What are the treatment options for a patient with acne?

Treatment of Acne Vulgaris

Start all acne patients on topical adapalene 0.1-0.3% combined with benzoyl peroxide 2.5-5% applied once nightly 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

Assessment and Severity Classification

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

Treatment Algorithm by Severity

Mild Acne (Comedonal and Minimal Inflammatory Lesions)

• First-line: Topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) + benzoyl peroxide 2.5-5% applied once nightly 1, 2
• Adapalene is preferred due to superior tolerability, lack of photolability, and ability to combine with benzoyl peroxide without oxidation concerns 1
• Apply after washing face and waiting 20-30 minutes for skin to dry completely 3
• Use pea-sized amount for entire face, applying to forehead, chin, and both cheeks 3
• Alternative for post-inflammatory hyperpigmentation: Add azelaic acid 15-20% twice daily, particularly for Fitzpatrick skin types IV or greater 1, 4

Moderate Acne (More Inflammatory Lesions)

• 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
• Never use topical antibiotics as monotherapy—this rapidly increases bacterial resistance 1

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 as alternative) 1
  • Sarecycline (newer tetracycline option) 1
• Critical: Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance 1
• Always combine oral antibiotics with benzoyl peroxide to prevent resistance development 1

Severe Nodular or Recalcitrant Acne

• Isotretinoin is indicated for: 1
  • 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
• Daily dosing preferred over intermittent dosing 1
• Monitoring: Liver function tests and lipids only—CBC monitoring not needed in healthy patients 1
• Mandatory: Pregnancy prevention through iPLEDGE program for persons of childbearing potential 1, 5
• Safety note: 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 1
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics 1
• No potassium monitoring needed in healthy patients without risk factors for hyperkalemia 1

Special Populations and Considerations

Adult Females with Inflammatory Acne

• Topical dapsone 5% gel is particularly effective 1
• No glucose-6-phosphate dehydrogenase testing required before starting 1

Preadolescent Children

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used 1

Back Acne

• Follow same severity-based approach as facial acne 1
• Adapalene 0.1% gel available over-the-counter for mild back acne 1

Patients with Post-Inflammatory Hyperpigmentation

• Azelaic acid 15-20% is conditionally recommended with moderate certainty of evidence 4
• Especially recommended for Fitzpatrick skin types IV or greater 4

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely to prevent recurrence. 1, 2 Topical retinoids prevent new microcomedone formation and maintain clearance. 2 Benzoyl peroxide can also be continued as maintenance. 1

Managing Side Effects and Tolerability

• Common retinoid side effects: Dry skin, peeling, erythema, burning, photosensitivity 2, 3
• Mitigation strategies: 2, 3
  • Start with reduced frequency (every other night) for sensitive skin
  • Use concurrent emollients
  • Apply daily sunscreen (SPF 30+) to reduce photosensitivity
  • Apply moisturizer every morning after washing
• Lower benzoyl peroxide concentrations (2.5%) cause less irritation than higher concentrations with similar efficacy 2
• Initial worsening expected: New blemishes may appear at 3-6 weeks due to medication acting on deep lesions—continue therapy 3

Adjunctive Therapies for Acute Severe Lesions

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

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1
• Never extend oral antibiotics beyond 3-4 months without re-evaluation due to dramatically increased resistance risk 1
• Do not underestimate severity when scarring is present—this warrants aggressive treatment 1
• Avoid applying tretinoin with benzoyl peroxide simultaneously (traditional formulations)—oxidation inactivates tretinoin 1
• Do not use topical antibiotics for comedonal acne—they are ineffective against comedones and increase resistance 2
• Avoid applying retinoids to broken skin or active wounds 1

Complementary and Alternative Options

• Salicylic acid 0.5-2% available over-the-counter as comedolytic agent, though clinical trial evidence is limited 2
• Salicylic acid chemical peels 20-30% for 2-4 minutes provide intensive treatment for resistant comedonal acne 1
• Dietary modifications: Low-glycemic diet and reducing dairy/whey protein intake may provide benefit 1
• Topical botanicals (tea tree oil, green tea) and oral supplements (zinc, niacinamide) have limited evidence 1

When to Refer to Dermatology

Consider referral if treatment goals are not met after appropriate therapy duration, severe scarring develops, significant psychosocial impact persists, or isotretinoin is being considered. 6