What is the recommended treatment regimen for acne (pimples)?

Treatment Regimen for Acne (Pimples)

Begin with a topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% applied nightly and in the morning respectively as first-line therapy for mild to moderate acne, and add oral doxycycline 100 mg daily (maximum 3-4 months) for moderate-to-severe inflammatory disease, always with concurrent benzoyl peroxide to prevent antibiotic resistance. 1

Severity-Based Treatment Algorithm

Mild Acne (Primarily Comedones, Few Inflammatory Lesions)

• Start with topical retinoid monotherapy OR topical retinoid + benzoyl peroxide as recommended first-line treatment 1
• Topical retinoid options include:
  • Adapalene 0.1% gel (available over-the-counter) or 0.3% gel (prescription) 1
  • Tretinoin 0.025-0.1% cream, gel, or microsphere gel (prescription) 1
  • Tazarotene 0.05-0.1% cream, gel, or foam (prescription) 1
• Apply retinoid once nightly to completely dry skin (wait 20-30 minutes after washing) 2
• Add benzoyl peroxide 2.5-5% gel in the morning for antimicrobial effect and mild comedolytic properties 1
• Alternative option: Azelaic acid 15-20% for patients with post-inflammatory hyperpigmentation, particularly useful in darker skin tones 1

Moderate Acne (Mixed Comedonal and Inflammatory Lesions)

• Use fixed-dose combination of topical retinoid + benzoyl peroxide as first-line treatment 1
• Add topical antibiotics (clindamycin 1% or erythromycin 3%) ONLY in combination with benzoyl peroxide to prevent bacterial resistance 1, 3
• Fixed-combination products enhance compliance: erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, or clindamycin 1%/BP 3.75% 1
• Alternative for adult females: Topical dapsone 5% gel is particularly effective for inflammatory acne in this population, with no need for G6PD testing before starting 1
• Never use topical antibiotics as monotherapy due to rapid resistance development 1, 3

Moderate-to-Severe Acne (Extensive Inflammatory Lesions, Nodules)

• Triple therapy is mandatory: oral antibiotics + topical retinoid + benzoyl peroxide 1
• Oral antibiotic selection (strongly recommended):
  • Doxycycline 100 mg once daily (preferred) 1
  • Minocycline 100 mg once daily (alternative) 1
  • Limit duration to 3-4 months maximum to minimize bacterial resistance 1, 3
  • Always prescribe with concurrent benzoyl peroxide to prevent resistance 1, 3
• Continue topical retinoid + benzoyl peroxide throughout and after antibiotic course 1
• For large, painful nodules: Intralesional triamcinolone acetonide 10 mg/mL provides rapid pain relief within 48-72 hours and prevents scarring 1

Severe Nodular/Cystic Acne or Scarring Acne

• Isotretinoin 0.5-1.0 mg/kg/day is the definitive treatment targeting all four pathogenic factors of acne 1, 4
• Indications for isotretinoin (any of the following):
  • Severe nodular or conglobate acne 1
  • Moderate acne with scarring (presence of scarring automatically warrants aggressive treatment regardless of lesion count) 1
  • Significant psychosocial burden or quality of life impairment 1
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy 1
• Target cumulative dose of 120-150 mg/kg over 15-20 weeks 1
• Mandatory monitoring: Baseline and at least one follow-up liver function test and lipid panel 1
• Mandatory pregnancy prevention: All patients of childbearing potential must enroll in iPledge program 1, 5
• Population studies show no increased risk of depression or inflammatory bowel disease, so routine monitoring for these is not required 1

Hormonal Therapy for Female Patients

• Combined oral contraceptives (COCs) are effective for inflammatory acne in females, reducing inflammatory lesions by 62% at 6 months 1, 6
• Spironolactone 25-200 mg daily is useful for females with:
  • Hormonal acne patterns or premenstrual flares 1
  • Those who cannot tolerate or prefer to avoid oral antibiotics 1
  • No potassium monitoring needed in healthy patients without renal impairment or relevant concomitant medications 7, 1

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence after achieving clearance 1
• Benzoyl peroxide can be continued as maintenance therapy 1
• Never stop treatment once acne clears without transitioning to maintenance regimen 1

Application Instructions for Topical Retinoids

• Wash face with mild, non-medicated soap and pat dry 2
• Wait 20-30 minutes for skin to be completely dry before applying retinoid to minimize irritation 2
• Apply once nightly before bedtime (or every other night initially if skin is sensitive) 2
• Use approximately half-inch or less for entire face 2
• Avoid corners of nose, mouth, eyes, and open wounds 2
• Apply moisturizer with sunscreen every morning after washing 2
• Expect initial adjustment period: Some discomfort, peeling, or new blemishes may appear at 3-6 weeks, but continue treatment as improvement typically occurs by 6-12 weeks 2

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy - resistance develops rapidly without concurrent benzoyl peroxide 1, 3
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 3
• Do not underestimate severity when scarring is present - any scarring warrants aggressive treatment regardless of total lesion count 1
• Avoid using multiple drying or irritating products simultaneously (astringents, alcohol-containing products, medicated soaps) as this may worsen acne 2
• Counsel about photosensitivity: Topical retinoids and doxycycline both cause photosensitivity; daily sunscreen use is mandatory 1, 2
• Benzoyl peroxide bleaches fabric: Warn patients to use white towels and old clothing 8

Special Populations

• Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 1
• Pregnant or nursing patients: Avoid tretinoin and isotretinoin; consult physician before using any acne medications 2
• Back/trunk acne: Follow the same severity-based algorithm as facial acne 1, 8