What is the recommended treatment for a patient with acne vulgaris?

Treatment for Acne Vulgaris

Begin all acne patients on topical adapalene 0.1-0.3% combined with benzoyl peroxide 2.5-5% as the foundation, 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 (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) + benzoyl peroxide 2.5-5% applied once daily in the evening 1
• Adapalene is preferred over tretinoin because it can be applied simultaneously with benzoyl peroxide without oxidation concerns and lacks photolability restrictions 1, 2
• Apply to completely dry skin 20-30 minutes after washing, using a pea-sized amount for each facial area (forehead, chin, each cheek) 1
• Alternative options: Azelaic acid 15-20% for patients with post-inflammatory hyperpigmentation, particularly relevant for darker skin tones 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females, with no glucose-6-phosphate dehydrogenase testing required 1

Moderate Acne

• First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 1
• Add: Topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions 1
• Fixed-combination products (clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, erythromycin 3%/BP 5%) enhance compliance 1
• Critical: Never use topical antibiotics as monotherapy due to rapid resistance development 1, 3

Moderate-to-Severe Inflammatory Acne

• First-line triple therapy: Oral antibiotics + topical retinoid + benzoyl peroxide 1
• Oral antibiotic options:
  • Doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1
  • Minocycline 100 mg once daily (conditionally recommended) 1
  • Sarecycline (newer tetracycline option) 1
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development 1, 2
• Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy in moderate inflammatory acne 1

Severe Nodular or Recalcitrant Acne

• Isotretinoin is indicated for:
  • Severe nodular or conglobate acne 1
  • Treatment-resistant moderate acne after 3-4 months of appropriate therapy 1
  • Any acne with scarring or significant psychosocial burden 1, 4
• 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
• Monitoring: Liver function tests and lipids only; 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
• Mandatory: Pregnancy prevention through iPledge program for persons of childbearing potential 1, 2
• Adjunctive: Intralesional triamcinolone acetonide 10 mg/mL for individual large, painful nodules provides rapid pain relief within 48-72 hours 1

Hormonal Therapy for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended for inflammatory acne in females 1
• 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 1
• Spironolactone avoids antibiotic resistance concerns and provides long-term maintenance without the 3-4 month limitation of oral antibiotics 2

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence 1, 2
• Benzoyl peroxide can be continued as maintenance therapy 1, 2
• Reduce to 2-3 times weekly for long-term maintenance 2

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, as this dramatically increases resistance risk 1, 2
• Avoid underestimating severity when scarring is present — the presence of scarring alone warrants consideration of isotretinoin 1, 4
• Avoid applying retinoids to broken skin or areas with active wounds 1
• Use daily sunscreen with retinoids due to photosensitivity risk 1

Special Populations

• Preadolescent children: Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 1
• Pregnant patients: Azelaic acid is a safer alternative (pregnancy category B) compared to retinoids (category C) or tazarotene (category X) 1
• Back acne: Treatment follows the same severity-based approach as facial acne, with adapalene 0.1% gel available over-the-counter for mild back acne 1