What is the recommended treatment protocol for acne?

Acne Treatment Protocol

Foundation: Start All Patients on Topical Retinoid + Benzoyl Peroxide

Begin every acne patient on a 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. 1, 2

• Adapalene 0.1% gel is available over-the-counter, making it an accessible first-line option 1, 3
• Apply retinoid once daily at bedtime to completely dry skin (wait 20-30 minutes after washing) 4
• Benzoyl peroxide prevents bacterial resistance and provides antimicrobial activity with no reported resistance 1, 3
• This combination targets comedones, inflammation, and bacterial proliferation simultaneously 5, 6

Severity-Based Treatment Algorithm

Mild Acne (Predominantly Comedonal)

• Topical retinoid + benzoyl peroxide monotherapy 1, 2
• Alternative: Add azelaic acid for patients with post-inflammatory hyperpigmentation 1
• Salicylic acid 0.5-2% can be used as adjunctive over-the-counter exfoliant for comedonal acne 1

Moderate Acne (Mixed Comedonal and Inflammatory)

• Fixed-dose combination: topical retinoid + benzoyl peroxide + topical antibiotic 1, 2
• Add topical clindamycin 1% or erythromycin 3%, but never as monotherapy due to rapid resistance development 1, 2
• Fixed-combination products (clindamycin 1%/BP 5%, erythromycin 3%/BP 5%) enhance compliance 1, 3
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1, 3

Moderate-to-Severe Inflammatory Acne

• Triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline 100 mg once daily is strongly recommended (first-line oral antibiotic) 1, 2
• Minocycline 100 mg once daily is a conditionally recommended alternative 1, 2
• Limit systemic antibiotics to 3-4 months maximum to prevent resistance 1, 2, 3
• Subantimicrobial doxycycline (20 mg twice daily to 40 mg daily) has efficacy for moderate inflammatory acne 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
• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1
• Daily dosing is preferred over intermittent dosing 2
• Mandatory iPledge enrollment for all persons of childbearing potential 1, 7, 6
• Monitor liver function tests and lipids only; CBC monitoring not needed in healthy patients 2
• Population studies show no increased risk of depression or inflammatory bowel disease 1, 2

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/chin distribution)
  • Premenstrual flares
  • Patients who cannot tolerate or prefer to avoid oral antibiotics
• No potassium monitoring needed in healthy patients without risk factors 1, 2

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely to prevent recurrence 1, 2, 3

• Benzoyl peroxide can be continued as maintenance therapy 1, 2
• Topical retinoids prevent microcomedone formation, the precursor lesion in acne 5, 8
• Maintenance therapy is essential; stopping treatment leads to relapse 2, 3

Application Instructions for Topical Retinoids

• Wash with mild, non-medicated soap and pat dry 4
• Wait 20-30 minutes for skin to be completely dry before application 4
• Apply pea-sized amount (approximately half-inch) once daily at bedtime 4
• Avoid corners of nose, mouth, eyes, and open wounds 1, 4
• Medication should become invisible almost immediately; if visible, using too much 4
• Apply moisturizer or non-comedogenic sunscreen every morning 4
• Initial irritation (erythema, dryness, peeling) typically subsides within 2-4 weeks 4, 5
• Improvement typically seen by 6-12 weeks; new blemishes may appear at 3-6 weeks (continue therapy) 4

Critical Pitfalls to Avoid

Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 3

• Never extend oral antibiotics beyond 3-4 months without re-evaluation 1, 2
• Do not stop treatment once acne clears; maintenance is essential 2, 3
• Avoid using topical antibiotics alone, which increases resistance risk 1, 3
• Do not underestimate severity when scarring is present—warrants aggressive treatment 1
• Minimize sun exposure and use daily sunscreen with retinoids due to photosensitivity 1, 4
• Benzoyl peroxide bleaches clothing and bedding; use white or old fabrics 3

Special Populations and Considerations

Pregnancy and Nursing

• No human safety studies exist for tretinoin in pregnancy; consult physician before use 4
• Isotretinoin is highly teratogenic and absolutely contraindicated 1, 7

Preadolescent Children

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

Back Acne (Truncal)

• Follow same severity-based approach as facial acne 1, 3
• Adapalene 0.1% gel available over-the-counter for mild back acne 3
• Fixed-combination products enhance compliance for hard-to-reach areas 3

Acne Conglobata

• Oral antibiotics should NOT be used as primary therapy—they are inadequate and delay definitive isotretinoin treatment 1

Assessment and Monitoring

• Use Physician Global Assessment (PGA) to classify severity consistently 1, 2
• Evaluate for scarring, post-inflammatory dyspigmentation, and psychosocial impact—these warrant aggressive treatment regardless of lesion count 1
• Intralesional triamcinolone acetonide for larger nodules at risk of scarring provides rapid relief 1

Drug Interactions and Contraindications

• Avoid concomitant use of medicated/abrasive soaps, astringents, products with high alcohol content, or preparations with sulfur, resorcinol, or salicylic acid with tretinoin 4
• "Rest" skin from other preparations before starting tretinoin 4
• Minimize sunlight exposure including sunlamps; patients with sunburn should not use retinoids until fully recovered 4