What are the different grades of acne and their corresponding treatment options?

Acne Grading and Treatment by Severity

Classification System

Use the Physician Global Assessment (PGA) to classify acne as mild, moderate, or severe—this standardized approach directly guides treatment selection and ensures consistent escalation of therapy. 1, 2, 3

• Evaluate beyond lesion count: assess for scarring, post-inflammatory dyspigmentation, and psychosocial impact, as these factors mandate more aggressive treatment regardless of numerical severity 2, 3

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Mild Acne: Predominantly Comedonal with Minimal Inflammation

Start with adapalene 0.1% gel once nightly combined with benzoyl peroxide 2.5-5% gel once daily in the morning—this dual-mechanism approach targets both comedones and prevents future bacterial resistance. 4, 2

First-Line Topical Regimen

• Adapalene 0.1% gel is the preferred initial retinoid due to superior tolerability, lack of photolability, and compatibility with benzoyl peroxide without oxidation concerns 4, 2
• Apply adapalene to completely dry skin once nightly to the entire affected area, not just visible lesions 4
• Benzoyl peroxide 2.5% is equally effective as higher concentrations but causes significantly less irritation 1, 4

Alternative Fixed-Combination Products

• Adapalene 0.1%/benzoyl peroxide 2.5% gel applied once nightly provides convenient single-product option that enhances compliance 4
• Tretinoin 0.025% cream/gel can be substituted for sensitive skin, but must be applied separately from benzoyl peroxide due to oxidation inactivation 4, 2

Adjunctive Options for Specific Situations

• Azelaic acid 15-20% gel twice daily is particularly useful for patients with post-inflammatory hyperpigmentation or darker skin types 4, 2
• Salicylic acid 0.5-2% serves as an over-the-counter alternative, though clinical evidence is limited compared to retinoids 4, 5

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Moderate Acne: Mixed Comedonal and Inflammatory Lesions

Use fixed-dose combination of topical retinoid + benzoyl peroxide, and add topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions—never use topical antibiotics as monotherapy due to rapid resistance development. 1, 2, 3

Recommended Combination Approach

• Fixed-combination products (clindamycin 1%/benzoyl peroxide 5%, clindamycin 1%/benzoyl peroxide 3.75%, or erythromycin 3%/benzoyl peroxide 5%) applied once daily enhance compliance 2
• Continue adapalene 0.1-0.3% or tretinoin 0.025-0.1% as the retinoid foundation 2

Alternative Topical Agents

• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females, with no glucose-6-phosphate dehydrogenase testing required 2
• Clascoterone (topical antiandrogen) is conditionally recommended based on high certainty evidence for inflammatory lesions 1, 2

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Moderate-to-Severe Acne: Extensive Inflammatory Lesions

Initiate triple therapy with oral doxycycline 100 mg once daily + topical retinoid + benzoyl peroxide, but limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance. 1, 2, 3

Oral Antibiotic Selection

• Doxycycline 100 mg once daily is strongly recommended with moderate evidence as first-line oral antibiotic 1, 2
• Minocycline 100 mg once daily is conditionally recommended as an alternative 1, 2
• Sarecycline is a newer tetracycline-class option for moderate-to-severe inflammatory acne 2
• Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy in moderate inflammatory acne 2

Critical Antibiotic Stewardship

• Always combine oral antibiotics with benzoyl peroxide to prevent bacterial resistance 1, 2
• Re-evaluate after 3-4 months and transition to maintenance therapy with topical retinoid alone 1, 2

Hormonal Therapy for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended 2, 3
• Spironolactone 25-200 mg daily (typically start at 50-100 mg) is effective for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 2, 3
• No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia 2, 3

Adjunctive Procedures

• Intralesional triamcinolone acetonide 10 mg/mL for individual large, painful nodules provides rapid pain relief and inflammation reduction within 48-72 hours 2, 3

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Severe Acne: Nodular, Conglobate, or Treatment-Resistant Disease

Initiate oral isotretinoin immediately for severe nodular acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden—this is the only drug affecting all four pathogenic factors of acne. 1, 2, 3

Isotretinoin Indications

• Severe nodular or conglobate acne 2
• Moderate acne with scarring or significant psychosocial burden 2
• Treatment-resistant moderate acne after 3-4 months of appropriate therapy 2

Dosing and Monitoring

• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 2
• Daily dosing is preferred over intermittent dosing 2
• Monitor only liver function tests and lipids—CBC monitoring is not needed in healthy patients 2
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 2, 6

Mandatory Pregnancy Prevention

• Persons of childbearing potential must enroll in the iPLEDGE program before starting isotretinoin 1, 2, 6

Critical Pitfall

• Oral antibiotics should NOT be used as primary therapy for severe acne (acne conglobata), as they are inadequate and delay definitive isotretinoin treatment 2

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Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence—this is the most critical step to prevent relapse. 4, 2

• Benzoyl peroxide can be continued as maintenance therapy to prevent recurrence 2
• Topical retinoids are essential for long-term maintenance regardless of initial severity 1, 2

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Common Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 4, 2, 3
• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk 1, 2
• Avoid applying retinoids immediately after washing—wait for skin to be completely dry to minimize irritation 4
• Do not underestimate severity when scarring is present—this warrants more aggressive treatment 2, 3
• Apply daily sunscreen with retinoids due to photosensitivity risk 2