Treatment Protocol for Active Acne
Start All Patients with Topical Retinoid + Benzoyl Peroxide
Begin treatment 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. 1
Severity-Based Treatment Algorithm
Mild Acne (Predominantly Comedonal)
- First-line: Topical retinoid + benzoyl peroxide 1, 2
- Adapalene 0.1% gel is available over-the-counter and should be applied once daily to the entire affected area (not just individual lesions) 3, 4
- Apply retinoid to clean, dry skin in the evening; benzoyl peroxide can be applied in the morning 3, 5
- Alternative for post-inflammatory hyperpigmentation: Add azelaic acid, which provides comedolytic, antibacterial, and anti-inflammatory effects 2
Moderate Acne (Mixed Comedonal and Inflammatory)
- First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
- Add topical antibiotics (clindamycin 1% or erythromycin 3%) for inflammatory lesions, but always combined with benzoyl peroxide—never as monotherapy to prevent bacterial resistance 3, 1, 2
- Fixed-combination products enhance compliance: clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5% 3, 2
- For adult females with inflammatory acne: Consider topical dapsone 5% gel (no G6PD testing required for topical formulation) 3, 2
Moderate-to-Severe Inflammatory Acne
- First-line triple therapy: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
- Preferred oral antibiotics: Doxycycline 100 mg once daily (strongly recommended) or minocycline 100 mg once daily 3, 1, 2
- Critical time limit: Restrict systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 3, 1, 2
- For larger nodules at risk of scarring: Intralesional triamcinolone acetonide provides rapid pain relief and inflammation reduction 2
Severe Nodular or Recalcitrant Acne
- Isotretinoin is indicated for: 2
- Severe nodular or conglobate acne
- Moderate acne with scarring or significant psychosocial burden
- Treatment-resistant moderate acne after 3-4 months of appropriate therapy
- Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 2
- Monitor liver function tests and lipids; routine depression or IBD monitoring not required based on population studies 2
- Mandatory iPledge enrollment for persons of pregnancy potential 2
Hormonal Therapy for Female Patients
- Combined oral contraceptives (COCs): Reduce inflammatory lesions by 62% at 6 months 1, 6
- Spironolactone 25-200 mg daily: Useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 1, 2
- No potassium monitoring needed in healthy patients without risk factors 1, 2
Maintenance Therapy After Clearance
Continue topical retinoid monotherapy indefinitely to prevent recurrence—this is essential and non-negotiable. 1, 2
- Benzoyl peroxide can also be continued as maintenance 1, 2
- Never stop treatment once acne clears; relapse is highly likely without maintenance 3, 1
Application Instructions
Topical Retinoids
- Apply once daily to entire affected area (e.g., entire face, not just spots) on clean, dry skin 4
- Use in the evening due to photolability 2
- Daily sunscreen is mandatory due to photosensitivity 3, 2
- Start with lower concentrations to minimize irritation 2
Benzoyl Peroxide
- Available in 2.5-5% concentrations; lower concentrations cause less irritation 3, 5
- For new users: sensitivity test on 1-2 small areas for 3 days before full application 5
- Start with once-daily application, gradually increase to 2-3 times daily if needed 5
- Warning: Bleaches clothing and bedding—wear old or white clothing 3
Reassessment Timeline
- Comedonal or papulopustular acne: Evaluate treatment response at 8 weeks 7
- Nodular/conglobate acne: Evaluate at 12 weeks 7
- If no improvement, escalate therapy based on severity algorithm above 2
Critical Pitfalls to Avoid
- Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 3, 1, 2
- Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk 3, 1, 2
- Never stop treatment once acne clears—maintenance with topical retinoids is essential to prevent relapse 3, 1, 2
- Do not underestimate severity when scarring is present—this warrants more aggressive treatment regardless of lesion count 2
- Do not apply retinoids to broken skin or active wounds 2