What are the treatment options for a patient presenting with acne?

Acne Treatment

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 of therapy, then escalate based on severity. 1

• Adapalene 0.1% + benzoyl peroxide is the optimal starting regimen due to superior tolerability, excellent efficacy, lack of photolability concerns, and over-the-counter availability 1
• This combination addresses both comedonal and inflammatory components while preventing antibiotic resistance 1
• Apply adapalene once nightly to completely dry skin (wait 20-30 minutes after washing face) 1
• Apply benzoyl peroxide once daily in the morning 1
• Apply daily non-comedogenic sunscreen with moisturizer every morning 1

Severity-Based Treatment Algorithm

Mild Acne

• Use topical retinoid (adapalene preferred) + benzoyl peroxide alone 1, 2
• No additional agents needed for mild disease 1

Moderate Acne

• Add fixed-dose combination topical antibiotic with benzoyl peroxide (clindamycin 1%/BP 5% or erythromycin 3%/BP 5%) to the adapalene + BP regimen 1, 2
• Apply the antibiotic/BP combination once daily in the morning 2
• Continue adapalene nightly 1

Moderate-to-Severe Inflammatory Acne

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

Severe Nodular or Treatment-Resistant Acne

• Isotretinoin is indicated for:
  • 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
• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 2
• Daily dosing preferred over intermittent dosing 2
• Monitor only liver function tests and lipids (CBC not needed in healthy patients) 2
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential 2, 3
• Population studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 2

Hormonal Therapy Options for Female Patients

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

Adjunctive Therapies

• Intralesional triamcinolone acetonide 10 mg/mL for large, painful nodules provides rapid pain relief within 48-72 hours 1, 2
• Azelaic acid is conditionally recommended and particularly useful for post-inflammatory hyperpigmentation, especially in Fitzpatrick skin types IV or greater 1, 5
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 2

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely to prevent recurrence 1, 2, 5

• Maintenance with retinoids prevents new microcomedone formation and maintains clearance 5
• Benzoyl peroxide can also be continued as maintenance therapy 2

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 5
• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk 1, 2
• Do not stop treatment once acne clears—maintenance with topical retinoids is essential 1, 3
• Do not underestimate severity when scarring or significant psychosocial burden is present—these patients warrant more aggressive treatment regardless of lesion count 1, 2
• Avoid applying retinoids to broken skin or immediately after washing (wait 20-30 minutes for skin to dry completely) 1, 5, 3
• Do not apply traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin 2

Managing Retinoid Side Effects

• Common side effects include dry skin, peeling, scaling, erythema, burning sensation, and photosensitivity 5, 3
• Mitigate irritation by starting with reduced frequency of application and using concurrent emollients 2, 5
• Apply daily sunscreen to reduce photosensitivity and sunburn risk 5, 3
• Reactions typically subside within 2-4 weeks as skin adjusts 3
• If effects become excessively troublesome, reduce frequency or temporarily discontinue use 3

Special Populations

• Pregnant patients: Azelaic acid is safer (pregnancy category B) compared to retinoids (category C) or tazarotene (category X) 2
• Tretinoin safety in pregnancy has not been established in humans—consult physician if pregnant, planning pregnancy, or nursing 3
• Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 2