Recommended Topical Medications for Acne Treatment
Start with a topical retinoid (adapalene 0.1-0.3%, tretinoin 0.025-0.1%, or tazarotene 0.05-0.1%) combined with benzoyl peroxide 2.5-5% as your foundation for all acne severities, then add topical antibiotics (always with benzoyl peroxide) for moderate inflammatory acne. 1
First-Line Topical Therapy Foundation
Topical retinoids are the cornerstone of acne treatment because they target microcomedones, provide comedolytic effects, and deliver direct anti-inflammatory benefits. 1, 2, 3 The American Academy of Dermatology positions these agents as essential for both active treatment and long-term maintenance. 1
Retinoid Options (Choose One):
Adapalene 0.1% gel is available over-the-counter and represents an excellent starting point due to superior tolerability compared to other retinoids while maintaining equivalent efficacy to tretinoin 0.025-0.1%. 1, 4, 2, 5
Tretinoin 0.025-0.1% (available as cream, gel, or microsphere formulations) is FDA-approved for acne vulgaris and should be applied in the evening due to photolability. 1, 6 Do not combine with benzoyl peroxide simultaneously—apply at different times of day. 1
Tazarotene 0.05-0.1% (cream, gel, or foam) demonstrates superior efficacy compared to tretinoin 0.025% or adapalene 0.1%, but causes more irritation. 7, 1, 2 Reserve this for patients who fail milder retinoids.
Trifarotene is a newer retinoid option for patients seeking alternatives. 1
Benzoyl Peroxide (Add to Retinoid):
Use 2.5-5% concentrations—lower strengths cause less irritation while maintaining antimicrobial efficacy. 1 Higher concentrations add no benefit. 1
Benzoyl peroxide kills Cutibacterium acnes through free oxygen radical release and provides mild comedolytic effects. 1, 8
No bacterial resistance has ever been reported, making this agent indispensable for preventing antibiotic resistance. 1, 8
Warn patients that benzoyl peroxide bleaches clothing and bedding. 4
Severity-Based Algorithm
Mild Acne (Comedonal or Minimal Inflammatory):
Topical retinoid + benzoyl peroxide is sufficient. 1
Alternative for sensitive skin or darker skin types (Fitzpatrick IV+): Add azelaic acid 15-20%, which provides comedolytic, antibacterial, and anti-inflammatory effects while lightening post-inflammatory hyperpigmentation. 7, 1 Azelaic acid is pregnancy category B. 7
Moderate Acne (Mixed Comedonal and Inflammatory):
Topical retinoid + benzoyl peroxide + topical antibiotic (clindamycin 1% or erythromycin 3%). 1, 8
Critical: Never use topical antibiotics as monotherapy—this rapidly induces bacterial resistance. 1, 4, 8 Always combine with benzoyl peroxide. 1
Fixed-combination products enhance compliance: clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5%. 7, 1, 4 These are FDA-approved for acne vulgaris. 9
For adult females with inflammatory acne: Consider topical dapsone 5% gel twice daily, which shows particular efficacy in this population. 7, 1, 4, 8 No glucose-6-phosphate dehydrogenase testing is required for topical formulation. 7, 1 Avoid concurrent benzoyl peroxide application as it oxidizes dapsone, causing orange-brown skin discoloration. 7
Moderate-to-Severe Acne (Extensive Inflammatory):
Oral antibiotics (doxycycline or minocycline) + topical retinoid + benzoyl peroxide is first-line. 1, 8
Continue topical retinoid + benzoyl peroxide even when adding systemic therapy. 7, 1
Limit oral antibiotics to 3-4 months maximum and re-evaluate to prevent resistance. 7, 1, 4, 8
Additional Topical Agents (Adjunctive or Alternative)
Salicylic acid 0.5-2% (over-the-counter) provides comedolytic effects with good tolerability in both wash-off and leave-on formulations, though clinical trial evidence is limited. 7
Clascoterone is a newer topical antiandrogen that inhibits androgen-mediated sebum production and inflammation, conditionally recommended based on high-certainty evidence. 1
Maintenance Therapy After Clearance
Continue topical retinoid monotherapy indefinitely to prevent microcomedone formation and recurrence. 1, 4, 8 This is the most commonly neglected aspect of acne management—patients stop treatment once clear and relapse within months. 4
Benzoyl peroxide can also be continued for maintenance. 1
Critical Pitfalls to Avoid
Never use topical antibiotics alone—resistance develops rapidly without concurrent benzoyl peroxide. 1, 4, 8
Apply daily sunscreen when using retinoids due to photosensitivity. 1, 4
Start retinoids slowly (every other night initially) to minimize irritation, then advance to nightly application as tolerated. 2, 3
Do not apply tretinoin and benzoyl peroxide simultaneously—use at different times (tretinoin evening, benzoyl peroxide morning). 1
Do not underestimate severity when scarring is present—this warrants more aggressive treatment regardless of lesion count. 1