What is the best oral treatment for a young adult or adolescent with acne?

Best Oral Treatment for Acne

For adolescents and young adults with moderate-to-severe inflammatory acne requiring oral therapy, doxycycline 100 mg once daily is the strongly recommended first-line oral antibiotic, always combined with topical benzoyl peroxide and a topical retinoid. 1, 2

Treatment Algorithm by Acne Severity

Mild Acne

• Oral antibiotics are not indicated for mild acne 2, 3
• Start with topical retinoid (adapalene 0.1-0.3%) combined with benzoyl peroxide 2.5-5% 2, 3

Moderate-to-Severe Inflammatory Acne

• Doxycycline 100 mg once daily is the preferred oral antibiotic with strong recommendation and moderate evidence 1, 2, 3
• Minocycline 100 mg once daily is a conditionally recommended alternative 1, 2, 3
• Sarecycline is a newer tetracycline option with conditional recommendation 1, 2
• Always combine oral antibiotics with:
  • Topical retinoid (adapalene or tretinoin) 2, 3
  • Benzoyl peroxide (to prevent bacterial resistance) 1, 2, 3
• Limit duration to 3-4 months maximum to minimize antibiotic resistance 1, 2, 3

Severe, Scarring, or Treatment-Resistant Acne

• Oral isotretinoin 0.5-1.0 mg/kg/day is the gold standard and strongly recommended 1, 2, 3
• Target cumulative dose of 120-150 mg/kg 2
• Isotretinoin is indicated for:
  • Severe nodular or conglobate acne 1, 2
  • Any acne with scarring (regardless of lesion count) 2, 3
  • Significant psychosocial burden 1, 2
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy 1, 2, 3

Hormonal Therapy Options for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended 1, 2
• Spironolactone 25-200 mg daily is useful for:
  • Hormonal acne patterns 1, 2
  • Premenstrual flares 1, 2
  • Patients who cannot tolerate or prefer to avoid oral antibiotics 1, 2
• No potassium monitoring needed in healthy patients without risk factors 2, 3

Critical Monitoring for Isotretinoin

• Mandatory pregnancy prevention through iPLEDGE program for persons of childbearing potential 2, 4
• Baseline and repeat liver function tests and lipid panels required 2, 3
• No routine monitoring needed for:
  • Complete blood count 2
  • Depression screening (population studies show no increased risk) 2, 4
  • Inflammatory bowel disease (no increased risk identified) 2, 4

Critical Pitfalls to Avoid

• Never use oral or topical antibiotics as monotherapy - resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 3
• Never extend oral antibiotics beyond 3-4 months without re-evaluation - this dramatically increases resistance risk 1, 2, 3
• Do not underestimate severity when scarring is present - presence of scarring automatically warrants aggressive treatment with isotretinoin regardless of total lesion count 2, 3
• Doxycycline causes significant photosensitivity - counsel patients about strict sun protection and daily sunscreen use 3
• Avoid oral antibiotics for acne conglobata - they are inadequate and delay definitive isotretinoin treatment 2

Maintenance After Clearance

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence 2, 3
• This applies after successful treatment with either oral antibiotics or isotretinoin 3
• Benzoyl peroxide can be continued as maintenance therapy 2

Special Considerations for Adolescents

• Tetracycline antibiotics are approved for patients ≥9 years of age 3
• Isotretinoin is equally effective in pediatric patients (13-17 years) compared to adults at 1 mg/kg/day 4
• Adolescents on isotretinoin have increased incidence of back pain, arthralgia, and myalgia compared to adults 4