What are the treatment options for acne?

Acne Treatment

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 topical antibiotics for moderate disease or oral doxycycline 100 mg daily for moderate-to-severe inflammatory acne, always with concurrent benzoyl peroxide to prevent resistance. 1

Assessment and Severity Classification

• Use the Physician Global Assessment (PGA) to classify acne as mild, moderate, or severe 1
• Evaluate for scarring, post-inflammatory dyspigmentation, and psychosocial impact—these factors warrant more aggressive treatment regardless of lesion count 1
• Presence of scarring or significant quality of life impact should trigger consideration of more intensive therapy early 1

Treatment Algorithm by Severity

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 application with benzoyl peroxide without oxidation concerns 1
• Apply retinoid once nightly to completely dry skin; apply benzoyl peroxide once daily 2
• Alternative for comedonal acne: Salicylic acid 0.5-2% as an over-the-counter option, though evidence is more limited 1
• For post-inflammatory hyperpigmentation: Add azelaic acid 15-20% gel or cream twice daily 1, 2

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1
• Add for inflammatory lesions: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide—never as monotherapy due to rapid resistance development 1, 2
• Fixed-combination products (clindamycin 1%/BP 5%, erythromycin 3%/BP 5%) enhance compliance 1
• Alternative for inflammatory acne in adult females: Topical dapsone 5% gel twice daily (no G6PD testing required) 1
• Newer option: Clascoterone 1% cream twice daily (topical antiandrogen, conditionally recommended due to high cost) 1

Moderate-to-Severe Inflammatory Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide (triple therapy) 1
• Oral antibiotic options:
  • Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1, 2
  • Minocycline 100 mg once daily (conditionally recommended) 1, 2
  • Sarecycline (newer tetracycline option) 1
• Critical: 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
• Subantimicrobial doxycycline dosing (20 mg twice daily to 40 mg daily) has shown efficacy for moderate inflammatory acne 1

Severe Nodular or Recalcitrant Acne

• Definitive treatment: Isotretinoin 0.5-1.0 mg/kg/day, targeting cumulative dose of 120-150 mg/kg 1, 2
• Indications for isotretinoin: 1
  • Severe nodular or conglobate acne
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy
  • Any acne with scarring or significant psychosocial burden
• Daily dosing preferred over intermittent dosing 1
• Monitoring: Liver function tests and lipids only; CBC not needed in healthy patients 1
• Population studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 1, 3
• Mandatory: Pregnancy prevention through iPledge program for persons of childbearing potential 1, 3
• Adjunctive for large nodules: Intralesional triamcinolone acetonide 10 mg/mL for rapid pain relief within 48-72 hours 1
• Oral corticosteroids can provide temporary benefit while starting standard therapy 1

Hormonal Therapy for Female Patients

• Combined oral contraceptives: Reduce inflammatory lesions by 62% at 6 months; conditionally recommended with moderate certainty evidence 1
• Use at standard contraceptive dosing per product labeling 2
• Spironolactone 25-200 mg daily: Useful for hormonal acne patterns, premenstrual flares, or antibiotic-intolerant patients 1, 2
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 1, 2

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 2
• Topical retinoids are essential for long-term maintenance as they prevent microcomedone formation 1

Special Populations

Pediatric Patients (Ages 12-17)

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children 1
• Isotretinoin use in ages 12-17 should be given careful consideration, especially with known metabolic or structural bone disease 3
• Increased incidence of back pain, arthralgia, and myalgia in pediatric patients on isotretinoin 3

Back Acne

• Treatment follows the same severity-based approach as facial acne 1, 4
• Adapalene 0.1% gel available over-the-counter for mild back acne 4
• Practical consideration: Benzoyl peroxide can bleach clothing and bedding; wear old or white clothing 4

Emerging and Adjunctive Therapies

Light-Based Treatments

• Photodynamic therapy (PDT): ALA-PDT followed by adapalene showed greater reduction in inflammatory lesions compared to oral doxycycline plus adapalene at 12 weeks in one randomized trial, though more high-quality studies are needed 5
• Blue/red light devices, intense pulsed light (IPL), and pulsed dye laser (PDL) have been explored, but evidence quality is low 5
• 1450 nm diode laser can improve acne and causes sebaceous gland destruction 5

Dietary and Complementary Approaches

• Low-glycemic diet and reducing dairy/whey protein intake may provide benefit 1
• Oral supplements (zinc, niacinamide, pantothenic acid) have some supporting data 1
• Topical botanicals (tea tree oil, green tea, witch hazel) have limited evidence 1
• Salicylic acid 20-30% chemical peels for resistant comedonal acne 1

Novel Topical Agents Under Investigation

• Nitric oxide-releasing particles (SB204) showed significant reduction in lesion counts in phase 2 studies 5
• Anti-androgen cream (cortexolone 17α-propionate 1%) improved lesion counts in phase 2 study 5
• Topical agents targeting sebum production (SCD1 inhibitors, α-MSH mimetics) are in clinical trials 5

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1
• Do not underestimate severity when scarring is present—this warrants more aggressive treatment 1
• Do not apply tretinoin with benzoyl peroxide simultaneously (except adapalene)—oxidation inactivates tretinoin 1
• Do not stop treatment once acne clears—maintenance with topical retinoids is essential to prevent relapse 4
• Recommend daily sunscreen with retinoid use due to photosensitivity 1, 4

Practical Application Tips

• Start retinoids with reduced frequency and concurrent emollients to mitigate initial irritation 1
• Lower benzoyl peroxide concentrations (2.5%) cause less irritation than higher concentrations with similar efficacy 1
• Fixed-combination products enhance compliance compared to multiple separate agents 1
• Allow 6-8 weeks for most treatments to work before altering the regimen 6