What is the treatment protocol for active acne?

Treatment Protocol for Active Acne

Begin with a topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% as the foundation for all acne treatment, then escalate based on severity by adding topical antibiotics for moderate disease or oral antibiotics (doxycycline or minocycline) for moderate-to-severe inflammatory acne, always with concurrent benzoyl peroxide to prevent resistance. 1

Severity-Based Treatment Algorithm

Mild Acne (Few comedones and inflammatory lesions)

• First-line: Topical retinoid + benzoyl peroxide 2, 1

  • Adapalene 0.1% gel is available over-the-counter 1
  • Tretinoin 0.025-0.1% (prescription) applied once nightly to completely dry skin, waiting 20-30 minutes after washing 3
  • Benzoyl peroxide 2.5-5% (lower concentrations cause less irritation while maintaining efficacy) 1

• Alternative options:

  • Azelaic acid 15-20% for patients with post-inflammatory hyperpigmentation, particularly valuable for darker skin tones 1, 4
  • Salicylic acid 0.5-2% as an over-the-counter comedolytic agent, though clinical trial evidence is limited 1

Moderate Acne (Multiple comedones and inflammatory papules/pustules)

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 2, 1

• Add topical antibiotics (but never as monotherapy due to rapid resistance development): 1

  • Clindamycin 1% + benzoyl peroxide 5% or 3.75% (fixed combinations enhance compliance) 1
  • Erythromycin 3% + benzoyl peroxide 5% 1

• Alternative for adult females: Topical dapsone 5% gel is particularly effective for inflammatory acne in this population, with no G6PD testing required 1

• Adjunctive option: Clascoterone (topical antiandrogen) conditionally recommended based on high certainty evidence 2

Moderate-to-Severe Inflammatory Acne (Extensive papules, pustules, nodules)

• First-line triple therapy: Oral antibiotics + topical retinoid + benzoyl peroxide 2, 1

• Oral antibiotic options:

  • Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 2, 1
  • Minocycline 100 mg once daily (conditionally recommended with moderate evidence) 2, 1
  • Subantimicrobial doxycycline 40 mg daily is effective for moderate inflammatory acne 1
  • Critical limitation: Restrict systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 2, 1

• For larger nodules at risk of scarring: Intralesional triamcinolone acetonide provides rapid pain relief and inflammation reduction 1

• Temporary adjunct for severe inflammatory acne: Oral corticosteroids can provide benefit while initiating standard therapy 1

Severe, Recalcitrant, or Scarring Acne

• Isotretinoin is strongly recommended for: 2, 1

  • Severe nodular or conglobate acne
  • Moderate acne with scarring or significant psychosocial burden
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy

• Dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1

• Monitoring: Liver function tests and lipids required; routine monitoring for depression or inflammatory bowel disease is not recommended based on population studies 1

• Mandatory: iPledge program registration for all patients of pregnancy potential due to teratogenicity risk 1

Hormonal Therapy Options for Female Patients

• Combined oral contraceptives (COCs): Effective for inflammatory acne in females, with 62% reduction in inflammatory lesions at 6 months 2, 5

• Spironolactone 25-200 mg daily: Useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 2, 1

  • No potassium monitoring needed in healthy patients without risk factors 1

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence 1

• Benzoyl peroxide can be continued as maintenance therapy 1

Critical Application Instructions for Topical Retinoids

• Apply once nightly to completely dry skin (wait 20-30 minutes after washing with mild soap) 3

• Use approximately half-inch or less for entire face; medication should become invisible almost immediately 3

• Avoid corners of nose, mouth, eyes, and open wounds 3

• Apply moisturizer or non-comedogenic sunscreen every morning, as retinoids cause photosensitivity 3

• Expect initial adjustment period with possible discomfort or peeling for 2-4 weeks 3

• Improvement typically visible by 6-12 weeks; new blemishes may appear at 3-6 weeks (continue treatment through this phase) 3

Essential Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy - resistance develops rapidly without concurrent benzoyl peroxide 2, 1

• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 2, 1

• Do not stop treatment once acne clears - maintenance with topical retinoids is essential to prevent relapse 1

• Avoid concurrent use of: 3

  • Medicated or abrasive soaps
  • Products with high alcohol, astringents, spices, or lime
  • Preparations containing sulfur, resorcinol, or salicylic acid (allow effects to subside before starting retinoid)

• Do not underestimate severity when scarring is present - this warrants more aggressive treatment regardless of lesion count 1

• Minimize sun exposure during retinoid therapy due to heightened photosensitivity; use sunscreen and protective clothing 3

• Warning for benzoyl peroxide: Can bleach clothing and bedding; wear old or white clothing when applying 6

Special Populations

• Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 1

• Pregnancy: Tretinoin is not established as safe in pregnant women; consult physician before use 3

  • Azelaic acid is pregnancy category B, making it safer for women of childbearing age 4

• Back acne: Follow the same severity-based approach as facial acne 1, 6