What are the next steps for treating acne in a teenager who has tried over-the-counter (OTC) salicylic acid pads for 3 months without improvement?

Next-Step Treatment for Teen Acne After Failed OTC Salicylic Acid

Start a topical retinoid (adapalene 0.1% or tretinoin) combined with benzoyl peroxide, as this represents the evidence-based standard for acne that has not responded to over-the-counter therapy. 1

Why Salicylic Acid Alone Was Insufficient

• Salicylic acid has limited clinical trial evidence demonstrating efficacy in acne, and guidelines note this weakness 1
• While salicylic acid is mildly comedolytic, it does not address the inflammatory component or bacterial colonization that drives most acne progression 1
• The 2024 American Academy of Dermatology guidelines give salicylic acid only a "conditional" recommendation with "low" certainty of evidence 1

First-Line Prescription Therapy: Topical Retinoid + Benzoyl Peroxide

Topical retinoids are the cornerstone of acne therapy because they:

• Resolve the precursor microcomedone lesion that causes all acne 1
• Provide anti-inflammatory effects 1
• Work for both comedonal and inflammatory acne 1
• Allow maintenance of clearance long-term 1

Specific retinoid options for adolescents:

• Adapalene 0.1% gel is available over-the-counter, well-tolerated, and has strong evidence in adolescents 1, 2
• Tretinoin 0.025% cream or gel is prescription-only but equally effective 1, 3
• Apply once daily at bedtime to completely dry skin (wait 20-30 minutes after washing) 3

Add benzoyl peroxide because:

• It provides antibacterial activity against P. acnes 1
• Prevents antibiotic resistance if antibiotics are later needed 1
• Fixed-dose combination products (retinoid + benzoyl peroxide) receive "strong" recommendations with "moderate" certainty 1
• Can be applied in the morning while retinoid is used at night, or use a combination product 1

When to Add Topical Antibiotics

If inflammatory lesions (papules/pustules) are prominent, add a topical antibiotic:

• Use clindamycin or erythromycin combined with benzoyl peroxide (never as monotherapy to prevent resistance) 1
• Fixed-dose combinations of topical antibiotic + benzoyl peroxide receive "strong" recommendations 1
• The three-agent approach (retinoid + antibiotic/benzoyl peroxide combination) is appropriate for moderate inflammatory acne 1

When to Escalate to Oral Antibiotics

Consider oral antibiotics if:

• Moderate to severe inflammatory acne persists after 8-12 weeks of topical therapy 1
• Acne is treatment-resistant to topical agents 1

Preferred oral antibiotic:

• Doxycycline receives a "strong" recommendation (more effective than tetracycline, equal to minocycline) 1
• Limit duration to 3-4 months maximum to minimize resistance 1
• Must continue topical benzoyl peroxide during and after oral antibiotic use 1

Critical Pitfalls to Avoid

Retinoid irritation management:

• Initial dryness, peeling, and erythema are normal and typically subside within 2-4 weeks 3
• If sensitive skin, start every-other-night application 3
• Avoid excessive washing (2-3 times daily maximum with mild soap) 3
• Use non-comedogenic moisturizer daily 3
• Avoid waxing in treated areas 2

Sun protection is mandatory:

• Retinoids increase photosensitivity 3, 2
• Use sunscreen daily and limit sun exposure including tanning beds 2

Expect initial worsening:

• New papules and pustules may appear at 3-6 weeks (this is normal purging) 3
• Improvement typically seen by 6-12 weeks 3
• Continue treatment through this phase unless irritation becomes severe 3

Never use topical antibiotics alone:

• Monotherapy causes bacterial resistance 1
• Always pair with benzoyl peroxide 1

Pregnancy Considerations for Female Teens

• Adapalene and tretinoin are pregnancy category C 3, 2
• If pregnancy is possible or confirmed, discontinue retinoids immediately and consult physician 3, 2
• Benzoyl peroxide remains safe in pregnancy 1

Timeline for Re-evaluation

• Assess response at 8-12 weeks of topical therapy 1, 3
• If inadequate improvement, escalate to oral antibiotics or consider hormonal therapy (for females) 1
• Patients with psychosocial burden or scarring should be considered for isotretinoin referral earlier 1