What is the recommended treatment protocol for acne?

Acne Treatment Protocol

Start all acne patients with a topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% applied once daily at bedtime, then escalate based on severity by adding topical antibiotics for moderate disease or oral doxycycline 100 mg daily for moderate-to-severe inflammatory acne, always maintaining benzoyl peroxide to prevent antibiotic resistance. 1, 2

Severity-Based Treatment Algorithm

Mild Acne (Comedonal or Few Inflammatory Lesions)

• First-line: Topical retinoid + benzoyl peroxide 2.5-5% 3, 1
• Adapalene 0.1% gel is available over-the-counter and represents an accessible starting point 1, 4
• Apply retinoid once daily at bedtime after washing with mild soap and waiting 20-30 minutes for skin to dry completely 5
• Alternative agents for specific situations:
  • Azelaic acid 15-20% for patients with post-inflammatory hyperpigmentation 3, 2
  • Salicylic acid 0.5-2% as an over-the-counter option, though evidence is limited 3, 2
  • Clascoterone (topical antiandrogen) as a newer conditionally recommended option 3

Moderate Acne (Multiple Inflammatory Papules/Pustules)

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 3, 1
• Add: Topical antibiotic (clindamycin 1% or erythromycin 3%) ALWAYS combined with benzoyl peroxide—never as monotherapy 3, 1, 2
• Fixed-combination products enhance compliance: erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, or clindamycin 1%/BP 3.75% 3, 2
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1, 2

Moderate-to-Severe Inflammatory Acne

• First-line triple therapy: Oral antibiotic + topical retinoid + benzoyl peroxide 3, 1, 2
• Oral antibiotic selection:
  • Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 3, 1
  • Minocycline 100 mg once daily (conditionally recommended with moderate evidence) 3, 2
  • Sarecycline (conditionally recommended with high certainty evidence) 3
• Critical limitation: Restrict oral antibiotics to 3-4 months maximum to minimize resistance development 1, 2
• Subantimicrobial doxycycline 40 mg daily has shown efficacy for moderate inflammatory acne 2

Severe Nodular/Recalcitrant Acne

• Isotretinoin is indicated for: 3, 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
• Dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 2
• Monitoring: Only liver function tests and lipids required—CBC monitoring not needed in healthy patients 3
• Population-based studies have NOT identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 3
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 3, 6
• Daily dosing preferred over intermittent dosing 3

Hormonal Therapy for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months 1, 7
• Spironolactone 25-200 mg daily is effective for: 3, 1, 2
  • Hormonal acne patterns (jawline/lower face distribution)
  • Premenstrual flares
  • Patients who cannot tolerate or prefer to avoid oral antibiotics
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia (older age, medical comorbidities, concurrent medications) 3, 1

Adjunctive Treatments

• Intralesional triamcinolone acetonide for larger papules or nodules at risk of scarring provides rapid pain relief and inflammation reduction 3, 2
• Use lower concentrations and volumes to minimize risk of local corticosteroid adverse events (atrophy, hypopigmentation) 3
• Oral corticosteroids can provide temporary benefit in severe inflammatory acne while initiating standard therapy 2

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence 1, 2
• Benzoyl peroxide can be continued as maintenance 1, 2
• Never stop treatment once acne clears—this is the most common cause of relapse 1

Application Technique for Topical Retinoids

• Apply once daily at bedtime to completely dry skin 5
• Wait 20-30 minutes after washing before application 5
• Use approximately half-inch or less for entire face—medication should become invisible immediately 5
• Avoid corners of nose, mouth, eyes, and open wounds 5
• Apply moisturizer or non-comedogenic sunscreen every morning 5

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, as this dramatically increases resistance risk 1, 2
• Do not underestimate severity when scarring or significant psychosocial burden is present—these patients warrant more aggressive treatment regardless of lesion count 2
• Minimize sun exposure during retinoid therapy due to photosensitivity; daily sunscreen is mandatory 5
• Avoid harsh scrubbing or frequent washing—acne is not caused by dirt, and excessive washing may worsen inflammation 5
• Do not use concurrent drying agents (astringents, alcohol-containing products, medicated soaps) with retinoids without physician guidance 5
• Avoid sulfur, resorcinol, or salicylic acid preparations when starting retinoids—allow skin to "rest" until effects subside 5

Managing Initial Tolerability Issues

• Expect transient discomfort, peeling, or erythema during first 2-4 weeks of retinoid therapy 5
• If irritation is excessive, reduce frequency to every other night initially 5
• Patient education to set expectations minimizes discontinuation 8
• New blemishes may appear at 3-6 weeks—this is expected and patients should continue therapy 5
• Improvement typically visible by 6-12 weeks; full benefit may take up to 12 weeks 5, 8

Special Populations

• Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 2
• Pregnant/nursing patients: Avoid tretinoin and isotretinoin due to teratogenicity risk 5, 6
• Patients with eczematous skin: Use retinoids with extreme caution due to risk of severe irritation 5