What is the best treatment for a typical patient with acne, assuming no significant past medical history or allergies?

Best Treatment 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, 3

First-Line Treatment Foundation

Adapalene 0.1% gel combined with benzoyl peroxide 2.5-5% is the optimal starting regimen due to superior tolerability, excellent efficacy, lack of photolability concerns, and over-the-counter availability. 2, 3, 4 This combination addresses both comedonal and inflammatory components while preventing antibiotic resistance. 1, 2

Application Instructions

• Apply adapalene once nightly to completely dry skin (wait 20-30 minutes after washing). 4, 5
• Apply benzoyl peroxide once daily in the morning. 4
• Use a mild, non-medicated soap and wash only 2-3 times daily—excessive washing worsens acne. 5
• Apply daily sunscreen with moisturizer (non-comedogenic) every morning. 2, 5

Severity-Based Escalation Algorithm

Mild Acne

• Topical retinoid + benzoyl peroxide alone. 1, 2, 3, 4
• Adapalene 0.1% is available over-the-counter, making it highly accessible. 2, 3

Moderate Acne

• Add fixed-dose combination topical antibiotic with benzoyl peroxide (clindamycin 1%/BP 5% or erythromycin 3%/BP 5%). 1, 2, 3, 4
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2, 3, 4

Moderate-to-Severe Inflammatory Acne

• Triple therapy: oral doxycycline 100 mg once daily + topical retinoid + benzoyl peroxide. 1, 2, 3, 4
• Doxycycline is strongly recommended with moderate evidence over minocycline (conditionally recommended). 1, 2, 3
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development. 1, 2, 3, 4
• Always use oral antibiotics concomitantly with benzoyl peroxide and topical retinoids. 1, 2

Severe Acne or Treatment-Resistant Cases

• Isotretinoin is indicated for severe nodular acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden. 1, 2, 3
• 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. 1, 2
• Monitor liver function tests and lipids, but CBC monitoring is not needed in healthy patients. 1, 2
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential. 1, 2, 3
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease. 1, 2

Hormonal Therapy Options for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended. 1, 2, 3, 4
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics. 1, 2, 3, 4
• No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia. 1, 2

Adjunctive Therapies

• Intralesional triamcinolone acetonide 10 mg/mL for large, painful nodules provides rapid pain relief within 48-72 hours. 1, 2, 4
• Use judiciously for patients at risk of scarring, using lower concentrations to minimize adverse events. 1
• Azelaic acid is conditionally recommended and particularly useful for post-inflammatory hyperpigmentation. 1, 2

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely to prevent recurrence. 2, 3, 4 This is the most critical step—stopping treatment once acne clears leads to relapse. 3 Benzoyl peroxide can also be continued as maintenance. 2, 3, 4

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2, 3, 4
• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk. 1, 2, 3, 4
• Do not stop treatment once acne clears—maintenance with topical retinoids is essential. 3
• Do not apply traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin (adapalene lacks this concern). 2
• Avoid excessive washing, harsh scrubbing, and astringent products—these worsen acne. 5
• Do not underestimate severity when scarring or significant psychosocial burden is present—these patients warrant more aggressive treatment regardless of lesion count. 2, 4

Expected Timeline

• Initial irritation, dryness, or peeling may occur in the first 2-4 weeks as skin adjusts. 5
• New blemishes may appear at 3-6 weeks—continue treatment through this phase. 5
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required for definite beneficial effects. 5
• Continued improvement typically occurs after 6-12 weeks of therapy. 5