What are the treatment options for acne in adults?

Treatment of Acne in Adults

Begin with combination topical therapy using adapalene 0.1-0.3% plus benzoyl peroxide 2.5-5% applied once daily in the evening as the foundation for all adult acne treatment, then escalate based on severity by adding oral doxycycline 100 mg daily for moderate-to-severe inflammatory disease (limited to 3-4 months maximum), or consider hormonal therapy (combined oral contraceptives or spironolactone) for women with hormonal patterns, and reserve isotretinoin for severe, scarring, or treatment-resistant cases. 1, 2

Severity-Based Treatment Algorithm

Mild Acne

• Start with topical retinoid + benzoyl peroxide combination as first-line therapy 1, 2
• Adapalene 0.1% is preferred due to superior tolerability, lack of photolability, and over-the-counter availability 1
• Apply once daily in the evening after washing and allowing skin to dry for 20-30 minutes 1, 3
• Use pea-sized amount for each facial area (forehead, chin, each cheek) 1
• Alternative agents for specific concerns:
  • Azelaic acid for post-inflammatory hyperpigmentation 1, 2
  • Topical dapsone 5% gel particularly effective for inflammatory acne in adult females (no G6PD testing required) 1
  • Clascoterone as newer topical antiandrogen option 1

Moderate Acne

• Use fixed-dose combination of topical retinoid + benzoyl peroxide 1, 2
• Add topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions 1, 2
• Fixed-combination products (clindamycin 1%/BP 5% or 3.75%, erythromycin 3%/BP 5%) enhance compliance 1
• Never use topical antibiotics as monotherapy due to rapid resistance development 1, 2
• If inadequate response after 6-8 weeks, escalate to oral antibiotics 2, 4

Moderate-to-Severe Inflammatory Acne

• Triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline 100 mg once daily is strongly recommended as first-line oral antibiotic (for patients ≥9 years) 1, 2, 4
• Minocycline 100 mg once daily is conditionally recommended as alternative 1, 2
• Sarecycline is a newer tetracycline option 1
• Limit systemic antibiotics to 3-4 months maximum to prevent bacterial resistance 1, 2, 4
• Always combine oral antibiotics with benzoyl peroxide to prevent resistance 1, 2
• Subantimicrobial doxycycline dosing (20 mg twice daily to 40 mg daily) has shown efficacy 1

Severe, Scarring, or Treatment-Resistant Acne

• Isotretinoin 0.5-1.0 mg/kg/day is the definitive treatment targeting cumulative dose of 120-150 mg/kg 1, 2
• Indications for isotretinoin: 1, 2
  • Severe nodular or conglobate acne
  • Any acne with scarring (regardless of lesion count)
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy
  • Significant psychosocial burden
• Daily dosing preferred over intermittent dosing 1
• Mandatory monitoring: baseline and repeat liver function tests and lipid panels 1, 2
• No routine monitoring needed for: CBC, depression screening, or inflammatory bowel disease (population studies show no increased risk) 1
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 1, 5, 6
• Intralesional triamcinolone acetonide 10 mg/mL for large painful nodules provides rapid relief within 48-72 hours 1

Hormonal Therapy for Female Patients

Combined oral contraceptives or spironolactone should be considered for women with hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics. 1, 2

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months 1, 7
• Can be used as monotherapy or combined with topical agents 1
• Spironolactone 25-200 mg daily is effective for hormonal acne 1, 2
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 1
• Consider hormonal workup in women with severe acne, hirsutism, or irregular menses to evaluate for PCOS 2

Maintenance Therapy

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence. 1, 2

• This applies after successful treatment with oral antibiotics or isotretinoin 2
• Benzoyl peroxide can also be continued as maintenance 1

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 - dramatically increases resistance risk 1, 2
• Never underestimate severity when scarring is present - this automatically warrants aggressive treatment with isotretinoin regardless of lesion count 1, 2
• Counsel about photosensitivity with doxycycline and topical retinoids - strict sun protection and daily sunscreen mandatory 2, 3
• Do not apply tretinoin with benzoyl peroxide simultaneously (traditional formulations) - oxidation inactivates tretinoin 1
• Wait 20-30 minutes after washing before applying retinoids to minimize irritation 1, 3

Special Considerations for Adult Acne

• Topical dapsone 5% gel is particularly effective in adult females with inflammatory acne 1
• Back acne follows same severity-based approach as facial acne 1
• Adapalene 0.1% gel available over-the-counter for mild back acne 1
• Assess quality of life impact, satisfaction with appearance, and scarring - these factors warrant more aggressive treatment 1
• Use standardized scales like Physician Global Assessment (PGA) to guide treatment selection 1

Adjunctive and Alternative Options

• Azelaic acid particularly useful for post-inflammatory hyperpigmentation in darker skin tones 1, 2
• Salicylic acid 0.5-2% available over-the-counter as comedolytic agent (limited evidence) 1
• Salicylic acid 20-30% chemical peels for resistant comedonal acne 1
• Oral corticosteroids provide temporary benefit in severe inflammatory acne while starting standard treatment 1
• Limited evidence for topical botanicals (tea tree oil, green tea, witch hazel) and oral supplements (zinc, niacinamide) 1
• Low-glycemic diet and reducing dairy/whey protein may provide benefit 1