What are the treatment options for acne vulgaris?

Treatment for Acne Vulgaris

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. 1, 2, 3

Severity-Based Treatment Algorithm

Mild Acne

• First-line: Topical retinoid + benzoyl peroxide 2.5-5% 1, 2, 3
• Preferred retinoid: Adapalene 0.1% due to superior tolerability, lack of photolability, over-the-counter availability, and ability to be applied simultaneously with benzoyl peroxide without oxidation concerns 1, 2
• Alternative options: Azelaic acid for patients with post-inflammatory hyperpigmentation 2

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2, 3
• Add for inflammatory lesions: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide—never as monotherapy 1, 2, 3, 4, 5
• Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) enhance compliance 2
• Alternative for adult females: Topical dapsone 5% gel is particularly effective for inflammatory acne, with no G6PD testing required 2

Moderate-to-Severe Inflammatory Acne

• First-line (triple therapy): Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2, 3
• Preferred oral antibiotic: Doxycycline 100 mg once daily (strongly recommended) 1, 2, 3
• Alternative: Minocycline 100 mg once daily (conditionally recommended) 2, 3
• Critical limitation: Restrict systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1, 2, 3
• Mandatory combination: Always use oral antibiotics with benzoyl peroxide to prevent resistance development 1, 2, 3, 6

Severe Nodular or Recalcitrant Acne

• Isotretinoin is indicated for: 1, 2, 3
  • Severe nodular or conglobate acne
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy
  • Any acne causing scarring or significant psychosocial burden
• Dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1, 2
• Monitoring: Liver function tests and lipids only—CBC monitoring not needed in healthy patients 2
• Pregnancy prevention: Mandatory iPledge program enrollment for persons of childbearing potential 1, 2, 3
• Reassurance: Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 2

Hormonal Therapy for Female Patients

• Combined oral contraceptives: Reduce inflammatory lesions by 62% at 6 months, conditionally recommended 1, 2, 3, 7
• Spironolactone 25-200 mg daily: Useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 1, 2, 3
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 2, 3

Adjunctive Treatments

• Intralesional triamcinolone acetonide 10 mg/mL: For larger nodules, provides rapid pain relief within 48-72 hours and prevents scarring 1, 2
• Topical clascoterone: Newer antiandrogen, conditionally recommended based on high certainty evidence 1, 2
• Salicylic acid 20-30% chemical peels: For resistant comedonal acne, applied for 2-4 minutes 2, 8

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence 1, 2, 3
• Benzoyl peroxide can be continued as maintenance 1, 2, 3

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 3, 6
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 2, 3
• Never apply traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin 2
• Never use oral antibiotics as primary therapy for acne conglobata—they are inadequate and delay definitive isotretinoin treatment 2

Special Considerations

• Assess psychological impact using standardized scales like Physician Global Assessment (PGA), as psychosocial burden warrants more aggressive treatment 1, 2
• Evaluate for scarring at every visit—presence of scarring is an indication for isotretinoin 1, 2
• Preadolescent children (≥9 years): Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 2, 3
• Daily sunscreen use recommended with retinoids due to photosensitivity risk 2