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
• Add topical antibiotics (clindamycin 1% or erythromycin 3%) ONLY when combined with benzoyl peroxide—never as monotherapy due to rapid resistance development 3, 1, 2
• Fixed-combination options include: clindamycin 1%/benzoyl peroxide 5%, erythromycin 3%/benzoyl peroxide 5%, or adapalene/benzoyl peroxide 3, 1
• For adult females with inflammatory acne, topical dapsone 5% gel is particularly effective and does not require G6PD testing 3, 1

Moderate-to-Severe Acne (Extensive Inflammatory Lesions)

• Initiate triple therapy: oral antibiotic + topical retinoid + benzoyl peroxide 3, 1, 2
• Oral antibiotics (first-line): Doxycycline 100 mg once daily OR minocycline 100 mg once daily 3, 1, 2
• Doxycycline and minocycline are equally effective and superior to tetracycline 3
• Critical: Limit oral antibiotics to 3-4 months maximum and re-evaluate to prevent bacterial resistance 3, 1, 2
• Always continue topical retinoid + benzoyl peroxide during and after oral antibiotic therapy 3, 1
• Avoid oral erythromycin or azithromycin except in patients who cannot tolerate tetracyclines (pregnant women, children <8 years) due to high resistance rates 3

Severe Nodulocystic Acne

• Consider oral isotretinoin for severe, recalcitrant disease 5, 6
• Short-term oral corticosteroids can provide temporary benefit while initiating standard therapy 1

Hormonal Therapy for Female Patients

For females with hormonal acne (jawline/chin distribution, premenstrual flares, or polycystic ovarian features), add combined oral contraceptives or spironolactone to topical therapy. 1, 2

• Combined oral contraceptives are effective for inflammatory acne in females 1, 2
• Spironolactone is useful for females with hormonal components or those preferring to avoid oral antibiotics 1

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
• Do not discontinue therapy once improvement occurs—this leads to rapid relapse 4

Application Instructions for Topical Retinoids

• Wash face with mild, non-medicated soap and pat dry 4
• Wait 20-30 minutes for skin to be completely dry before application 4
• Apply once daily in the evening (tretinoin is photolabile) 3, 4
• Use pea-sized amount for entire face—spread to forehead, chin, and both cheeks 3, 4
• Avoid corners of nose, mouth, eyes, and open wounds 4
• Apply moisturizer with sunscreen every morning 4
• Expect initial irritation, peeling, or new blemishes at 3-6 weeks—this is normal adjustment and should not prompt discontinuation 4

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
• Do not combine topical and systemic antibiotics of the same class 7
• Do not apply topical retinoids to wet skin—this dramatically increases irritation 4
• Do not use potentially irritating products (astringents, alcohol-containing products, medicated soaps) concurrently with retinoids 4
• Avoid excessive washing or scrubbing—this worsens acne rather than improving it 4
• Do not underestimate severity when scarring is present—this warrants more aggressive therapy 1, 2

Special Populations

Children <12 Years

• Start with benzoyl peroxide 2.5% as first-line 2, 8
• For children ≥9 years with comedonal acne, consider adapalene 0.1% gel 2
• Tetracycline antibiotics are contraindicated in children <8 years due to permanent tooth discoloration risk 2, 8

Pregnancy

• Tretinoin is pregnancy category C—avoid in pregnant or potentially pregnant women 3, 4
• Tazarotene is pregnancy category X—absolutely contraindicated 3
• Benzoyl peroxide and azelaic acid are safer alternatives during pregnancy 3

Expected Timeline

• Initial adjustment period with possible irritation/peeling: 2-4 weeks 4
• New blemishes may appear at 3-6 weeks—continue therapy 4
• Noticeable improvement: 6-12 weeks 4
• Full therapeutic effect: 12 weeks minimum 4