What are the treatment options for acne?

Treatment of Acne

Start all acne patients on adapalene 0.1-0.3% gel once nightly combined with benzoyl peroxide 2.5-5% once daily as the foundation, then escalate based on severity by adding oral 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: Topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) + benzoyl peroxide 2.5-5% 1, 2
• Adapalene 0.1% is available over-the-counter and is more photostable than tretinoin, allowing concurrent use with benzoyl peroxide without oxidation concerns 1, 2
• Apply retinoid once nightly to completely dry skin (wait 20-30 minutes after washing), starting with lower concentrations in sensitive skin 1, 3
• Apply benzoyl peroxide once daily in the morning 1

Moderate Acne

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

Moderate-to-Severe Inflammatory Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide (triple therapy) 1, 2
• Doxycycline 100 mg once daily is strongly recommended with moderate evidence 1, 2
• Minocycline 100 mg once daily is conditionally recommended as an alternative 1, 2
• Limit systemic antibiotics to 3-4 months maximum to minimize resistance development 1, 2
• Always combine oral antibiotics with benzoyl peroxide 1, 2

Severe or Recalcitrant Acne

• Isotretinoin is indicated for: 1, 2
  • Severe nodular or conglobate acne
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy
  • Any acne with scarring or significant psychosocial burden
• Dosing: Start 0.5 mg/kg/day, increase to 1.0 mg/kg/day as tolerated, targeting cumulative dose of 120-150 mg/kg 1
• For moderate treatment-resistant acne, lower doses (0.25-0.4 mg/kg/day) show equal efficacy with fewer side effects 1
• Monitoring: Only liver function tests and lipids required; CBC monitoring not needed in healthy patients 2
• Population studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 2
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 2

Hormonal Therapy for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended 2, 4
• Spironolactone 25-200 mg daily is useful for: 1, 2
  • Hormonal acne patterns or premenstrual flares
  • Patients who cannot tolerate or prefer to avoid oral antibiotics
  • No potassium monitoring needed in healthy patients without risk factors 2

Additional Topical Options

• Azelaic acid 15-20% applied twice daily, particularly effective for post-inflammatory hyperpigmentation 1, 2
• Topical dapsone 5% gel applied twice daily, particularly effective for inflammatory acne in adult females; no G6PD testing required 1, 2
• Clascoterone 1% cream applied twice daily, conditionally recommended due to high cost 1

Maintenance Therapy After Clearance

• Continue topical retinoid once nightly indefinitely to prevent recurrence 1, 2
• Add benzoyl peroxide 2.5-5% once daily if needed for more severe baseline disease 1

Critical Application Instructions for Topical Retinoids

• Wash with mild soap, pat dry, wait 20-30 minutes before applying to ensure skin is completely dry 3
• Apply once nightly before bedtime 3
• Use approximately half-inch or less for entire face; medication should become invisible almost immediately 3
• Avoid corners of nose, mouth, eyes, and open wounds 3
• Do not apply traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation 2
• Apply daily sunscreen due to photosensitivity risk 2, 3
• Initial irritation or peeling typically subsides within 2-4 weeks 3
• Therapeutic results typically seen after 2-3 weeks, but may require 6-12 weeks for definite beneficial effects 3

Common Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly 1, 2
• Never extend oral antibiotics beyond 3-4 months without re-evaluation 1, 2
• Do not underestimate severity when scarring is present 2
• Do not stop treatment at first signs of improvement; continue through maintenance phase 2
• Avoid excessive washing or scrubbing—acne is not caused by dirt 3
• Do not apply more medication than recommended; excess irritates skin without improving results 3

Special Populations

• Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 2
• Pregnant/nursing patients: No studies establish safety of tretinoin in pregnancy; consult physician before use 3
• Back acne: Follow same severity-based approach as facial acne 2, 5