What is the appropriate acne treatment regimen for an 18‑year‑old female with sensitive skin?

Acne Treatment for an 18-Year-Old Female with Sensitive Skin

First-Line Recommendation

Start with adapalene 0.1% combined with benzoyl peroxide 2.5% applied once daily in the evening, paired with a gentle dermocosmetic regimen including a non-irritating cleanser, moisturizer, and daily sunscreen to minimize retinoid-induced skin discomfort. 1

Treatment Foundation

• Adapalene 0.1% is the optimal retinoid choice for sensitive skin because it has superior tolerability compared to other retinoids while maintaining excellent efficacy, and it can be applied with benzoyl peroxide without oxidation concerns or photolability restrictions 1
• The combination of adapalene and benzoyl peroxide is more effective than either agent alone, with adapalene addressing comedones and microcomedones while benzoyl peroxide provides antimicrobial activity 1
• This fixed-dose combination has demonstrated 21-47% successful treatment rates in clinical trials 1

Application Protocol for Sensitive Skin

• Apply once daily in the evening after washing and allowing skin to completely dry for 20-30 minutes to minimize irritation 1
• Use a pea-sized amount for each facial area (forehead, chin, each cheek) 1
• Start with reduced frequency of application (every other night initially) and use concurrent emollients to mitigate initial irritation, which is especially important for sensitive skin 1

Essential Dermocosmetic Support

• A dermocosmetic regimen significantly reduces retinoid-induced skin discomfort (RISD), especially during the first 14 days of treatment, without interfering with clinical efficacy 2
• Daily use of gentle cleansers, moisturizers, and sunscreens can reduce both inflammatory and non-inflammatory acne lesion counts when combined with specific acne drugs 3
• Daily sunscreen use is mandatory due to photosensitivity risk with retinoids 1

Escalation Algorithm Based on Severity

If Mild Acne (Primarily Comedonal)

• Continue adapalene 0.1% + benzoyl peroxide 2.5% as monotherapy 1
• Consider adding azelaic acid if post-inflammatory hyperpigmentation develops, as it is particularly useful for patients with darker skin tones and is pregnancy category B 1, 4

If Moderate Acne (Mixed Inflammatory and Comedonal)

• Add a fixed-dose combination topical antibiotic with benzoyl peroxide (clindamycin 1%/BP 5% or clindamycin 1%/BP 3.75%) to enhance treatment compliance 1
• Never use topical antibiotics as monotherapy due to rapid resistance development 1

If Moderate-to-Severe Inflammatory Acne

• Add oral doxycycline 100 mg once daily (strongly recommended with moderate evidence) 1
• Always combine oral antibiotics with benzoyl peroxide to prevent resistance 1
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development 1

Hormonal Therapy Considerations for Female Patients

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and can be used as monotherapy or combined with topical agents 1
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics, with no potassium monitoring needed in healthy patients 1

Alternative Options for Sensitive Skin

• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and may be better tolerated than some other options, with no glucose-6-phosphate dehydrogenase testing required 1
• Clascoterone is a newer topical antiandrogen conditionally recommended based on high certainty evidence, which may be considered if standard therapy is not tolerated 1, 5

Maintenance After Clearance

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence 1
• Benzoyl peroxide can be continued as maintenance therapy 1

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy, as resistance develops rapidly without concurrent benzoyl peroxide 1
• Do not apply traditional tretinoin formulations with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin (this is not an issue with adapalene) 1
• Avoid underestimating severity when scarring is present, as this warrants more aggressive treatment regardless of lesion count 1
• Do not stop treatment too early if hyperpigmentation develops, as it takes longer to resolve than acne lesions 4