What are the treatment options for acute acne vulgaris?

Acute Treatment of Acne Vulgaris

For acute acne vulgaris, begin immediately 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 in the evening, and for moderate-to-severe inflammatory acne, add oral doxycycline 100 mg or minocycline 100 mg once daily for a maximum of 3-4 months. 1, 2

Treatment Algorithm Based on Severity

Mild Acne (Predominantly Comedonal)

• Start with topical retinoid + benzoyl peroxide as first-line therapy 3, 1, 2
• Apply tretinoin 0.025-0.1% cream/gel OR adapalene 0.1-0.3% gel once daily in the evening to completely dry skin (wait 20-30 minutes after washing) 4
• Add benzoyl peroxide 2.5-5% once daily (lower concentrations cause less irritation while maintaining efficacy) 1, 2
• For patients with post-inflammatory hyperpigmentation, substitute azelaic acid 15-20% as the comedolytic agent 1, 2

Moderate Acne (Mixed Comedonal and Inflammatory)

• Use fixed-combination products containing topical retinoid + benzoyl peroxide as first-line 1, 2
• Options include: adapalene 0.1-0.3%/benzoyl peroxide 2.5% gel applied once daily 3
• Add topical antibiotics ONLY in combination with benzoyl peroxide, never as monotherapy 3, 1, 2
• Fixed combinations: clindamycin 1%/benzoyl peroxide 5% or erythromycin 3%/benzoyl peroxide 5% applied twice daily 3, 1
• For adult females with inflammatory acne, topical dapsone 5% gel is particularly effective (no G6PD testing required) 3, 1

Moderate-to-Severe Acne (Extensive Inflammatory Lesions)

• Initiate triple therapy: oral antibiotic + topical retinoid + benzoyl peroxide 3, 1, 2
• First-line oral antibiotics:
  • Doxycycline 100 mg once daily (strongly recommended) 3, 1, 2
  • Minocycline 100 mg once daily (conditionally recommended) 3, 1
• Critical: Limit oral antibiotics to 3-4 months maximum and re-evaluate to prevent resistance 3, 1, 2
• Continue topical retinoid + benzoyl peroxide throughout and after antibiotic course 3, 1
• Subantimicrobial doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy for moderate inflammatory acne 3, 1

Severe Nodulocystic Acne

• Consider short-term oral corticosteroids for temporary benefit while initiating standard therapy 1
• Refer for isotretinoin evaluation if inadequate response to conventional therapy 5, 6

Hormonal Therapy for Female Patients

For females with hormonal acne patterns (jawline/lower face distribution, premenstrual flares, or polycystic ovarian syndrome features), add hormonal therapy to topical regimen: 1, 2

• Combined oral contraceptives (estrogen-containing) are effective for inflammatory acne 1, 2
• Spironolactone is useful for females who cannot tolerate or prefer to avoid oral antibiotics 1, 2

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence 1, 2

• Benzoyl peroxide can be continued as maintenance therapy 1, 2
• This prevents the formation of new microcomedones that lead to clinical lesions 1

Application Instructions for Optimal Results

Topical Retinoids

• Apply once daily in the evening to completely dry skin 4
• Wait 20-30 minutes after washing before application to minimize irritation 4
• Use a pea-sized amount for the entire face (forehead, chin, both cheeks) 4
• Avoid corners of nose, mouth, eyes, and open wounds 4
• Tretinoin formulations should not be used with benzoyl peroxide due to photolability 1
• Apply moisturizer with sunscreen every morning (non-comedogenic) 4

Benzoyl Peroxide

• Start with 2.5% concentration to minimize irritation 2, 7
• Can be applied morning or evening depending on combination regimen 3
• No bacterial resistance has been reported 1, 2

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 3, 1, 2
• Never extend oral antibiotics beyond 3-4 months without re-evaluation 3, 1, 2
• Avoid using topical retinoids on areas with active eczema or dermatitis 7
• Do not apply excessive amounts of medication—more is not better and increases irritation 4
• Avoid harsh scrubbing, frequent washing, or astringent products that worsen irritation 4
• Minimize sun exposure and use daily sunscreen, as retinoids cause photosensitivity 3, 1
• Do not underestimate severity when scarring is present—this warrants more aggressive treatment 1, 2

Expected Timeline and Patient Counseling

• Initial adjustment period: 2-4 weeks of possible discomfort, peeling, or new blemishes 4
• Improvement typically visible by 6-12 weeks—patience is essential 4
• Assess treatment response at 3-4 months and adjust if inadequate improvement 3, 1
• Continue treatment even after clearance to prevent recurrence 1, 4

Special Populations

Pediatric Patients (Age 9-11 years)

• Benzoyl peroxide 2.5% is first-line for children under 12 2, 7
• Adapalene 0.1% gel can be considered for predominantly comedonal acne in patients ≥9 years 1, 2
• Tetracycline antibiotics are contraindicated under age 8 due to permanent tooth discoloration risk 2, 7

Pregnancy

• Tretinoin is pregnancy category C; avoid in pregnancy 3, 4
• Tazarotene is pregnancy category X; absolutely contraindicated 3
• Benzoyl peroxide and azelaic acid are safer alternatives during pregnancy 3
• For pregnant women requiring systemic therapy, erythromycin is preferred over tetracyclines 3