraceptives are effective for inflammatory acne in females (conditionally recommended with moderate evidence) 1, 2

  • In meta-analysis, COCs reduced inflammatory lesions by 62% at 6 months 4

• Spironolactone is useful for females with hormonal components to acne or those who cannot tolerate oral antibiotics (conditionally recommended with moderate evidence) 1, 2

  • Potassium monitoring is not needed in healthy patients without risk factors for hyperkalemia 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
  • Use lower concentrations and volumes to minimize adverse effects 1

Maintenance Therapy

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

Application Guidelines

• Apply topical retinoids once daily before bedtime as a thin layer to all affected areas 3
• Keep away from eyes, mouth, nasal creases, and mucous membranes 3
• Use daily sunscreen due to photosensitivity from retinoids 2, 3
• Benzoyl peroxide can bleach clothing and bedding—wear old or white clothing 5

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 6
• Do not extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 2
• Do not underestimate severity when scarring is present—these patients should be considered candidates for isotretinoin 1
• Do not stop treatment once acne clears—maintenance with topical retinoids is essential 2, 3
• Some tretinoin formulations should not be used simultaneously with benzoyl peroxide due to oxidation and inactivation 3

Special Populations

• Back acne: Follow the same severity-based approach as facial acne 2, 5
• Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 2
• Pregnancy/lactation: Benzoyl peroxide and azelaic acid are safe options (BPO is degraded to benzoic acid) 7