Management of Acne
First-Line Foundation for All Acne Patients
Start every acne patient on adapalene 0.1% gel combined with benzoyl peroxide 2.5-5% as the foundation therapy, then escalate based on severity. 1 This combination is optimal due to superior tolerability, excellent efficacy, lack of photolability concerns, and over-the-counter availability. 1
Application Protocol
- Apply adapalene once nightly to completely dry skin (wait 20-30 minutes after washing with mild soap). 1, 2
- Apply benzoyl peroxide once daily in the morning. 1
- Apply non-comedogenic sunscreen with moisturizer every morning. 1, 2
This combination addresses both comedonal and inflammatory components while preventing antibiotic resistance. 1 Adapalene can be applied with benzoyl peroxide without oxidation concerns, unlike traditional tretinoin formulations. 3
Severity-Based Treatment Algorithm
Mild Acne (Comedones and Few Inflammatory Lesions)
Use topical retinoid + benzoyl peroxide alone. 1, 3
- Continue this regimen for at least 12 weeks before assessing response. 2
- For patients with post-inflammatory hyperpigmentation, add azelaic acid 15-20% twice daily. 1, 4
Moderate Acne (Multiple Inflammatory Papules/Pustules)
Add fixed-dose combination topical antibiotic with benzoyl peroxide (clindamycin 1%/BP 5% or erythromycin 3%/BP 5%) to the retinoid + benzoyl peroxide foundation. 1, 3
- Apply the antibiotic/BP combination once daily in the morning or evening. 3
- Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 3
Moderate-to-Severe Inflammatory Acne (Numerous Papules, Pustules, or Nodules)
Use triple therapy: oral doxycycline 100 mg once daily + topical retinoid + benzoyl peroxide. 1, 3
- Doxycycline is strongly recommended with moderate evidence over minocycline (conditionally recommended). 1, 3
- Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development. 1, 3
- Always combine oral antibiotics with benzoyl peroxide to prevent resistance. 1, 3
Severe Nodular or Recalcitrant Acne
Isotretinoin is indicated for:
- Severe nodular or conglobate acne 3
- Moderate acne with scarring or significant psychosocial burden 3
- Treatment-resistant moderate acne after 3-4 months of appropriate therapy 3
Dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg. 3 Daily dosing is preferred over intermittent dosing. 3
Monitoring: Check liver function tests and lipids only—CBC monitoring is not needed in healthy patients. 3 Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease. 3
Mandatory pregnancy prevention for persons of childbearing potential through iPledge program. 3, 2
Hormonal Therapy Options for Female Patients
Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended. 1, 3 They can be used as monotherapy or combined with topical agents. 3
Spironolactone 25-200 mg daily is useful for:
- Hormonal acne patterns 1, 3
- Premenstrual flares 1, 3
- Patients who cannot tolerate oral antibiotics 1, 3
No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia. 3
Adjunctive Therapies
Intralesional triamcinolone acetonide 10 mg/mL for large, painful nodules provides rapid pain relief within 48-72 hours. 1, 3
Azelaic acid 15-20% is particularly useful for post-inflammatory hyperpigmentation and is recommended for Fitzpatrick skin types IV or greater. 1, 4
Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females. 3 No glucose-6-phosphate dehydrogenase testing is required before starting. 3
Salicylic acid 20-30% chemical peels can provide intensive treatment for resistant comedonal acne. 3, 4
Maintenance Therapy After Clearance
Continue topical retinoid monotherapy indefinitely to prevent recurrence. 1, 3, 4 Maintenance with retinoids prevents new microcomedone formation and maintains clearance. 4, 5
Benzoyl peroxide can also be continued as maintenance therapy. 3
Critical Pitfalls to Avoid
Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 3
Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk. 1, 3
Do not stop treatment once acne clears—maintenance with topical retinoids is essential to prevent recurrence. 1, 4
Do not underestimate severity when scarring or significant psychosocial burden is present—these patients warrant more aggressive treatment regardless of lesion count. 1, 3
Avoid applying traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin. 3 Adapalene does not have this limitation. 3
Do not apply retinoids to broken skin or active wounds. 3
Managing Retinoid Side Effects
Common side effects include dry skin, peeling, erythema, and photosensitivity. 4, 6, 7
Mitigation strategies:
- Start with reduced frequency (every other night) for sensitive skin. 3, 2
- Use concurrent emollients and moisturizers. 3, 4
- Apply daily sunscreen. 1, 4
- Ensure skin is completely dry (wait 20-30 minutes after washing) before application. 1, 2
Initial irritation typically subsides within 2-4 weeks as skin adjusts. 2 An apparent exacerbation of inflammatory lesions may occur in early weeks due to action on deep, previously unseen lesions—this should not be considered a reason to discontinue therapy. 2