What are the recommended treatments for acne?

Acne Treatment Recommendations

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

Severity-Based Treatment Algorithm

Mild Acne

• First-line therapy: Adapalene 0.1% gel applied once nightly to completely dry skin + benzoyl peroxide 2.5-5% gel applied once daily in the morning 2
• Adapalene 0.1% is the preferred initial retinoid due to superior tolerability, lack of photolability, and ability to be combined with benzoyl peroxide without oxidation concerns 1
• Start with benzoyl peroxide 2.5% rather than higher concentrations, as lower concentrations are equally effective but cause significantly less irritation 2
• Fixed-combination option: Adapalene 0.1%/benzoyl peroxide 2.5% gel applied once nightly for enhanced compliance 2
• Alternative for post-inflammatory hyperpigmentation: Azelaic acid 15-20% gel or cream applied twice daily, particularly useful for darker skin types 2

Moderate Acne

• First-line therapy: Fixed-dose combination of topical retinoid + benzoyl peroxide 1
• Add topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions, but never as monotherapy due to resistance risk 1
• Fixed-combination products (clindamycin 1%/BP 5% or erythromycin 3%/BP 5%) enhance compliance 1
• Alternative for adult females: Topical dapsone 5% gel is particularly effective for inflammatory acne in this population 1

Moderate-to-Severe Inflammatory Acne

• Triple therapy approach: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 3
• Preferred oral antibiotic: Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1
• Alternative oral antibiotic: Minocycline 100 mg once daily (conditionally recommended) 1
• Critical limitation: Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1, 3
• Counsel patients on doxycycline about significant photosensitivity risk and strict sun protection 3

Severe/Cystic Acne or Scarring

• Isotretinoin is the definitive treatment and should be initiated immediately for severe acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden regardless of lesion count 1, 3
• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1
• Daily dosing is preferred over intermittent dosing 1
• Mandatory monitoring: Baseline and repeat liver function tests and lipid panels at least once during treatment 3, 4
• No routine monitoring needed for CBC, depression, or inflammatory bowel disease based on population studies 1, 4
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 1, 4
• Adjunctive therapy: Intralesional triamcinolone acetonide 10 mg/mL for individual large, painful cystic nodules provides rapid pain relief within 48-72 hours 3

Hormonal Therapy for Female Patients

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

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence—this is the most critical step to prevent relapse 2, 1, 3
• Benzoyl peroxide can be continued as maintenance therapy 1

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 2, 1, 3, 5, 6
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 3
• Avoid applying retinoids immediately after washing; wait for skin to be completely dry to minimize irritation 2
• Do not apply traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin 1
• Presence of scarring automatically indicates need for aggressive treatment (isotretinoin) regardless of total lesion count 3
• Use daily sunscreen with retinoids due to photosensitivity risk 1

Practical Application Tips

• Allow 6-8 weeks for most treatments to work before altering the regimen 7
• Start with reduced frequency of application and concurrent emollients to mitigate initial retinoid irritation 1
• Combining topical antibiotics with benzoyl peroxide is synergistic and well-tolerated 6, 8
• Combining topical retinoids with antibiotics enhances efficacy since the retinoid improves antibiotic penetration 8