What is the recommended treatment approach for acne in family medicine?

Family Medicine Approach to Treating Acne

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

Initial Assessment

Assess acne severity using the Physician Global Assessment (PGA) scale to classify 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. Patients with any scarring or significant psychosocial burden should be considered candidates for more intensive therapy, potentially including isotretinoin 2, 1.

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoid + benzoyl peroxide 2, 1
• Preferred retinoid: Adapalene 0.1% gel applied once nightly to completely dry skin (wait 20-30 minutes after washing) 3, 4
• Benzoyl peroxide: Start with 2.5-5% gel applied once daily in the morning 2, 3
• Alternative: Azelaic acid 15-20% for patients with post-inflammatory hyperpigmentation or darker skin tones 1, 3
• Fixed-combination option: Adapalene 0.1%/benzoyl peroxide 2.5% gel once nightly for enhanced compliance 3

Moderate Acne

• First-line: Fixed-dose combination topical retinoid + benzoyl peroxide 2, 1
• Add: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions 1
• Fixed-combination products: Clindamycin 1%/BP 5% or erythromycin 3%/BP 5% to enhance compliance 2, 1
• Alternative for adult females: Topical dapsone 5% gel is particularly effective for inflammatory acne 1

Moderate-to-Severe Inflammatory Acne

• First-line: Oral antibiotics + topical retinoid + benzoyl peroxide (triple therapy) 2, 1
• Preferred oral antibiotic: Doxycycline 100 mg once daily (strong recommendation, moderate evidence) 2, 1
• Alternative: Minocycline 100 mg once daily (conditional recommendation, moderate evidence) 2, 1
• Duration: Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 2, 1
• Critical: Always use oral antibiotics concomitantly with benzoyl peroxide and topical retinoid 2, 1

Severe or Treatment-Resistant Acne

• Isotretinoin indications: 2, 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
• Dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1
• Monitoring: Liver function tests and lipids only; CBC monitoring not needed in healthy patients 2, 1
• Pregnancy prevention: Mandatory through iPledge program for persons of childbearing potential 2, 1
• Evidence on safety: Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 2, 1

Hormonal Therapy for Female Patients

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

Adjunctive Therapies

• Intralesional corticosteroids: Triamcinolone acetonide 10 mg/mL for large, painful nodules to provide rapid pain relief within 48-72 hours 2, 1
• Use judiciously: Lower concentration and volume minimize risks of local adverse events 2

Maintenance Therapy

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

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 2, 1, 3
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1
• Avoid applying retinoids immediately after washing—wait 20-30 minutes for skin to be completely dry to minimize irritation 3, 4
• Do not underestimate severity when scarring is present—these patients warrant more aggressive treatment 1
• Avoid excessive washing or harsh scrubbing—this may worsen acne 4

Practical Application Tips

• Sun protection: Retinoids cause photosensitivity; recommend daily sunscreen use 1, 4
• Benzoyl peroxide warning: Can bleach clothing and bedding; advise wearing old or white clothing 5
• Timeline expectations: Therapeutic results typically seen after 2-3 weeks, but may require 6-12 weeks for definite beneficial effects 4
• Initial worsening: An apparent exacerbation of inflammatory lesions may occur in early weeks due to action on deep, previously unseen lesions—this should not be considered a reason to discontinue therapy 4
• Starting sensitive skin: For sensitive skin, start retinoids every other night and titrate up as tolerated 3, 4