What are the first line treatments for acne?

First-Line Treatments for 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. 1, 2

Severity-Based Treatment Algorithm

Mild Acne

• Topical retinoid + benzoyl peroxide is the recommended first-line treatment 1, 2
• Adapalene 0.1% gel is available over-the-counter, making it highly accessible for initial therapy 1, 2
• Adapalene is preferred over tretinoin because it can be applied simultaneously with benzoyl peroxide without oxidation concerns and lacks photolability restrictions 1
• Apply retinoid once daily at bedtime after waiting 20-30 minutes for skin to dry completely 3
• Benzoyl peroxide should be applied in concentrations of 2.5-5%, as lower concentrations cause less irritation while maintaining efficacy 1

Moderate Acne

• Fixed-dose combination of topical retinoid + benzoyl peroxide as first-line treatment 1, 2
• Add topical antibiotics (clindamycin 1% or erythromycin 3%) only in combination with benzoyl peroxide, never as monotherapy due to rapid resistance development 1, 2
• Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, or clindamycin 1%/BP 3.75%) enhance compliance 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and can be used as an alternative topical agent 1

Moderate-to-Severe Inflammatory Acne

• Triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide 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
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development 1, 2
• Always use benzoyl peroxide concurrently with antibiotics to prevent resistance 1, 2

Hormonal Therapy for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are effective first-line options for females with inflammatory acne 1, 2
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 1, 2
• No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia taking spironolactone 1

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely to prevent recurrence 1, 2
• Benzoyl peroxide can also be continued as maintenance therapy 1, 2
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required before definite beneficial effects are seen 3
• Improvement is typically seen by 6-12 weeks of therapy 3

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 2
• Avoid applying tretinoin with benzoyl peroxide simultaneously (use adapalene instead, or apply tretinoin at night and benzoyl peroxide in the morning) 1
• Do not underestimate severity when scarring is present, as this warrants more aggressive treatment 1

Practical Application Tips

• Start with reduced frequency (every other night) if skin is sensitive, then increase as tolerated 3
• Use concurrent emollients and daily sunscreen to mitigate irritation and photosensitivity 1, 3
• Expect transient irritation, peeling, or apparent worsening during the first 2-4 weeks as the medication works on deep, previously unseen lesions 3
• Benzoyl peroxide can bleach clothing and bedding - warn patients to use white or old fabrics 4
• Azelaic acid is particularly useful for patients with post-inflammatory hyperpigmentation 1