What is the recommended treatment approach for a patient presenting with acne?

Acne Vulgaris Treatment Approach

Initial Assessment

Begin with topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% as first-line therapy for all acne patients, then escalate based on severity by adding topical or oral antibiotics for moderate-to-severe disease—always with concurrent benzoyl peroxide to prevent resistance. 1, 2

Use the Physician Global Assessment (PGA) scale to classify acne as mild, moderate, or severe 1, 2. Critically, evaluate for scarring, post-inflammatory dyspigmentation, and psychosocial impact—these factors warrant more aggressive treatment regardless of lesion count 1, 2.

Treatment Algorithm by Severity

Mild Acne

• First-line: Topical retinoid + benzoyl peroxide 1, 2
• Preferred retinoid: Adapalene 0.1% gel applied once nightly to completely dry skin 2
• Benzoyl peroxide: 2.5-5% gel applied once daily in the morning 2
• Alternative for post-inflammatory hyperpigmentation: Add azelaic acid 1
• Over-the-counter option: Adapalene 0.1% is available without prescription 1

Adapalene is preferred over tretinoin because it can be applied with benzoyl peroxide without oxidation concerns, lacks photolability restrictions, and demonstrates superior tolerability compared to tretinoin 0.025-0.05% 1, 3.

Moderate Acne

• First-line: Fixed-dose combination topical retinoid + benzoyl peroxide 1, 2
• Add for inflammatory lesions: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide 1, 2
• Fixed-combination products: Clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5% enhance compliance 1
• For adult females with inflammatory acne: Consider topical dapsone 5% gel (no G6PD testing required) 1

Moderate-to-Severe Inflammatory Acne

• First-line triple therapy: Oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Preferred oral antibiotic: Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1, 2
• Alternative: Minocycline 100 mg once daily (conditionally recommended) 1, 2
• Critical duration limit: Restrict systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1, 2
• Subantimicrobial option: Doxycycline 20 mg twice daily to 40 mg daily for moderate inflammatory acne 1

Severe Nodular or Recalcitrant Acne

Isotretinoin is indicated for: 1, 2

• 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. Daily dosing is preferred over intermittent dosing 1.

Monitoring: Only liver function tests and lipids are required—CBC monitoring is not needed in healthy patients 1. Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 1.

Mandatory pregnancy prevention: iPledge program enrollment required for persons of childbearing potential 1, 2, 4.

Hormonal Therapy for Female Patients

• Combined oral contraceptives: Reduce inflammatory lesions by 62% at 6 months 1, 2, 5
• 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

Adjunctive Therapies

• Intralesional triamcinolone acetonide 10 mg/mL: For large, painful nodules to provide rapid pain relief and inflammation reduction within 48-72 hours 1, 2
• Oral corticosteroids: Temporary benefit in severe inflammatory acne while starting standard treatment 1
• Salicylic acid 20-30% chemical peels: For resistant comedonal acne 1

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence 1, 2. Benzoyl peroxide can also be continued as maintenance 1, 2.

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 4
• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk 1, 2
• Never apply traditional tretinoin formulations with benzoyl peroxide simultaneously—oxidation inactivates tretinoin 1, 4
• Never underestimate severity when scarring is present—this warrants more aggressive treatment 1
• Always use daily sunscreen with retinoids due to photosensitivity risk 1, 4

Application Technique for Retinoids

Apply retinoids once nightly as a thin layer to completely dry skin 2, 4. Start with every-other-night application if skin is sensitive 4. Use concurrent emollients to mitigate initial irritation 1.

Special Populations

Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 1. Tretinoin is not established for use in children under 10 years 4.

Back acne: Follow the same severity-based approach as facial acne 1.