What are the treatment options for acne vulgaris?

Treatment for Acne Vulgaris

Foundation: Start All Patients on Topical Retinoid + Benzoyl Peroxide

Begin every acne patient on adapalene 0.1-0.3% combined with benzoyl peroxide 2.5-5% as foundational therapy, then escalate based on severity. 1, 2 This combination addresses multiple pathogenic factors and serves as the backbone for all acne treatment algorithms. 1

Why Adapalene is Preferred

• Adapalene offers superior tolerability compared to other retinoids while maintaining excellent efficacy. 1
• Available over-the-counter in 0.1% formulation, making it highly accessible 1
• Can be applied simultaneously with benzoyl peroxide without oxidation concerns, unlike tretinoin 1
• Lacks photolability restrictions that limit traditional tretinoin use 1
• FDA-approved for acne treatment with moderate certainty evidence 1, 3

Application Instructions

• Apply once daily before bedtime after washing with mild soap 3
• Wait 20-30 minutes after washing to ensure skin is completely dry before application 3
• Use approximately half-inch of product for entire face 3
• Avoid corners of nose, mouth, eyes, and open wounds 3
• Start every-other-night application if skin is sensitive, then advance to nightly 3
• Apply daily sunscreen every morning due to photosensitivity risk 1

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Severity-Based Treatment Algorithm

Mild Acne (Predominantly Comedonal or Minimal Inflammatory Lesions)

First-line: Topical retinoid (adapalene preferred) + benzoyl peroxide 2.5-5% 1, 2, 4

Alternative options:

• Azelaic acid for patients with post-inflammatory hyperpigmentation, particularly those with darker skin tones 1
• Salicylic acid 0.5-2% as over-the-counter comedolytic agent, though clinical trial evidence is limited 1
• Topical dapsone 5% gel, particularly effective for inflammatory acne in adult females 1

Moderate Acne (Mixed Comedonal and Inflammatory Lesions)

First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2, 4

Add for inflammatory lesions: Topical antibiotic (clindamycin 1% or erythromycin 3%) ALWAYS combined with benzoyl peroxide 1, 2, 4

• Fixed-combination products enhance compliance: erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, or clindamycin 1%/BP 3.75% 1, 2
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 4

Moderate-to-Severe Inflammatory Acne

First-line: Triple therapy = Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2, 4

Oral antibiotic selection:

• Doxycycline 100 mg once daily (strongly recommended, first-line) 1, 2, 4
• Minocycline 100 mg once daily (conditionally recommended, alternative) 1, 2
• Sarecycline (newer tetracycline option) 5
• Subantimicrobial-dose doxycycline 40 mg daily has shown efficacy for moderate inflammatory acne 1

Critical antibiotic stewardship rules:

• Limit systemic antibiotics to 3-4 months maximum to prevent resistance 1, 2, 4
• Always combine with benzoyl peroxide to prevent bacterial resistance 1, 2
• Never use oral antibiotics as monotherapy 1, 2
• Tetracyclines contraindicated in children under 8 years due to permanent tooth discoloration risk 4

Severe Nodular or Recalcitrant Acne

Isotretinoin is the definitive treatment and should be initiated immediately for: 1

• Severe nodular or conglobate acne 1
• Treatment-resistant moderate acne after 3-4 months of appropriate therapy 1, 2
• Any acne with scarring or significant psychosocial burden 1, 2

Isotretinoin dosing:

• Standard: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1
• Daily dosing preferred over intermittent dosing 2
• Either lidose-isotretinoin or standard formulations are acceptable 1

Monitoring requirements:

• Monitor liver function tests and lipids 1, 2
• CBC monitoring not needed in healthy patients 2
• No routine monitoring for depression or inflammatory bowel disease based on population studies 1, 2
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 1, 2, 3

Adjunctive therapy for immediate relief:

• Intralesional triamcinolone acetonide 10 mg/mL for individual large, painful nodules provides rapid pain relief within 48-72 hours 1
• Oral corticosteroids (prednisolone/prednisone) can provide temporary benefit while starting standard therapy 1

