What is the best approach to treating acne?

Best Approach to Treating Acne

Begin all acne patients on a topical retinoid (adapalene 0.1-0.3%) combined with benzoyl peroxide (2.5-5%) as the foundation of therapy, then escalate based on severity by adding topical antibiotics for moderate disease or oral antibiotics (doxycycline 100 mg daily) for moderate-to-severe inflammatory acne, always with concurrent benzoyl peroxide to prevent resistance. 1

Severity-Based Treatment Algorithm

Mild Acne

• First-line: Topical retinoid + benzoyl peroxide 1, 2

  • Adapalene 0.1-0.3% is the preferred retinoid due to superior tolerability, lack of photolability, and over-the-counter availability 1, 3
  • Apply adapalene once nightly to completely dry skin (wait 20-30 minutes after washing) 1
  • Apply benzoyl peroxide 2.5-5% once daily in the morning 2
  • Lower concentrations of benzoyl peroxide (2.5%) cause less irritation while maintaining efficacy 1

• Alternative options:

  • Azelaic acid for patients with post-inflammatory hyperpigmentation 1
  • Topical dapsone 5% gel, particularly effective for inflammatory acne in adult females (no G6PD testing required) 1

Moderate Acne

• First-line: 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
  • Critical: Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2
  • Fixed-combination products (clindamycin 1%/BP 5% or 3.75%, erythromycin 3%/BP 5%) enhance compliance 1

Moderate-to-Severe Inflammatory Acne

• First-line: Triple therapy = oral antibiotics + topical retinoid + benzoyl peroxide 1, 2

  • Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1, 2
  • Minocycline 100 mg once daily as alternative (conditionally recommended) 1, 2
  • Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1, 2
  • Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy 1

• Adjunctive therapy:

  • Intralesional triamcinolone acetonide 10 mg/mL for large, painful nodules provides rapid pain relief within 48-72 hours 1, 2
  • Oral corticosteroids can provide temporary benefit in severe inflammatory acne while initiating standard therapy 1

Severe or Recalcitrant Acne

• Isotretinoin indications: 1, 2

  • Severe nodular or conglobate acne
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy
  • Any acne with scarring or significant psychosocial burden

• Dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 1

• Monitoring: Liver function tests and lipids only—CBC monitoring not needed in healthy patients 1

• Important: Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 1

• Mandatory: Pregnancy prevention through iPledge program for persons of childbearing potential 1, 4

Hormonal Therapy for Female Patients

• Combined oral contraceptives: Reduce inflammatory lesions by 62% at 6 months 1, 2, 5

  • Can be used as monotherapy or combined with topical agents 1

• Spironolactone 25-200 mg daily: 1, 2

  • Useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics
  • No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 1

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence. 1, 2 Benzoyl peroxide can also be continued as maintenance 1, 2

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2
• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk 1, 2
• Never use topical corticosteroids for acne treatment—they can induce or exacerbate acne 2
• Never underestimate severity when scarring is present—any scarring warrants more aggressive treatment regardless of lesion count 1, 2
• Never apply tretinoin with benzoyl peroxide simultaneously—oxidation inactivates tretinoin (adapalene does not have this limitation) 1

Special Populations

Pediatric Patients (≥12 years)

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 1, 3
• Isotretinoin use requires careful consideration, especially with known metabolic or structural bone disease 1, 4

Pregnant Patients

• Azelaic acid is safer (pregnancy category B) compared to retinoids (category C) or tazarotene (category X) 1
• Isotretinoin is absolutely contraindicated (category X) 4

Back Acne

• Follow the same severity-based approach as facial acne 1, 6
• Benzoyl peroxide can bleach clothing—wear old or white clothing 6

Practical Application Tips

• Start with reduced frequency of retinoid application and concurrent emollients to mitigate initial irritation 1
• Use daily sunscreen with retinoids due to photosensitivity risk 1, 6
• Assess quality of life, satisfaction with appearance, and presence of scarring—these factors warrant more aggressive treatment 1, 2
• Use standardized scales like Physician Global Assessment (PGA) to consistently classify severity 1, 2