Acne Treatment
Start all acne patients 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 by adding topical antibiotics for moderate disease or oral antibiotics (doxycycline 100 mg daily) for moderate-to-severe inflammatory acne, always with concurrent benzoyl peroxide to prevent resistance. 1, 2
Treatment Algorithm by Severity
Mild Acne (Primarily Comedonal)
- Apply adapalene 0.1% gel (available over-the-counter) or tretinoin 0.025-0.1% once nightly to completely dry skin, plus benzoyl peroxide 2.5-5% gel once daily in the morning. 3, 1
- Adapalene is more photostable than tretinoin and can be safely combined with benzoyl peroxide in the same regimen. 1
- Start with lower retinoid concentrations in sensitive skin and titrate up as tolerated. 1
Moderate Acne (Mixed Comedonal and Inflammatory)
- Use a fixed-dose combination product containing topical retinoid + benzoyl peroxide as first-line, then add topical clindamycin 1% or erythromycin 2-3% twice daily if needed. 3, 2
- Fixed-combination products (clindamycin 1%/BP 5%, erythromycin 3%/BP 5%) enhance compliance and prevent bacterial resistance. 3
- Never use topical antibiotics as monotherapy—this rapidly induces bacterial resistance. 3, 2
- Topical dapsone 5% gel twice daily is particularly effective for inflammatory lesions in adult females. 3
Moderate-to-Severe Inflammatory Acne
- Prescribe triple therapy: oral doxycycline 100 mg once or twice daily with food + topical retinoid once nightly + benzoyl peroxide 2.5-5% once daily. 1, 2, 4
- Doxycycline and minocycline (100 mg once or twice daily) are more effective than tetracycline. 3, 5
- Limit oral antibiotics to 3-4 months maximum to minimize resistance development, then transition to maintenance therapy. 5, 1, 2
- Always combine oral antibiotics with benzoyl peroxide to prevent C. acnes resistance. 3, 2
Severe, Recalcitrant, or Scarring Acne
- Prescribe isotretinoin 0.5 mg/kg/day initially, increasing to 1.0 mg/kg/day as tolerated, targeting a cumulative dose of 120-150 mg/kg. 1, 4
- For moderate treatment-resistant acne, lower doses (0.25-0.4 mg/kg/day) provide equal efficacy with fewer side effects. 1
- Isotretinoin requires enrollment in the iPledge program due to teratogenicity risk. 6
Hormonal Therapy for Female Patients
- Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are effective for hormonal acne patterns. 2, 4
- Spironolactone 25-200 mg daily is useful for hormonal acne, premenstrual flares, or antibiotic-intolerant patients, with no potassium monitoring needed in healthy patients. 1, 2
Adjunctive Topical Agents
- Azelaic acid 15-20% gel or cream twice daily is particularly effective for post-inflammatory hyperpigmentation and is safe in darker skin types (Fitzpatrick IV or greater). 3, 1
- Clascoterone 1% cream twice daily is a newer anti-androgen option but is conditionally recommended due to high cost. 1
Maintenance Therapy After Clearance
- Continue topical retinoid once nightly indefinitely to prevent recurrence—this is essential and often overlooked. 5, 1, 2
- Add benzoyl peroxide 2.5-5% once daily if baseline disease was more severe. 1
- Topical retinoids are ideal for maintenance because they resolve microcomedones and have no risk of inducing bacterial resistance. 3, 7
Critical Pitfalls to Avoid
- Never prescribe topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 3, 2
- Never extend oral antibiotics beyond 3-4 months without re-evaluation, as prolonged use dramatically increases resistance risk. 5, 1, 2
- Never stop treatment once acne clears—maintenance with topical retinoids is essential to prevent relapse. 5, 2
- Warn patients that benzoyl peroxide bleaches clothing and bedding; recommend wearing old or white clothing when applying to large areas like the back. 5
- Topical retinoids cause photosensitivity; instruct patients to apply sunscreen daily. 5
- Local irritation (erythema, dryness, itching) is common early in retinoid therapy but improves with continued use and moisturizers. 8, 7