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Hormonal Therapy for Female Patients

Combined Oral Contraceptives (COCs)

Conditionally recommended for inflammatory acne in females, reducing inflammatory lesions by 62% at 6 months 1, 2, 6

• Effective for hormonal acne patterns and premenstrual flares 1
• Can be used as monotherapy or combined with topical agents 5

Spironolactone

Useful for female patients with hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 1, 2

• Dosing: 25-200 mg daily 1, 2
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 1, 2
• Particularly effective for adult female acne with hormonal component 1

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Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely to prevent recurrence 1, 2, 4

• Benzoyl peroxide can be continued as maintenance therapy 1, 2, 4
• Maintenance is essential—acne commonly recurs without ongoing treatment 1

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Special Populations

Preadolescent Children (≥9 Years)

Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 1, 2

• Start with low concentration benzoyl peroxide 2.5% 4
• Consider adapalene 0.1% gel for predominantly comedonal acne 4
• Tetracycline antibiotics contraindicated under age 8 due to permanent tooth discoloration risk 4

Back/Truncal Acne

Treatment follows same severity-based approach as facial acne 1

• Adapalene 0.1% gel available over-the-counter for mild back acne 1
• Consider body washes containing benzoyl peroxide or salicylic acid for large surface areas 1

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Physical Modalities (Adjunctive Options)

Chemical Peels

Salicylic acid 20-30% chemical peels applied for 2-4 minutes provide intensive treatment for resistant comedonal acne 1

• Glycolic acid, lactic acid, and mandelic acid are alternative alpha hydroxy acids 5
• Particularly useful for comedonal acne on buttocks or back 1

Light-Based Therapies

• Photochemical therapy (combined blue/red light) showed 35% improvement in mild-to-moderate acne 7
• Photodynamic therapy (light enhanced by photosensitizing chemical) showed 40% improvement in moderate-to-severe acne 7
• Evidence quality is limited; further research warranted 7

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Complementary Therapies (Limited Evidence)

Topical Botanicals

• Tea tree oil, green tea, witch hazel have been studied but evidence remains limited 5

Oral Supplements

• Zinc, niacinamide, pantothenic acid have some supporting data 5
• Topical zinc and niacinamide formulations available 5

Dietary Modifications

• Low-glycemic diet may provide benefit 5
• Consider reducing dairy and whey protein intake 5
• Omega-3 supplementation has been studied 5

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Critical Pitfalls to Avoid

Antibiotic Misuse

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly 1, 2, 4
• Never extend oral antibiotics beyond 3-4 months without re-evaluation 1, 2
• Always combine antibiotics with benzoyl peroxide 1, 2, 4

Severity Underestimation

• Never underestimate severity when scarring is present—this warrants aggressive treatment regardless of lesion count 1, 4
• Evaluate psychological impact; significant psychosocial burden warrants more aggressive therapy 1, 4

Tretinoin-Specific Errors

• Do not apply traditional tretinoin formulations simultaneously with benzoyl peroxide—oxidation inactivates tretinoin 1
• Avoid applying to broken skin or active wounds 1
• Some tretinoin formulations must be applied in evening due to photolability 1

Patient Education Failures

• Warn patients about initial adjustment period with possible peeling/discomfort in first 2-4 weeks 3
• Explain that new blemishes may appear at 3-6 weeks—this is normal and treatment should continue 3
• Set realistic expectations: improvement typically seen by 6-12 weeks 3
• Emphasize that excessive washing and scrubbing worsen acne 3

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Practical Treatment Selection Summary

Mild acne: Adapalene + benzoyl peroxide 1, 2, 4

Moderate acne: Adapalene + benzoyl peroxide + topical antibiotic (with BP) 1, 2, 4

Moderate-to-severe acne: Doxycycline 100 mg daily + adapalene + benzoyl peroxide for 3-4 months maximum 1, 2, 4

Severe/scarring/recalcitrant acne: Isotretinoin 1, 2

Female hormonal acne: Add COC or spironolactone to topical regimen 1, 2

Maintenance after clearance: Continue topical retinoid indefinitely 1, 2, 4