What are the treatment options for acne?

Treatment for Acne

First-Line Foundation for All Acne

Start every acne patient 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

• Adapalene 0.1% gel is the preferred first-line retinoid because it has superior tolerability, can be applied simultaneously with benzoyl peroxide without oxidation concerns, lacks photolability restrictions, and is available over-the-counter. 1, 2
• Benzoyl peroxide prevents antibiotic resistance and provides antimicrobial effects with no bacterial resistance reported. 1, 2
• Apply retinoid once nightly after waiting 20-30 minutes for skin to dry completely, and apply benzoyl peroxide once daily (can be morning application). 1, 3

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Severity-Based Treatment Algorithm

Mild Acne (Comedonal or Minimal Inflammatory Lesions)

• Use topical retinoid + benzoyl peroxide as monotherapy. 1, 2
• Adapalene 0.1% is available over-the-counter, making it highly accessible. 1, 2
• For comedonal acne specifically, topical retinoids are the cornerstone because they directly normalize follicular keratinization and resolve microcomedones. 4

Moderate Acne (More Inflammatory Lesions)

• Use fixed-dose combination of topical retinoid + benzoyl peroxide, and add topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions. 1, 2
• Fixed-combination products (clindamycin 1%/BP 5% or erythromycin 3%/BP 5%) enhance compliance. 2
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2

Moderate-to-Severe Inflammatory Acne

• Use triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide. 1, 2
• Doxycycline 100 mg once daily is the strongly recommended first-line oral antibiotic (moderate evidence). 1, 2
• Minocycline 100 mg once daily is a conditionally recommended alternative. 1, 2
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance. 1, 2
• Always combine oral antibiotics with benzoyl peroxide to prevent resistance. 1, 2

Severe Nodular or Recalcitrant Acne

• Isotretinoin is indicated for severe nodular acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden. 2
• Standard dosing is 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg. 2
• Daily dosing is preferred over intermittent dosing. 2
• Monitor only liver function tests and lipids; CBC monitoring is not needed in healthy patients. 2
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential. 2
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease. 2

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Hormonal Therapy Options for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended for inflammatory acne in females. 1, 2
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics. 1, 2
• No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia. 1, 2

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Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence. 1, 2
• Benzoyl peroxide can be continued as maintenance therapy. 1, 2
• Do not stop treatment once acne clears—maintenance is essential to prevent relapse. 1

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Alternative and Adjunctive Topical Agents

• Azelaic acid 15-20% is particularly useful for post-inflammatory hyperpigmentation in patients with darker skin tones (Fitzpatrick IV or greater). 2, 4
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females. 2
• No glucose-6-phosphate dehydrogenase testing is required before starting topical dapsone. 2
• Salicylic acid 0.5-2% is available over-the-counter as a comedolytic agent but has limited clinical trial evidence. 2, 4
• Clascoterone is a newer topical antiandrogen conditionally recommended based on high certainty evidence. 2

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Managing Retinoid Side Effects

• Common side effects include dry skin, peeling, erythema, and photosensitivity. 4, 3
• Mitigate irritation by starting with reduced frequency (every other night initially), using concurrent emollients, and applying daily sunscreen. 2, 4, 3
• Wait 20-30 minutes after washing for skin to dry completely before applying retinoid. 3
• If irritation is excessive, reduce frequency or temporarily discontinue until tolerance improves. 3

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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, as this dramatically increases resistance risk. 1, 2
• Do not apply traditional tretinoin formulations simultaneously with benzoyl peroxide due to oxidation inactivating tretinoin (adapalene does not have this limitation). 2
• Avoid applying retinoids to broken skin or areas with active wounds. 2
• Do not underestimate severity when scarring is present—this warrants more aggressive treatment. 2
• Minimize sun exposure during retinoid therapy and use daily sunscreen due to photosensitivity risk. 2, 4, 3

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Special Considerations

• For large, painful nodules, intralesional triamcinolone acetonide 10 mg/mL provides rapid pain relief and inflammation reduction within 48-72 hours. 2
• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children with acne. 2
• Treatment for back acne follows the same severity-based approach as facial acne. 2
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required before definite beneficial effects are seen. 3
• An apparent exacerbation of inflammatory lesions may occur during early weeks due to medication acting on deep, previously unseen lesions—this should not be considered a reason to discontinue therapy. 3