What is the recommended treatment regimen for acne vulgaris?

Acne Vulgaris Treatment

Foundation Therapy for All Patients

Begin every patient with acne vulgaris on a topical retinoid combined with benzoyl peroxide as the cornerstone of therapy, then escalate based on severity by adding topical or oral antibiotics for moderate-to-severe inflammatory disease. 1

• Adapalene 0.1-0.3% gel + benzoyl peroxide 2.5-5% is the preferred first-line combination for all acne severities 1
• Apply adapalene once nightly to completely dry skin (wait 20-30 minutes after washing), and benzoyl peroxide once daily in the morning 1
• Adapalene is superior to other retinoids due to its lack of photolability, compatibility with benzoyl peroxide without oxidation, and excellent tolerability profile 1, 2, 3
• Fixed-dose combination products (adapalene/benzoyl peroxide) enhance compliance and demonstrate 21-47% successful treatment rates 1

Severity-Based Treatment Algorithm

Mild Acne (Predominantly Comedonal)

• Topical retinoid (adapalene 0.1-0.3%) + benzoyl peroxide 2.5-5% as monotherapy 1, 4
• Alternative: Add azelaic acid 15-20% for patients with post-inflammatory hyperpigmentation 1, 5
• Over-the-counter adapalene 0.1% is available and effective 1

Moderate Acne (Mixed Comedonal and Inflammatory)

• Fixed-dose combination of adapalene/benzoyl peroxide as foundation 1, 4
• Add topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions 1, 6
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 4
• Fixed-combination products (clindamycin 1%/BP 5% or erythromycin 3%/BP 5%) applied once daily enhance compliance 1
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females 1

Moderate-to-Severe Inflammatory Acne

• Triple therapy: Oral antibiotic + topical retinoid + benzoyl peroxide 1, 4
• Doxycycline 100 mg once daily is the strongly recommended first-line oral antibiotic (moderate certainty evidence) 1, 4
• Minocycline 100 mg once daily is a conditionally recommended second-line alternative 1, 4
• Limit systemic antibiotics to 3-4 months maximum to prevent resistance 1, 7, 4
• Always continue benzoyl peroxide concurrently with oral antibiotics 1, 4
• For large, painful nodules: Intralesional triamcinolone acetonide 2.5-10 mg/mL provides rapid relief within 48-72 hours 1, 4

Severe Nodular or Recalcitrant Acne

Isotretinoin is indicated for: 1, 4

• Severe nodular or conglobate acne
• Moderate acne resistant after 3-4 months of appropriate therapy
• Any acne with scarring or significant psychosocial burden

Isotretinoin dosing and monitoring: 1

• Standard dose: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg
• Baseline and 2-month monitoring: liver function tests and lipid panel only 1
• CBC monitoring is not required in healthy patients 1
• Mandatory iPledge program enrollment for persons of childbearing potential 1
• Population studies show no increased risk of depression or inflammatory bowel disease 1

Hormonal Therapy for Female Patients

Indications for Hormonal Therapy

• Premenstrual flares, jaw-line distribution, or hormonal acne patterns 1
• Moderate-to-severe acne unresponsive to topical therapy 1
• Patients who cannot tolerate or prefer to avoid oral antibiotics 1

First-Line Hormonal Options

• Spironolactone 50-100 mg daily (titrate from 25 mg; maximum 200 mg daily) 1, 4

  • No potassium monitoring needed in healthy patients without renal disease or concurrent ACE inhibitors/ARBs 1
  • Clinical improvement typically seen after 3 months, maximal benefit at 6 months 1
  • Must be combined with reliable contraception due to teratogenic potential 1

• Combined oral contraceptives (COCs) containing norgestimate, norethindrone, or drospirenone 1, 4

  • Reduce inflammatory lesions by 62% at 6 months 1, 4
  • Can be used as monotherapy or combined with topical agents 1
  • Avoid during first 2 years after menarche or in patients <14 years unless clearly indicated 1

Maintenance Therapy After Clearance

Continue topical retinoid (adapalene) monotherapy indefinitely to prevent recurrence 1, 7, 4

• Benzoyl peroxide can be continued as additional maintenance 1, 4
• Maintain long-term hormonal therapy (spironolactone or COC) in female patients, as discontinuation commonly leads to relapse 1
• Systemic antibiotics are not appropriate for maintenance 7

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 4
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 7, 4
• Never underestimate severity when scarring is present—such cases warrant immediate escalation to isotretinoin regardless of lesion count 1, 4
• Never apply topical corticosteroids for acne treatment—they induce or exacerbate acne (steroid-induced acne) 4
• Never apply tretinoin with benzoyl peroxide simultaneously—oxidation inactivates tretinoin (adapalene does not have this limitation) 1

Essential Patient Counseling

• Use gentle, non-soap cleansers and avoid harsh scrubbing, which worsens inflammation 1
• Apply broad-spectrum SPF 30+ sunscreen daily—retinoids and oral antibiotics increase photosensitivity 1
• Apply fragrance-free moisturizer after topical medications dry to counteract treatment-related dryness 1
• Avoid tanning beds and sun lamps entirely when taking doxycycline due to severe phototoxic reaction risk 1
• Never pick, squeeze, or vigorously scrub lesions—this heightens inflammation and scarring risk 1
• Consider low-glycemic diet and reducing dairy/whey protein intake, which may worsen acne in susceptible individuals 1