What is the recommended treatment protocol for acne?

Acne Treatment Protocol

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

Severity-Based Treatment Algorithm

Mild Acne

• First-line: Topical retinoid + benzoyl peroxide 1, 2, 3
• Adapalene 0.1% gel is available over-the-counter and represents an accessible starting point 2, 3
• Apply retinoid once daily at bedtime to completely dry skin (wait 20-30 minutes after washing) 4
• Use benzoyl peroxide 2.5-5% in the morning; lower concentrations cause less irritation while maintaining efficacy 3

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2, 3
• Add: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions 2, 3
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 3
• Fixed-combination products (clindamycin 1%/BP 5%, erythromycin 3%/BP 5%) enhance compliance 3, 5

Moderate-to-Severe Inflammatory Acne

• First-line triple therapy: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2, 3
• Doxycycline 100 mg once daily is strongly recommended with moderate evidence 1, 2
• Minocycline 100 mg once daily is conditionally recommended as an alternative 1, 3
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1, 2, 3
• Subantimicrobial doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy for moderate inflammatory acne 3

Severe or Recalcitrant Acne

• Isotretinoin is indicated for severe nodular acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden 1, 6
• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 3
• Daily dosing is preferred over intermittent dosing 1
• Monitor only liver function tests and lipids—CBC monitoring is not needed in healthy patients 1
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease with isotretinoin 1
• Mandatory pregnancy prevention for persons of childbearing potential through iPledge program 1, 7

Hormonal Therapy for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended for inflammatory acne in females 1, 2, 6
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 1, 2, 3
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia (e.g., older age, medical comorbidities, medications) 1, 2, 3

Adjunctive Options

• Intralesional triamcinolone acetonide for larger papules or nodules at risk of scarring provides rapid pain relief and inflammation reduction 1, 3
• Use lower concentration and volume to minimize local corticosteroid adverse events 1
• Azelaic acid is particularly useful for post-inflammatory hyperpigmentation in darker skin tones 2, 3
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 3, 5
• No glucose-6-phosphate dehydrogenase testing required before starting topical dapsone 3

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence 2, 3
• Benzoyl peroxide can be continued as maintenance therapy 2, 3
• Never stop treatment once acne clears—maintenance is essential to prevent relapse 2, 5

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 3, 5
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 2, 3
• Avoid applying retinoids immediately after washing; wait 20-30 minutes for skin to dry completely to minimize irritation 4
• Keep retinoids away from corners of nose, mouth, eyes, and open wounds 4
• Minimize sun exposure during retinoid therapy and use daily sunscreen, as retinoids cause photosensitivity 3, 4
• Benzoyl peroxide bleaches clothing and bedding; wear old or white clothing when applying 5
• Expect initial adjustment period with possible erythema, dryness, and peeling during first 2-4 weeks of retinoid therapy 4, 8
• Some patients notice new blemishes at 3-6 weeks—this is expected and treatment should continue 4

Application Technique for Topical Retinoids

• Apply once daily before bedtime to completely dry skin 4
• Use approximately half-inch or less of medication for entire face 4
• Dab on forehead, chin, and both cheeks, then spread over entire affected area 4
• Medication should become invisible almost immediately; if visible, you are using too much 4
• Apply moisturizer or non-comedogenic moisturizer with sunscreen every morning after washing 4