Treatment for Acne Vulgaris
Begin with topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% applied once nightly as first-line therapy for mild to moderate acne, escalating to oral doxycycline 100 mg daily plus the topical combination for moderate-to-severe inflammatory disease, and reserve oral isotretinoin for severe acne, treatment-resistant cases, or when scarring or significant psychosocial burden exists. 1, 2
Treatment Algorithm by Acne Severity
Mild Acne (Predominantly Comedonal)
- Start with topical retinoid monotherapy (adapalene 0.1%, tretinoin 0.025-0.1%, or tazarotene 0.05-0.1%) applied once nightly to the entire affected area, not just individual lesions 1, 2, 3
- Add benzoyl peroxide 2.5-5% once daily if comedones are moderate or to prevent inflammatory progression 2, 3
- Adapalene 0.1% gel is available over-the-counter and may enhance accessibility 2
- Apply retinoid 20-30 minutes after washing and drying the face completely to minimize irritation 4
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 resistance risk 1, 2, 5
- Fixed-combination options include clindamycin 1%/benzoyl peroxide 5%, clindamycin 1%/benzoyl peroxide 3.75%, or erythromycin 3%/benzoyl peroxide 5% to enhance compliance 2, 6
Moderate-to-Severe Inflammatory Acne
- Initiate triple therapy: oral doxycycline 100 mg once daily + topical retinoid + benzoyl peroxide 1, 2, 5
- Doxycycline is strongly recommended with moderate-quality evidence over other oral antibiotics 1, 5
- Minocycline 100 mg once daily is conditionally recommended as an alternative 1, 2
- Limit systemic antibiotics to 3-4 months maximum to prevent bacterial resistance 1, 2, 5
- Always combine oral antibiotics with benzoyl peroxide to prevent development of antibiotic-resistant Cutibacterium acnes 1, 2, 7
Severe, Recalcitrant, or Scarring Acne
- Oral isotretinoin is strongly recommended for severe nodular acne, acne causing psychosocial burden or scarring, or acne failing standard oral/topical therapy 1, 5
- Isotretinoin is the only medication that targets all four pathogenic factors in acne (abnormal keratinization, sebum production, C. acnes proliferation, and inflammation) 8, 9
- Patients, prescribers, and pharmacists must register with the iPledge program before initiating isotretinoin due to teratogenicity risk 7
Hormonal Therapy for Female Patients
- Combined oral contraceptives (COCs) are conditionally recommended for inflammatory acne in females and reduce inflammatory lesions by approximately 62% at 6 months 1, 2, 5, 9
- Spironolactone is conditionally recommended for females with hormonal acne patterns, particularly those who cannot tolerate or prefer to avoid oral antibiotics 1, 2, 5
- Consider hormonal therapy for females with premenstrual flares, adult-onset acne, or acne resistant to conventional therapy 2
Alternative and Adjunctive Topical Agents
- Azelaic acid 15-20% applied twice daily is particularly useful for patients with post-inflammatory hyperpigmentation, especially in Fitzpatrick skin types IV-VI 1, 2, 3
- Topical clascoterone (antiandrogen) is conditionally recommended based on high-certainty evidence 1
- Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females; no G6PD testing required for topical formulation 2
- Salicylic acid 0.5-2% is available over-the-counter but has limited clinical trial evidence supporting efficacy 1, 2, 3
Maintenance Therapy After Clearance
- Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent microcomedone formation and recurrence 1, 2, 3, 5
- Benzoyl peroxide can be continued as maintenance therapy 2, 5
- Therapeutic results typically appear after 2-3 weeks, but more than 6 weeks may be required for definite beneficial effects 4
- Patients may notice apparent exacerbation during early weeks as the medication acts on deep, previously unseen lesions—this should not prompt discontinuation 4
Critical Pitfalls to Avoid
- Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 5, 10
- Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 2, 5
- Do not underestimate severity when scarring is present—this warrants more aggressive treatment 1, 2
- Avoid excessive washing or harsh scrubbing, which can worsen acne rather than improve it 4
- Do not apply tretinoin immediately after washing—wait 20-30 minutes for skin to dry completely to minimize irritation 4
Managing Treatment-Related Irritation
- Common retinoid side effects include dryness, peeling, erythema, and photosensitivity 3, 4
- Reduce application frequency to every other night initially for sensitive skin 2, 4
- Apply daily broad-spectrum sunscreen to reduce photosensitivity risk 2, 3
- Use non-comedogenic moisturizers every morning after washing 4
- Lower concentrations of benzoyl peroxide (2.5%) cause less irritation than higher concentrations (5-10%) with similar efficacy 2, 5
Special Populations
Preadolescent Children (≥9 years)
- Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children with acne 2
- For children under 12, benzoyl peroxide 2.5% is the primary treatment 5
- For children ≥9 years with predominantly comedonal acne, consider adapalene 0.1% gel 5
- Tetracycline antibiotics are contraindicated in children under 8 years due to risk of permanent tooth discoloration 5
Pregnant or Nursing Patients
- No studies have established safety of tretinoin in pregnant women—consult physician before use if pregnant, potentially pregnant, or nursing 4
- Isotretinoin is absolutely contraindicated in pregnancy due to severe teratogenicity 7