What are the treatment options for acne?

Acne Treatment

Start all acne patients on topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% as foundational therapy, 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

Severity-Based Treatment Algorithm

Mild Acne

• First-line: Topical retinoid + benzoyl peroxide 1, 2
• Adapalene 0.1% gel is available over-the-counter and is the preferred retinoid due to superior tolerability, lack of photolability, and compatibility with benzoyl peroxide without oxidation concerns 1, 2
• Apply retinoid once daily at bedtime to clean, completely dry skin (wait 20-30 minutes after washing) 3
• Alternative agents include azelaic acid for patients with post-inflammatory hyperpigmentation or salicylic acid 0.5-2% as an over-the-counter option 1, 2

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
• Add: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions—never as monotherapy due to rapid resistance development 1, 2
• Fixed-combination products (clindamycin 1%/BP 5%, erythromycin 3%/BP 5%) enhance compliance 2, 4
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and requires no G6PD testing 2

Moderate-to-Severe Inflammatory Acne

• First-line: Triple therapy with oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Strongly recommended: Doxycycline 100 mg once daily (moderate evidence) 1, 2
• Alternative: Minocycline 100 mg once daily (conditionally recommended) 1, 2
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1, 2
• Subantimicrobial doxycycline dosing (20 mg twice daily to 40 mg daily) has shown efficacy for moderate inflammatory acne 2

Severe Nodular or Recalcitrant Acne

• Definitive treatment: Isotretinoin 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 2
• Indications: Severe nodular/conglobate acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, any acne with scarring or significant psychosocial burden 1, 2
• Daily dosing is preferred over intermittent dosing 2
• Monitoring: Check triglycerides and liver enzymes at baseline and 2 months into treatment; routine CBC monitoring is unnecessary in healthy patients 5, 2
• Mandatory: Pregnancy prevention through iPLEDGE program for persons of childbearing potential 5, 2
• Population-based studies have not confirmed increased risk of depression or inflammatory bowel disease with isotretinoin 5, 2
• Intralesional triamcinolone acetonide 10 mg/mL can provide rapid relief (48-72 hours) for individual large, painful nodules 2

Hormonal Therapy for Female Patients

• Combined oral contraceptives: Reduce inflammatory lesions by 62% at 6 months and can be used as monotherapy or combined with topical agents 1, 2, 6
• Spironolactone 25-200 mg daily: Useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 1, 2
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 1, 2

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence 1, 2
• Benzoyl peroxide can be continued as maintenance therapy 1, 2
• Once acne lesions respond satisfactorily, maintenance with less frequent applications may be possible 3

Emerging and Adjunctive Therapies

• Photodynamic therapy (ALA-PDT) is an off-label treatment showing promise, with one trial demonstrating greater reduction in inflammatory and total lesion counts compared to oral doxycycline plus adapalene at 12 weeks 5
• Light-based therapies (blue/red light, IPL, pulsed dye laser, 1450 nm diode laser) have limited evidence but may be considered for select cases 5
• Topical clascoterone (antiandrogen) is conditionally recommended based on high certainty evidence 2
• Chemical peels with salicylic acid 20-30% can provide intensive treatment for resistant comedonal acne 2

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 stop treatment once acne clears—maintenance with topical retinoids is essential to prevent relapse 1, 2
• Avoid applying tretinoin with benzoyl peroxide simultaneously (oxidation inactivates tretinoin); adapalene does not have this limitation 2
• Do not apply retinoids to broken skin or active wounds 2
• Minimize sun exposure and use daily sunscreen with retinoids due to photosensitivity risk 2, 3
• Benzoyl peroxide can bleach clothing and bedding—advise patients to wear old or white clothing 7
• An apparent exacerbation of inflammatory lesions may occur during early weeks of retinoid therapy due to action on deep, previously unseen lesions—this should not prompt discontinuation 3
• Allow 6-12 weeks for therapeutic response before altering the regimen 3, 8