Acne 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% as the foundation, then escalate based on severity. 1, 2
- Adapalene 0.1% is the preferred first-line retinoid due to superior tolerability, lack of photolability, no oxidation with benzoyl peroxide, and over-the-counter availability 1
- Apply retinoid once daily at bedtime to completely dry skin (wait 20-30 minutes after washing) 3
- Benzoyl peroxide prevents antibiotic resistance and provides antimicrobial activity with no reported bacterial resistance 1, 2
Severity-Based Treatment Algorithm
Mild Acne (Comedonal or Minimal Inflammatory Lesions)
Topical retinoid + benzoyl peroxide monotherapy 1, 2
- Adapalene 0.1% gel (available OTC) + benzoyl peroxide 2.5-5% 1
- Alternative: Azelaic acid for patients with post-inflammatory hyperpigmentation 1
- Fixed-dose combination products enhance compliance 1
Moderate Acne (Inflammatory Lesions Present)
Fixed-dose combination of topical retinoid + benzoyl peroxide, with addition of topical antibiotic if needed 1, 2
- Add topical antibiotic (clindamycin 1% or erythromycin 3%) always combined with benzoyl peroxide—never as monotherapy 1, 2
- Fixed-combination options: clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5% 1
- Alternative for adult females: Topical dapsone 5% gel (no G6PD testing required) 1
Moderate-to-Severe Inflammatory Acne
Triple therapy: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
- Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1, 2
- Alternative: Minocycline 100 mg once daily (conditionally recommended) 1, 2
- Limit systemic antibiotics to 3-4 months maximum to prevent resistance 1, 2
- Always use concurrent benzoyl peroxide with oral antibiotics to prevent resistance 1, 2
- Subantimicrobial doxycycline (20 mg twice daily to 40 mg daily) has efficacy for moderate inflammatory acne 1
Severe Nodular or Recalcitrant Acne
Isotretinoin is the definitive treatment 1, 2
- Indications: Severe nodular/conglobate acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, any acne with scarring or significant psychosocial burden 1
- Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1
- Daily dosing preferred over intermittent dosing 2
- Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 1, 2
- Monitor only liver function tests and lipids; CBC monitoring not needed in healthy patients 2
- Population studies show no increased risk of depression or inflammatory bowel disease 1, 2
- Adjunctive: Intralesional triamcinolone acetonide 10 mg/mL for individual large nodules (rapid relief within 48-72 hours) 1
Hormonal Therapy for Female Patients
Combined oral contraceptives or spironolactone are effective options for hormonal acne patterns 1, 2
- Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months 1, 4
- Spironolactone 25-200 mg daily for hormonal patterns, premenstrual flares, or those unable to tolerate oral antibiotics 1, 2
- 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 be continued as maintenance 1, 2
- Never stop treatment once acne clears—maintenance is essential to prevent relapse 2
Special Considerations for Back/Trunk Acne
Treatment follows the same severity-based approach as facial acne 1, 5
- Adapalene 0.1% gel available OTC for mild back acne 5
- Benzoyl peroxide can bleach clothing and bedding; recommend wearing old or white clothing 5
- Daily sunscreen recommended for exposed areas due to retinoid photosensitivity 5
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 1, 2
- Avoid applying tretinoin with benzoyl peroxide simultaneously (oxidation inactivates tretinoin); adapalene does not have this limitation 1
- Do not underestimate severity when scarring is present—warrants more aggressive treatment 1
- Avoid topical antibiotics as monotherapy to prevent bacterial resistance 1, 2
- Do not apply retinoids to broken skin or active wounds 1
- Avoid harsh scrubbing, frequent washing, and drying preparations (astringents, alcohol-based products) 3
Patient Education Essentials
Set realistic expectations: improvement typically seen by 12 weeks, with initial adjustment period of 2-4 weeks 3
- Initial irritation, peeling, or new blemishes at 3-6 weeks is normal—continue therapy 3
- Apply moisturizer or non-comedogenic sunscreen every morning 3
- Minimize sun exposure and use sunscreen daily due to photosensitivity with retinoids 1, 3
- Wash gently with mild soap 2-3 times daily; excessive washing worsens acne 3
- Wait 20-30 minutes after washing before applying retinoid to minimize irritation 3
- Use pea-sized amount for entire face; medication should become invisible immediately 3