What are the treatment options for acne in a teenager?

Treatment of Acne in Teenagers

Start with combination topical therapy using benzoyl peroxide plus a topical retinoid for all teenagers with acne, escalating to oral antibiotics (doxycycline preferred) combined with topical agents for moderate inflammatory disease, and using isotretinoin for severe, scarring, or treatment-resistant cases. 1, 2

Initial Assessment

Evaluate acne severity using the Physician Global Assessment (PGA) scale to classify as mild, moderate, or severe 3. Critically, assess for any scarring or significant psychosocial burden—these factors automatically warrant aggressive treatment regardless of lesion count. 2, 3

Treatment Algorithm by Severity

Mild Acne

• Begin with topical retinoid (adapalene 0.1-0.3%, tretinoin 0.025-0.1%, or tazarotene) combined with benzoyl peroxide 2.5-5%. 1, 2, 4
• Adapalene 0.1% gel is available over-the-counter and is often best tolerated in adolescents 3, 4
• Benzoyl peroxide prevents bacterial resistance and provides antimicrobial effects without resistance development 1, 2, 5
• Alternative agents include azelaic acid (particularly useful for post-inflammatory hyperpigmentation in darker skin tones) or salicylic acid 0.5-2% 2, 3

Moderate Acne

• Use fixed-dose combination products: benzoyl peroxide + topical retinoid, OR benzoyl peroxide + topical antibiotic (clindamycin 1% or erythromycin 3%). 1, 2, 3
• Fixed combinations enhance adherence compared to separate products 3, 4
• Never use topical antibiotics as monotherapy—this rapidly causes bacterial resistance. 1, 2, 4
• Re-evaluate after 6-8 weeks; if inadequate response, escalate to oral antibiotics 2, 4

Moderate-to-Severe Inflammatory Acne

• Prescribe triple therapy: oral doxycycline 100 mg once daily + topical retinoid + benzoyl peroxide. 1, 2, 4
• Doxycycline is strongly recommended as first-line oral antibiotic for patients ≥9 years 1, 2
• Alternative oral antibiotics include minocycline or sarecycline (conditionally recommended) 1, 4
• Limit systemic antibiotics to 3-4 months maximum to prevent resistance. 1, 2, 4
• Always combine oral antibiotics with benzoyl peroxide to prevent bacterial resistance 2, 3, 4

Severe, Scarring, or Treatment-Resistant Acne

• Isotretinoin 0.5-1 mg/kg/day for 15-20 weeks is the gold standard and should be strongly considered. 1, 2
• Isotretinoin is indicated for: severe nodular/conglobate acne, any acne causing scarring or significant psychosocial burden, or moderate acne failing 3-4 months of appropriate therapy 2, 3
• Target cumulative dose of 120-150 mg/kg 3
• Requires iPledge program enrollment for all patients of childbearing potential due to teratogenicity risk 6, 7
• Obtain baseline liver function tests and lipid panel, with at least one repeat during treatment 2, 6
• For larger nodules at risk of scarring, add intralesional triamcinolone acetonide for rapid inflammation reduction 3, 4

Hormonal Therapy for Female Teenagers

• Consider combined oral contraceptives or spironolactone 25-200 mg daily for females with hormonal acne patterns, premenstrual flares, or clinical signs of hyperandrogenism. 1, 2, 3
• No potassium monitoring needed in healthy patients without risk factors on spironolactone 3
• Evaluate for PCOS or other endocrine disorders in females with severe acne, hirsutism, or irregular menses 2

Maintenance Therapy

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence. 2, 3, 4
• This applies after successful treatment with either oral antibiotics or isotretinoin 2
• Benzoyl peroxide can also be continued for maintenance 3

Critical Pitfalls to Avoid

• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk. 1, 2, 4
• Never use topical or oral antibiotics without concurrent benzoyl peroxide. 1, 2, 4
• Counsel patients on doxycycline about significant photosensitivity and mandatory daily sunscreen use. 2
• Avoid applying topical retinoids to broken skin or active wounds 3
• Benzoyl peroxide can bleach hair and dyed fabrics 5
• Topical retinoids may cause initial irritation; consider starting with lower concentrations or less frequent application 3

Special Considerations for Adolescents

• Topical adapalene, tretinoin, and benzoyl peroxide are safe in preadolescent children ≥9 years 2, 3
• Tetracycline antibiotics are absolutely contraindicated in children under 8 years due to permanent tooth discoloration risk 2
• Monitor for increased incidence of back pain, arthralgia, and myalgia in adolescents on isotretinoin 6
• Bone density monitoring may be considered for adolescents on isotretinoin, particularly those with known metabolic or structural bone disease 6