What is the recommended treatment protocol for acne?

Acne Vulgaris Treatment Protocol

Foundation: Universal First-Line Therapy

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% applied once daily at bedtime, then escalate based on severity. 1, 2

• Adapalene 0.1% gel is available over-the-counter; higher concentrations and tretinoin require prescription 1, 3
• Wait 20-30 minutes after washing face before applying tretinoin to minimize irritation 4
• Apply approximately a half-inch of medication to fingertip, dab on forehead, chin, and both cheeks, then spread over entire affected area 4
• Avoid corners of nose, mouth, eyes, and mucous membranes 4
• Use daily sunscreen as retinoids cause photosensitivity 1, 4

Severity-Based Treatment Algorithm

Mild Acne (Comedonal and Few Inflammatory Lesions)

Topical retinoid + benzoyl peroxide monotherapy is sufficient. 1, 2

• Alternative: Add azelaic acid if post-inflammatory hyperpigmentation is present, particularly in darker skin tones 1
• Alternative: Topical dapsone 5% gel for inflammatory lesions, especially effective in adult females 1
• No glucose-6-phosphate dehydrogenase testing required before starting topical dapsone 1

Moderate Acne (Multiple Inflammatory Papules/Pustules)

Add fixed-dose combination topical antibiotic with benzoyl peroxide to the retinoid + benzoyl peroxide foundation. 1, 2

• Use clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5% fixed combinations 1
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2
• Fixed-combination products enhance compliance compared to separate applications 1

Moderate-to-Severe Inflammatory Acne

Triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide. 1, 2

• Doxycycline 100 mg once daily is strongly recommended as first-line oral antibiotic (moderate evidence). 1, 2
• Minocycline 100 mg once daily is conditionally recommended as alternative 1, 2
• Subantimicrobial doxycycline dosing (20 mg twice daily to 40 mg daily) shows efficacy for moderate inflammatory acne 1
• Limit systemic antibiotics to 3-4 months maximum to prevent bacterial resistance. 1, 2
• Always use benzoyl peroxide concurrently with oral antibiotics to prevent resistance 1

Severe Nodular or Recalcitrant Acne

Isotretinoin is indicated for: 1, 2

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

Isotretinoin dosing and monitoring: 1, 2

• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1
• Daily dosing preferred over intermittent dosing 1
• Monitor liver function tests and lipids only; CBC monitoring not needed in healthy patients 1
• No routine monitoring for depression or inflammatory bowel disease required based on population studies 1
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 1, 5, 6

Hormonal Therapy for Female Patients

Combined oral contraceptives (COCs) 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: 1, 2

• Hormonal acne patterns (jawline 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 1, 2

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely to prevent recurrence. 1, 2

• Benzoyl peroxide can also be continued as maintenance 1, 2
• Stopping treatment once acne clears leads to relapse—maintenance is essential. 2

Special Considerations

Back Acne Treatment

• Follow same severity-based algorithm as facial acne 1, 3
• Benzoyl peroxide bleaches clothing and bedding; wear old or white clothing when applying 3

Preadolescent Children

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

Adjunctive Procedures

• Intralesional triamcinolone acetonide for larger nodules at risk of scarring provides rapid pain relief and inflammation reduction 1
• Oral corticosteroid therapy provides temporary benefit in severe inflammatory acne while starting standard treatment 1

Critical Pitfalls to Avoid

Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 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 is present—this warrants more aggressive treatment regardless of lesion count. 1

Avoid applying retinoids to broken skin or active wounds. 1

Do not use tretinoin with benzoyl peroxide simultaneously (tretinoin should be applied in evening due to photolability). 1

Avoid concomitant use of medicated/abrasive soaps, products with high alcohol content, or preparations containing sulfur, resorcinol, or salicylic acid with tretinoin without physician guidance. 4

Patient Education for Retinoid Therapy

• Expect initial adjustment period with possible dryness, erythema, or peeling for 2-4 weeks 4, 7
• New blemishes may appear at 3-6 weeks—continue treatment through this phase 4
• Improvement typically visible by 6-12 weeks; full benefit may take up to 12 weeks 4, 6
• Wash face gently 2-3 times daily with mild soap; excessive washing worsens acne 4
• Apply moisturizer or non-comedogenic moisturizer with sunscreen every morning 4