What is the recommended management for a typical adolescent or young adult with mild-to-moderate acne and no significant comorbidities?

Management of Mild-to-Moderate Acne in Adolescents and Young Adults

Start with adapalene 0.1–0.3% combined with benzoyl peroxide 2.5–5% applied once daily in the evening as the foundation for all acne therapy, regardless of severity. 1

Severity Assessment

• Use the Physician Global Assessment (PGA) to consistently classify acne severity and guide treatment escalation. 2, 1
• Evaluate for scarring, post-inflammatory dyspigmentation, and psychosocial impact—these factors warrant more aggressive treatment even when lesion counts suggest only mild disease. 2, 1

First-Line Treatment for Mild Acne

• Apply adapalene 0.1% gel (available over-the-counter) or adapalene 0.3% gel combined with benzoyl peroxide 2.5–5% once daily in the evening after washing and allowing skin to dry for 20–30 minutes. 1, 3
• Adapalene is preferred over tretinoin because it can be applied simultaneously with benzoyl peroxide without oxidation concerns and lacks photolability restrictions. 1
• Use a pea-sized amount for each facial area (forehead, chin, each cheek). 1
• Apply daily sunscreen every morning, as retinoids increase photosensitivity. 1, 3

Treatment Escalation for Moderate Acne

• Add a fixed-dose combination topical antibiotic with benzoyl peroxide (clindamycin 1%/benzoyl peroxide 5% or erythromycin 3%/benzoyl peroxide 5%) applied once daily in the morning for inflammatory lesions. 1
• Never use topical antibiotics as monotherapy—bacterial resistance develops rapidly without concurrent benzoyl peroxide. 1
• Alternative topical options include azelaic acid 15–20% for patients with post-inflammatory hyperpigmentation or topical dapsone 5% gel for inflammatory acne, particularly effective in adult females. 1

Treatment Escalation for Moderate-to-Severe Inflammatory Acne

• Add oral doxycycline 100 mg once daily (strongly recommended with moderate evidence) to the topical retinoid + benzoyl peroxide regimen. 1
• Minocycline 100 mg once daily is a conditionally recommended alternative. 1
• Limit systemic antibiotics to a maximum of 3–4 months to minimize bacterial resistance development. 1
• Always continue benzoyl peroxide concurrently with oral antibiotics to prevent resistance. 1
• Counsel patients about photosensitivity with doxycycline and strict sun protection. 4

Hormonal Therapy Options for Female Patients

• Consider combined oral contraceptives or spironolactone 50–100 mg daily for females with hormonal acne patterns (jawline distribution, premenstrual flares) or those who cannot tolerate oral antibiotics. 1
• Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months. 1, 5
• Spironolactone does not require potassium monitoring in healthy patients without risk factors for hyperkalemia (older age, renal disease, concurrent ACE inhibitors/ARBs). 2, 1
• Clinical improvement with spironolactone typically appears after 3 months, with maximal benefit at 6 months. 1

Adjunctive Treatment for Large Nodules

• Inject intralesional triamcinolone acetonide 10 mg/mL into individual large, painful nodules to flatten lesions within 48–72 hours and reduce scarring risk. 2, 1

Maintenance Therapy After Clearance

• Continue topical retinoid monotherapy indefinitely after discontinuing oral antibiotics to prevent recurrence. 1
• Benzoyl peroxide can be continued as maintenance therapy. 1

When to Consider Isotretinoin

• Isotretinoin is indicated for any acne with scarring or significant psychosocial burden, regardless of lesion count. 2, 1
• Also indicated for treatment-resistant moderate acne after 3–4 months of appropriate triple therapy (oral antibiotic + topical retinoid + benzoyl peroxide). 1
• Standard dosing is 0.5–1.0 mg/kg/day targeting cumulative dose of 120–150 mg/kg. 2
• Monitor only liver function tests and lipids—routine CBC, depression screening, or inflammatory bowel disease monitoring is not required based on population studies. 2, 1
• Mandatory pregnancy prevention through iPledge program for persons of childbearing potential. 2, 1

Critical Pitfalls to Avoid

• Never extend oral antibiotics beyond 3–4 months without transitioning to isotretinoin or maintenance topical therapy—this dramatically increases resistance risk. 1
• Never use topical or oral antibiotics without concurrent benzoyl peroxide. 1
• Do not underestimate severity when scarring is present—any scarring automatically warrants aggressive treatment. 1
• Avoid applying tretinoin to broken skin or with benzoyl peroxide simultaneously (oxidation inactivates tretinoin), though adapalene does not have this limitation. 1, 3
• Start retinoids at reduced frequency (every other night initially) with concurrent emollients to mitigate irritation. 1

Expected Timeline

• Patients typically see improvement by 12 weeks with topical retinoid therapy. 3, 6
• Transient increases in scaling, burning, and stinging may peak at week 4 but are generally mild (mean scores ≤0.6 on a 0–3 scale). 6