Acne Treatment: Stepwise Care from Topicals to Isotretinoin

Acne is a chronic inflammatory disease of the pilosebaceous unit. Management is about matchingseverity and morphology to the right treatment while preventing scarring and post-inflammatory hyperpigmentation (PIH).

Classify First

• Comedonal: open/closed comedones, minimal inflammation.
• Inflammatory: papules/pustules, mild–moderate erythema.
• Nodulocystic: nodules, cysts, scarring risk.
• Special variants: acne conglobata, acne fulminans (urgent specialty care).

Skincare Foundations (everyone, daily)

• Gentle cleanse 1–2×/day; avoid harsh scrubs and frequent face touching.
• Non-comedogenic moisturizer; buffer irritation from retinoids/benzoyl peroxide.
• Broad-spectrum SPF 30+ daily (critical for PIH prevention and retinoid tolerance).
• Check cosmetics, hair products, helmets, masks → reduce occlusion/friction (“acne mechanica”).

Topical Therapy (first line for most)

• Retinoids (adapalene, tretinoin, tazarotene): comedolytic + anti-inflammatory; apply pea-size at night, start 2–3×/week then increase as tolerated.
• Benzoyl peroxide (BPO): bactericidal vs C. acnes; reduces resistance when combined with antibiotics. 2.5–5% often as effective as higher with less irritation.
• Topical antibiotics (clindamycin, erythromycin): only in combination with BPO to prevent resistance; avoid monotherapy.
• Azelaic acid 15–20%: comedonal/mild inflammatory acne; helpful for PIH and pregnancy-compatible (confirm locally).

When Topicals Aren’t Enough

• Systemic antibiotics (moderate inflammatory acne): doxycycline, lymecycline, minocycline.Limit to the shortest effective course (often 6–12 weeks) and pair with topical BPO. Reassess at 8–12 weeks; avoid repeated long courses.
• Hormonal therapy (females): combined oral contraceptives and/or spironolactone (monitor K⁺ if combined with certain meds; pregnancy contraindication for spironolactone).
• Isotretinoin (severe nodulocystic, scarring, refractory, or significant psychosocial burden): see section below.

Isotretinoin Essentials

• Indications: severe inflammatory/nodulocystic acne, scarring, failure of adequate systemic/topical therapy, or rapid relapse.
• Dosing: start ~0.3–0.5 mg/kg/day; titrate to 0.5–1 mg/kg/day as tolerated; typical cumulative 120–150 mg/kg (practice varies).
• Monitoring: baseline triglycerides and liver enzymes; recheck periodically (frequency per local protocol). Address dryness (lip/skin/eyes), epistaxis, myalgias.
• Pregnancy prevention: strict teratogenicity precautions. Follow your country’s regulatory program and counseling requirements. Require effective contraception and documented testing as mandated.
• Drug interactions: avoid vitamin A supplements, tetracyclines (pseudotumor cerebri risk), and excessive alcohol.

PIH & Scarring Prevention

• Control inflammation early (topical retinoid + BPO backbone; escalate when needed).
• Daily sunscreen; consider azelaic acid or retinoids for PIH; hydroquinone under supervision when appropriate.
• For scars: defer procedures until acne is controlled; later consider microneedling, chemical peels, subcision, or laser by experienced clinicians.

Procedures (adjuncts)

• Intralesional triamcinolone for large inflammatory nodules (low dose, correct technique).
• Comedone extraction for recalcitrant closed comedones.
• Light/laser devices can help selected patients; set expectations—adjunctive, not curative alone.

Special Populations

• Pregnancy: avoid retinoids (topical and oral). Consider azelaic acid, BPO spot use; seek specialist guidance.
• Skin of color: prioritize PIH prevention—early anti-inflammatory control and rigorous photoprotection.
• Acne fulminans: systemic steroids + tailored isotretinoin plan under dermatology supervision.

Follow-up & Adherence

• Set expectations: visible improvement in 6–8 weeks; early irritation is common—buffer with moisturizer.
• Simplify regimens; document triggers; check for cosmetic or hair product comedogens.
• Depression screening and psychosocial support for severe or scarring acne.

Patient FAQs

“Can diet help?” Some patients note flares with high-glycemic diets or dairy; a balanced, low-glycemic pattern may help a subset—results vary.

“Do I need antibiotics again?” Avoid prolonged/repeated systemic antibiotics; step up to hormonal therapy or isotretinoin when indicated.

References & Notes

This stepwise approach reflects common dermatology and primary-care pathways: retinoid + BPO backbone, limited antibiotic exposure with stewardship, hormonal options in females, and isotretinoin for severe or scarring disease. Local regulations for pregnancy prevention and monitoring apply. Educational only.