Management of Acne Vulgaris
First-Line Treatment Approach
Begin with topical retinoids combined with benzoyl peroxide as the foundation for treating acne, regardless of severity, and add oral antibiotics only for moderate-to-severe inflammatory disease. 1
The 2024 American Academy of Dermatology guidelines provide the most current evidence-based framework for acne management, emphasizing combination therapy from the outset to target multiple pathogenic mechanisms simultaneously. 1
Treatment Algorithm by Severity
Mild Acne (Predominantly Comedonal)
Start with topical retinoid + benzoyl peroxide 2.5-5% applied once daily. 1, 2
Topical retinoid options include:
Apply tretinoin once daily at bedtime to completely dry skin (wait 20-30 minutes after washing). 4
Benzoyl peroxide kills Cutibacterium acnes without inducing bacterial resistance and provides mild comedolytic effects. 2, 3
Lower concentrations of benzoyl peroxide (2.5%) cause less irritation than 5% while maintaining efficacy. 2
Alternative agents for mild acne:
- Azelaic acid 20% for patients with post-inflammatory hyperpigmentation, particularly those with darker skin tones 1, 2
- Salicylic acid 0.5-2% (over-the-counter, limited evidence) 1, 2
- Topical clascoterone (newer topical antiandrogen) 1
Moderate Acne (Mixed Comedonal and Inflammatory)
Use fixed-dose combination products containing topical retinoid + benzoyl peroxide as first-line therapy. 1, 2
Add topical antibiotics (clindamycin 1% or erythromycin 3%) ONLY in combination with benzoyl peroxide—never as monotherapy due to rapid resistance development. 1, 2
Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and does not require G6PD testing before initiation. 1, 2
Moderate-to-Severe Inflammatory Acne
Initiate triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide. 1, 2
Oral antibiotic selection:
- Doxycycline 100 mg once daily (strongly recommended, first-line) 1, 2
- Minocycline 100 mg once daily (conditionally recommended) 1, 2
- Sarecycline (conditionally recommended) 1
- Subantimicrobial-dose doxycycline (20 mg twice daily or 40 mg daily) has efficacy for moderate inflammatory acne. 2
Critical antibiotic stewardship principles:
- Limit systemic antibiotics to 3-4 months maximum to prevent bacterial resistance. 1, 2
- Always combine oral antibiotics with benzoyl peroxide to prevent resistance development. 1, 2
- Never use topical or oral antibiotics as monotherapy. 2, 3
For acute severe inflammatory flares:
- Oral corticosteroids provide temporary benefit while initiating standard therapy 2
- Intralesional corticosteroid injections for larger nodular lesions 1
Severe, Recalcitrant, or Scarring Acne
Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral/topical therapy. 1
This represents the only single agent effective against all four pathogenic mechanisms of acne and should be considered earlier rather than later when these criteria are met. 1
Hormonal Therapy for Female Patients
For women with hormonal acne patterns (jawline/lower face distribution, premenstrual flares):
- Combined oral contraceptive pills (conditionally recommended) 1, 2
- Spironolactone (conditionally recommended, particularly for those who cannot tolerate or prefer to avoid oral antibiotics) 1, 2
These agents are appropriate additions to topical therapy and can be used as alternatives to oral antibiotics for moderate-to-severe inflammatory acne in appropriate candidates. 2
Maintenance Therapy After Clearance
Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence. 1, 2
- Topical retinoids resolve microcomedones and prevent new lesion formation 1, 2
- Benzoyl peroxide can be continued as adjunctive maintenance therapy 2, 3
- Stopping treatment once acne clears leads to relapse—maintenance is essential. 5, 3
Special Populations
Preadolescent Children (≥9 years)
- Benzoyl peroxide 2.5% as primary treatment 3
- Adapalene 0.1% gel for predominantly comedonal acne 2, 3
- Tetracycline antibiotics are contraindicated in children under 8 years due to permanent tooth discoloration risk. 3
Back Acne (Truncal Acne)
- Follow the same severity-based algorithm as facial acne 2, 5
- Adapalene 0.1% gel available over-the-counter for mild back acne 5
- Benzoyl peroxide can bleach clothing and bedding—advise patients to wear old or white clothing. 5
Pregnancy Considerations
- No human studies establish safety of tretinoin in pregnancy—consult physician before use if pregnant, planning pregnancy, or nursing. 4
- Azelaic acid is pregnancy category B 1
- Clindamycin topical is pregnancy category B 1
Critical Pitfalls to Avoid
Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 2, 3
Do not 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—this warrants more aggressive treatment including earlier consideration of isotretinoin. 1, 3
Avoid stopping treatment once acne clears—maintenance with topical retinoids is essential to prevent relapse. 5, 3
Do not apply tretinoin to wet skin—wait 20-30 minutes after washing for skin to completely dry to minimize irritation. 4
Avoid excessive application of retinoids—more is not better and increases irritation without improving efficacy. 4
Do not use tretinoin with benzoyl peroxide simultaneously (tretinoin is photolabile)—apply at different times of day. 2
Counsel patients about initial acne flare at 3-6 weeks—this represents medication action on deep lesions and should not prompt discontinuation. 4
Practical Application Guidance
Topical Retinoid Initiation
- Start sensitive patients with every-other-night application, advancing to nightly as tolerated. 4
- Apply to completely dry skin 20-30 minutes after washing. 4
- Use pea-sized amount for entire face—medication should become invisible immediately. 4
- Avoid corners of nose, mouth, eyes, and open wounds. 4
- Expect improvement by 12 weeks, but full benefit may require 6 months. 4
Sun Protection
- Topical retinoids increase photosensitivity—daily broad-spectrum sunscreen is mandatory. 2, 4
- Avoid artificial sunlamps and minimize sun exposure during treatment. 4
- Use non-comedogenic moisturizer with SPF every morning. 4