What is the recommended treatment regimen for an otherwise healthy adolescent with mild to moderate acne?

Treatment for Acne in Adolescence

Start all adolescents with mild to moderate acne on adapalene 0.1% gel once nightly combined with benzoyl peroxide 2.5-5% gel once daily in the morning as first-line therapy. 1, 2

Initial Treatment Approach

For Mild Acne (Comedones and Few Inflammatory Lesions)

• Apply adapalene 0.1% gel once nightly to completely dry skin (wait 20-30 minutes after washing) across the entire affected area, not just on individual lesions 1, 2
• Add benzoyl peroxide 2.5-5% gel once daily in the morning to provide antimicrobial activity and prevent antibiotic resistance if antibiotics are needed later 1, 2
• Alternatively, use a fixed-combination product (adapalene 0.1%/benzoyl peroxide 2.5%) once nightly for improved convenience and adherence 1, 2
• Lower concentrations of benzoyl peroxide (2.5%) are equally effective as higher concentrations but cause significantly less irritation 1

For Moderate Acne (More Inflammatory Papules and Pustules)

• Continue the topical retinoid + benzoyl peroxide foundation 2
• Add a fixed-combination topical antibiotic with benzoyl peroxide (clindamycin 1%/benzoyl peroxide 5% or 3.75%) applied once daily 2, 3
• Never use topical antibiotics as monotherapy—this rapidly induces bacterial resistance 1, 2

For Moderate-to-Severe Acne (Numerous Inflammatory Lesions, Nodules, or Risk of Scarring)

Initiate triple therapy immediately: 2, 3

• Oral doxycycline 100 mg once daily (first-line systemic antibiotic with strong evidence) 2, 3
• Topical retinoid (adapalene 0.3% gel, tretinoin 0.1% cream/gel, or tazarotene 0.1% gel) applied nightly 2, 3
• Benzoyl peroxide 2.5-5% gel applied in the morning 2, 3

Critical time limits for oral antibiotics: 2, 3

• Limit systemic antibiotics to 3-4 months maximum to prevent bacterial resistance 2, 3
• Always combine with benzoyl peroxide to reduce resistance development 2, 3
• Counsel about photosensitivity risk with doxycycline 3

Special Considerations for Adolescents

For Female Adolescents with Hormonal Patterns

• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and can be used as adjunctive therapy for females ≥14 years with menstrual periods who want contraception 2, 4
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns or premenstrual flares, with no potassium monitoring needed in healthy adolescents without risk factors 2
• Drospirenone-containing oral contraceptives are FDA-approved for moderate acne in females ≥14 years who have started menstruation and want contraception 4

For Severe Nodular/Cystic Acne or Treatment-Resistant Cases

Isotretinoin is the definitive treatment and should be initiated for: 2, 3

• Severe nodular or cystic acne 2, 3
• Moderate acne with scarring or significant psychosocial burden 2
• Treatment-resistant moderate acne after 3-4 months of appropriate therapy 2

Isotretinoin dosing and monitoring: 2, 3

• Dose at 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 2
• Obtain baseline liver function tests and lipid panel 2, 3
• Repeat laboratory testing at 2 months after initiation 2
• Mandatory pregnancy prevention through iPledge program for females of childbearing potential 2
• No routine monitoring for depression or inflammatory bowel disease needed based on population studies 2

Adjunctive Therapy for Large Painful Nodules

• Intralesional triamcinolone acetonide 10 mg/mL (diluted to 5 or 3.3 mg/mL) provides rapid pain relief and flattens nodules within 48-72 hours 2, 3
• Use cautiously to avoid local atrophy, pigmentary changes, and telangiectasias 3

Maintenance Therapy After Clearance

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence—this is the most critical step. 1, 2, 3

• Preferred agents: adapalene 0.1-0.3% gel or tretinoin 0.025-0.1% cream/gel applied once nightly 1, 3
• Benzoyl peroxide can be continued as additional maintenance therapy 2

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 3
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 2, 3
• Wait for skin to be completely dry (20-30 minutes) after washing before applying retinoids to minimize irritation 1
• Do not apply tretinoin with benzoyl peroxide simultaneously due to oxidation inactivating tretinoin (adapalene does not have this limitation) 2
• Do not underestimate severity when scarring is present—this indicates need for aggressive treatment (isotretinoin) regardless of lesion count 2, 3
• Always use daily sunscreen with retinoids due to photosensitivity risk 2

Alternative Options for Specific Situations

• Azelaic acid 15-20% gel or cream twice daily is particularly useful for adolescents with post-inflammatory hyperpigmentation or darker skin types 1, 2
• Salicylic acid 0.5-2% can be used as an over-the-counter alternative, though clinical evidence is limited compared to retinoids 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adolescent females, with no G6PD testing required 2