What is the recommended treatment approach for a patient presenting with acne?

Acne Vulgaris Treatment

First-Line Foundation Therapy

Start all acne patients on adapalene 0.1-0.3% combined with benzoyl peroxide 2.5-5% applied once nightly as the foundation of treatment, then escalate based on severity. 1

• Apply adapalene/benzoyl peroxide combination once daily in the evening after washing and allowing skin to dry for 20-30 minutes, using a pea-sized amount for each facial area (forehead, chin, each cheek). 1
• Adapalene is preferred over other retinoids due to superior tolerability, lack of photolability restrictions, and ability to be applied with benzoyl peroxide without oxidation concerns. 1
• Adapalene 0.1% is available over-the-counter, making it highly accessible. 1
• Apply tretinoin gel once daily before bedtime if using tretinoin instead of adapalene, waiting 20-30 minutes after washing for skin to completely dry. 2

Severity-Based Treatment Algorithm

Mild Acne

• Use topical retinoid (adapalene preferred) + benzoyl peroxide as monotherapy. 1, 3
• Azelaic acid can be added for patients with post-inflammatory dyspigmentation. 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females. 1

Moderate Acne

• Add fixed-dose combination topical antibiotic (clindamycin 1% or erythromycin 3%) with benzoyl peroxide to the retinoid/benzoyl peroxide foundation. 1, 3
• Fixed-combination products (clindamycin 1%/BP 5% or 3.75%, erythromycin 3%/BP 5%) enhance compliance. 1
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 3

Moderate-to-Severe Inflammatory Acne

• Initiate triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide. 1, 3
• Doxycycline 100 mg once daily is the preferred oral antibiotic (strongly recommended with moderate evidence). 1, 3
• Minocycline 100 mg once daily is an alternative (conditionally recommended). 1, 3
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance—never extend beyond this without re-evaluation. 1, 3
• Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy for moderate inflammatory acne. 1

Severe Nodular or Recalcitrant Acne

• Isotretinoin is the definitive treatment for severe acne, addressing all four pathogenic factors. 1
• Indications include: severe nodular/conglobate acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden. 1, 3
• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg. 1
• Daily dosing is preferred over intermittent dosing. 1
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential. 1, 4
• Monitor liver function tests and lipids; CBC monitoring is not needed in healthy patients. 1
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease. 1

Hormonal Therapy for Female Patients

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

Adjunctive Therapies for Rapid Relief

• Intralesional triamcinolone acetonide 10 mg/mL provides rapid pain relief within 48-72 hours for large, painful nodules at risk of scarring. 1, 3
• Oral corticosteroid therapy can provide temporary benefit in severe inflammatory acne while starting standard treatment. 1

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence. 1, 3
• Benzoyl peroxide can also be continued as maintenance. 1, 3
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required before definite beneficial effects are seen. 2

Critical Assessment Factors

• Use the Physician Global Assessment (PGA) scale to consistently classify acne severity as mild, moderate, or severe. 1, 3
• Evaluate for scarring, post-inflammatory dyspigmentation, and psychosocial impact—these factors warrant more aggressive treatment regardless of lesion count. 1, 3

Essential 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 apply traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin. 1
• Avoid topical corticosteroids for acne treatment—they can induce or exacerbate acne (steroid-induced acne). 3
• Use daily sunscreen with retinoids due to photosensitivity risk. 1
• Start with reduced frequency of application and concurrent emollients to mitigate initial irritation. 1
• Expect an apparent exacerbation of inflammatory lesions during early weeks of therapy due to medication action on deep, previously unseen lesions—this should not be considered a reason to discontinue therapy. 2