What are the treatment options for acne?

Treatment for Acne Vulgaris

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 foundational therapy, then escalate based on severity by adding topical antibiotics for moderate disease or oral doxycycline for moderate-to-severe inflammatory acne. 1, 2

Severity-Based Treatment Algorithm

Mild Acne (Comedonal or Minimal Inflammatory Lesions)

• First-line: Topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) applied once nightly PLUS benzoyl peroxide 2.5-5% applied once daily 1, 2, 3
• Adapalene is more photostable than tretinoin and can be safely combined with benzoyl peroxide in the same regimen 4
• Apply retinoid to completely dry skin 20-30 minutes after washing to minimize irritation 5
• Alternative agents for patients with post-inflammatory hyperpigmentation: Add azelaic acid 15-20% twice daily 1, 2, 3
• Salicylic acid 0.5-2% can be used as an over-the-counter alternative for patients intolerant to retinoids, though evidence is limited 1, 3

Moderate Acne (More Extensive Inflammatory Lesions)

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide PLUS topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide 1, 2
• Fixed-combination products (clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5%) enhance compliance and should be applied twice daily 1, 2, 4
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 4
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and can be used twice daily without requiring G6PD testing 2, 4

Moderate-to-Severe Inflammatory Acne

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

Severe Acne, Treatment-Resistant Acne, or Acne with Scarring/Psychosocial Burden

• Oral isotretinoin is strongly recommended and is the only drug affecting all four pathogenic factors of acne 1, 2, 4
• Indications: Severe nodular or conglobate acne, moderate acne with scarring or significant psychosocial burden, or treatment-resistant moderate acne after 3-4 months of appropriate therapy 1, 2, 4
• Dosing: Start 0.5 mg/kg/day and increase to 1.0 mg/kg/day as tolerated, targeting cumulative dose of 120-150 mg/kg 2, 4
• For moderate treatment-resistant acne, lower doses (0.25-0.4 mg/kg/day) provide equal efficacy with fewer side effects 4
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 2, 4
• Monitor liver function tests and lipids; CBC monitoring is not needed in healthy patients 2, 4
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 4
• Oral corticosteroids can provide temporary benefit in severe inflammatory acne while initiating standard therapy 2

Hormonal Therapy for Female Patients

• Combined oral contraceptives are conditionally recommended for inflammatory acne in females, reducing inflammatory lesions by 62% at 6 months 1, 2, 4
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or patients who cannot tolerate oral antibiotics 1, 2, 4
• No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia 2, 4

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence, as retinoids prevent new microcomedone formation 1, 2, 3, 4
• Add benzoyl peroxide 2.5-5% once daily if needed for more severe baseline disease 2, 4
• Topical retinoids are essential for maintenance after clearing 2

Adjunctive Treatments

• Intralesional triamcinolone acetonide for larger nodules at risk of scarring provides rapid pain relief and inflammation reduction 1, 2
• Clascoterone 1% cream applied twice daily is a newer topical antiandrogen, conditionally recommended based on high certainty evidence but limited by cost 1, 2, 4

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 4
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 2, 4
• Do not underestimate severity when scarring is present—this warrants more aggressive treatment regardless of lesion count 1, 2
• Avoid applying retinoids to broken skin or immediately after washing—wait 20-30 minutes for skin to dry completely 5
• Minimize sun exposure during retinoid therapy and use daily sunscreen, as retinoids cause photosensitivity 3, 5
• Do not use topical antibiotics for comedonal acne—they are ineffective against comedones 3

Managing Retinoid Side Effects

• Common side effects include dry skin, peeling, erythema, and burning sensation 3, 5
• Mitigate by reducing application frequency, using concurrent emollients, and applying moisturizer every morning 3, 5
• Start with lower concentrations in sensitive skin and titrate up as tolerated 4
• If excessive irritation occurs, reduce frequency to every other night initially 5

Special Populations

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children aged 9 years or older with acne 2
• Treatment for back acne follows the same severity-based approach as facial acne 2
• Azelaic acid is particularly useful for Fitzpatrick skin types IV or greater with post-inflammatory hyperpigmentation 3