What are the treatment options for managing acne vulgaris?

Management of 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 100 mg daily for moderate-to-severe inflammatory acne, always with concurrent benzoyl peroxide to prevent resistance. 1

Severity-Based Treatment Algorithm

Mild Acne (Comedonal or Minimal Inflammatory Lesions)

• First-line: Topical retinoid + benzoyl peroxide 2.5-5% 1, 2
• Retinoid options include adapalene 0.1-0.3% (preferred for tolerability and can be applied with benzoyl peroxide without oxidation), tretinoin 0.025-0.1%, tazarotene 0.05-0.1%, or trifarotene 3
• Apply retinoid once nightly after washing and waiting 20-30 minutes for skin to dry completely 4
• Benzoyl peroxide provides antimicrobial effects without resistance development 2

Alternative agents for mild acne:

• Azelaic acid 15-20% twice daily for patients with post-inflammatory hyperpigmentation, particularly Fitzpatrick skin types IV or greater 3, 5
• Salicylic acid 0.5-2% as over-the-counter option for those intolerant to retinoids, though evidence is limited 3, 5

Moderate Acne (More Extensive Inflammatory Lesions)

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
• Add: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions 3, 2
• Fixed-combination products (clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, erythromycin 3%/BP 5%) enhance compliance 3
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 3
• Topical clascoterone (newer antiandrogen) is conditionally recommended 1

Moderate-to-Severe Inflammatory Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide (triple therapy) 3, 2
• Strongly recommended: Doxycycline 100 mg once daily (moderate evidence) 1, 3, 2
• Conditionally recommended: Minocycline 100 mg once daily as alternative 1, 3, 2
• Sarecycline is conditionally recommended 1
• Critical: Limit systemic antibiotics to 3-4 months maximum to minimize resistance 1, 3, 2
• Always combine oral antibiotics with benzoyl peroxide and topical retinoid 1, 3
• Subantimicrobial doxycycline dosing (20 mg twice daily to 40 mg daily) shows efficacy for moderate inflammatory acne 3

Severe Acne or Treatment-Resistant Disease

Oral isotretinoin is strongly recommended for: 1, 3

• Severe nodular or conglobate acne
• Acne causing psychosocial burden or scarring (regardless of lesion count)
• Treatment-resistant moderate acne after 3-4 months of appropriate therapy

Isotretinoin dosing and monitoring: 3

• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg
• Daily dosing preferred over intermittent dosing 3
• Monitor liver function tests and lipids only; CBC monitoring not needed in healthy patients 3
• No routine monitoring for depression or inflammatory bowel disease required (population studies show no increased risk) 3
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 3

Hormonal Therapy for Female Patients

Combined oral contraceptives (COCs): 1, 3, 2

• Conditionally recommended for inflammatory acne in females
• Reduce inflammatory lesions by 62% at 6 months 3, 6

Spironolactone 25-200 mg daily: 1, 3, 2

• Useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 3

Good Practice Statements and Adjunctive Therapies

Combination therapy principles: 1

• Combine topical therapies with multiple mechanisms of action
• Always combine systemic antibiotics with benzoyl peroxide and topical retinoids

Intralesional corticosteroids: 1, 3

• Intralesional triamcinolone acetonide for larger nodules at risk of scarring
• Provides rapid pain relief and inflammation reduction

Oral corticosteroids: 3

• Short-term use can provide temporary benefit in severe inflammatory acne while starting standard treatment

Maintenance Therapy

After achieving clearance: 3, 2, 5

• Continue topical retinoid monotherapy indefinitely to prevent recurrence
• Benzoyl peroxide can be continued as maintenance 3, 2
• Maintenance therapy prevents new microcomedone formation 5

Special Populations

Preadolescent children (≥9 years): 3, 2

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used
• Start benzoyl peroxide at low concentration (2.5%) 2
• Consider adapalene 0.1% gel for predominantly comedonal acne 2

Children under 8 years: 2

• Tetracycline antibiotics contraindicated due to risk of permanent tooth discoloration

Pregnant or nursing patients: 4

• No studies establish safety of tretinoin in pregnancy
• Consult physician before using tretinoin if pregnant, potentially pregnant, or nursing

Critical Pitfalls to Avoid

Never use antibiotics as monotherapy: 1, 3, 2, 5

• Topical or oral antibiotics alone rapidly develop resistance
• Always combine with benzoyl peroxide

Never extend oral antibiotics beyond 3-4 months without re-evaluation: 1, 3, 2

• Dramatically increases resistance risk
• Have exit plan in place when starting antibiotics 7

Do not underestimate severity when scarring is present: 1, 2

• Scarring warrants more aggressive treatment regardless of lesion count
• Consider isotretinoin early

Avoid applying tretinoin with benzoyl peroxide simultaneously: 3

• Traditional tretinoin formulations oxidize and inactivate when combined
• Adapalene does not have this limitation

Do not skip the 20-30 minute wait after washing: 4

• Skin must be completely dry before applying tretinoin to minimize irritation

Avoid excessive washing or scrubbing: 4

• May worsen acne
• Wash gently 2-3 times daily with mild soap

Managing Retinoid Side Effects

Common side effects: 5, 4

• Dry skin, peeling, scaling, erythema, burning sensation, photosensitivity
• Usually subside within 2-4 weeks 4

Mitigation strategies: 3, 5

• Start with reduced frequency (every other night for sensitive skin) 4
• Use concurrent emollients
• Apply daily sunscreen to reduce photosensitivity risk
• Apply moisturizer or non-comedogenic moisturizer with sunscreen every morning 4

Treatment Timeline Expectations

Initial response: 4

• Some patients notice new blemishes at 3-6 weeks (continue treatment through this phase)
• Improvement typically seen by 6-12 weeks
• Many users see improvement by 12 weeks with proper use

Long-term management: 4

• Continue regular application until physician instructs otherwise
• Do not stop at first signs of improvement