Treatment for Acne
Start all acne patients on adapalene 0.1-0.3% gel combined with benzoyl peroxide 2.5-5% applied once daily as the foundation of therapy, then escalate based on severity by adding topical or oral antibiotics for moderate-to-severe disease—always with concurrent benzoyl peroxide to prevent resistance. 1, 2, 3
First-Line Therapy for All Acne Severities
Topical retinoids combined with benzoyl peroxide form the cornerstone of acne treatment because retinoids are comedolytic, resolve microcomedone precursor lesions, provide anti-inflammatory effects, and enable long-term maintenance of clearance. 1, 2, 4
Preferred Initial Regimen
- Adapalene 0.1-0.3% gel is the optimal first-choice retinoid due to superior tolerability, excellent efficacy, lack of photolability concerns, no oxidation with benzoyl peroxide, and over-the-counter availability. 2, 3, 5
- Apply adapalene once nightly to completely dry skin (wait 20-30 minutes after washing). 2, 6
- Apply benzoyl peroxide 2.5-5% gel once daily in the morning. 2, 3
- Use daily non-comedogenic sunscreen with moisturizer every morning, as retinoids cause photosensitivity. 1, 2, 6
Alternative Retinoid Options
- Tretinoin 0.025-0.1% (cream, gel, or microsphere formulations) is FDA-approved with moderate certainty evidence but requires evening application due to photolability and cannot be applied simultaneously with benzoyl peroxide due to oxidation inactivation. 1, 2, 6
- Tazarotene 0.05-0.1% (cream, gel, or foam) is more effective than tretinoin 0.025% or adapalene 0.1% but less well-tolerated. 1, 2, 5
- Trifarotene is a newer FDA-approved option. 1, 2
Severity-Based Treatment Algorithm
Mild Acne
- Use topical retinoid (adapalene preferred) + benzoyl peroxide alone. 1, 2, 3, 7
- This combination addresses both comedonal and inflammatory components while preventing antibiotic resistance. 2, 3
Moderate Acne
- Add fixed-dose combination topical antibiotic with benzoyl peroxide (clindamycin 1%/BP 5% or 3.75%, or erythromycin 3%/BP 5%) to the retinoid + benzoyl peroxide regimen. 1, 2, 3, 7
- Apply the fixed-combination product once daily in the evening. 2
- Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2, 3, 7
Moderate-to-Severe Inflammatory Acne
- Use triple therapy: oral doxycycline 100 mg once daily + topical retinoid + benzoyl peroxide. 1, 2, 3, 7
- Doxycycline is strongly recommended with moderate evidence over minocycline (conditionally recommended). 1, 2, 3
- Subantimicrobial dosing of doxycycline (20 mg twice daily to 40 mg daily) has shown efficacy for moderate inflammatory acne. 2
- Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development. 1, 2, 3, 7
- Sarecycline is a newer tetracycline option but was conditionally recommended due to high current cost. 1, 2
Severe or Treatment-Resistant Acne
Isotretinoin is the definitive treatment for severe acne as it addresses all four pathogenic factors and should be initiated immediately for patients with severe nodular acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden. 1, 2, 3, 7
Isotretinoin Dosing and Monitoring
- Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg. 2
- Daily dosing is preferred over intermittent dosing. 1, 3
- Either standard isotretinoin or lidose-isotretinoin formulations are acceptable. 1, 2
- Monitor liver function tests and lipids, but CBC monitoring is not needed in healthy patients. 1, 2, 3
- Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease with isotretinoin. 1, 2, 3
- Mandatory pregnancy prevention through iPledge program for persons of childbearing potential. 1, 2, 3
Hormonal Therapy for Female Patients
Combined Oral Contraceptives
- Conditionally recommended for inflammatory acne in females, reducing inflammatory lesions by 62% at 6 months. 1, 2, 3, 7
- Can be used as monotherapy or combined with topical agents. 2
Spironolactone
- Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate or prefer to avoid oral antibiotics. 1, 2, 3, 7
- No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia (e.g., older age, medical comorbidities, medications). 1, 2, 3
Adjunctive Therapies
Intralesional Corticosteroids
- Intralesional triamcinolone acetonide 10 mg/mL for large, painful nodules provides rapid pain relief and inflammation reduction within 48-72 hours. 1, 2, 3, 7
- Use judiciously for patients at risk of acne scarring; lower concentration and volume minimize risks of local adverse events. 1, 2
Additional Topical Options
- Azelaic acid is particularly useful for post-inflammatory hyperpigmentation, especially in patients with darker skin tones. 1, 2, 3
- Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females; no glucose-6-phosphate dehydrogenase testing is required. 1, 2
- Clascoterone is a newer topical antiandrogen conditionally recommended based on high certainty evidence but limited by high current cost. 1, 2
- Salicylic acid 0.5-2% is an over-the-counter comedolytic agent with limited clinical trial evidence. 1, 2
Oral Corticosteroids
- Short-term oral corticosteroid therapy can provide temporary benefit in severe inflammatory acne while starting standard treatment. 2
Maintenance Therapy After Clearance
Continue topical retinoid monotherapy indefinitely to prevent recurrence—this is essential and often overlooked. 1, 2, 3, 7
- Benzoyl peroxide can also be continued as maintenance therapy. 2, 7
- Do not stop treatment once acne clears; maintenance prevents relapse. 3
Critical Pitfalls to Avoid
- Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2, 3, 7, 8
- Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk. 1, 2, 3, 7
- Do not underestimate severity when scarring or significant psychosocial burden is present—these patients warrant more aggressive treatment (potentially isotretinoin) regardless of lesion count. 1, 2, 3, 7
- Avoid applying tretinoin with benzoyl peroxide simultaneously due to oxidation inactivation; adapalene lacks this restriction. 1, 2
- Start with reduced frequency of retinoid application and concurrent emollients to mitigate initial irritation (erythema, dryness, peeling). 1, 6, 9, 5
- Topical corticosteroids are not recommended for acne treatment—they can induce or exacerbate acne (steroid-induced acne). 7
Special Populations
Pediatric Patients
- Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children with acne. 2