Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
topical antibiotic + topical benzoyl peroxide
Patients with mild acne (i.e., grade 2 mild severity acne; some non-inflammatory lesions with no more than a few inflammatory lesions [papules/pustules only, no nodular lesions]) should be treated with multimodal topical therapy combining multiple mechanisms of action.[36]
A topical antibiotic plus topical benzoyl peroxide is a recommended option for patients with mild acne.[36] Examples of topical antibiotics used include clindamycin, erythromycin, minocycline, and dapsone.
In the UK, topical benzoyl peroxide monotherapy may be considered as an alternative for patients with mild acne if other treatments are contraindicated.[34]
A consensus statement from the Global Alliance to Improve Outcomes in Acne suggests that topical antibiotics may be tapered and discontinued once there is improvement, though chronic treatment is often needed. If no improvement is noted within 6-8 weeks, topical antibiotics should be discontinued and an alternative therapy considered.[45]
The use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[46]
[ 
]
These agents may be prescribed as proprietary combination formulations, or they may be prescribed using separate products. Consult your local drug information source for available products.
Primary options
clindamycin topical: (1% foam) children ≥12 years of age and adults: apply to the affected area(s) once daily; (1% gel, lotion, solution) children ≥12 years of age and adults: apply to the affected area(s) twice daily
or
erythromycin topical: (2%) children ≥12 years of age and adults: apply to the affected area(s) twice daily
or
minocycline topical: (4%) children ≥9 years of age and adults: apply to the affected area(s) once daily
or
dapsone topical: (5%) children ≥12 years of age and adults: apply to the affected area(s) twice daily; (7.5%) children ≥9 years of age and adults: apply to the affected area(s) once daily
-- AND --
benzoyl peroxide topical: (2.5% to 10%) children ≥12 years of age and adults: apply to the affected area(s) once to three times daily
topical retinoid + topical benzoyl peroxide
Patients with mild acne (i.e., grade 2 mild severity acne; some non-inflammatory lesions with no more than a few inflammatory lesions [papules/pustules only, no nodular lesions]) should be treated with multimodal topical therapy combining multiple mechanisms of action.[36]
A topical retinoid (e.g., tretinoin, adapalene, tazarotene, trifarotene) plus topical benzoyl peroxide is a recommended option for patients with mild acne.[36]
Topical adapalene appears to be associated with a lower rate of toxicity than topical tretinoin. In one systematic review, 62% of patients using topical tretinoin experienced adverse events; the comparable figures for adapalene 0.1% and adapalene 0.3% were 19% and 40%, respectively.[50]
Patients should be started with a lower potency retinoid, increasing to a higher potency if skin irritation is minimal. Topical adapalene is less likely to cause irritation than tretinoin.[51]
Topical retinoids should be continued until the acne is completely clear.[45]
In the UK, topical benzoyl peroxide monotherapy may be considered as an alternative for patients with mild acne if other treatments are contraindicated.[34]
The use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[46]
[ ]
These agents may be prescribed as proprietary combination formulations, or they may be prescribed using separate products. Consult your local drug information source for available products.
Primary options
tretinoin topical: (0.01 to 0.1%) children ≥12 years of age and adults: apply to the affected area(s) once daily at bedtime
or
adapalene topical: (0.1% or 0.3%) children ≥12 years of age and adults: apply to the affected area(s) once daily at bedtime
or
tazarotene topical: (0.1%) children ≥12 years of age and adults: apply to the affected area(s) once daily in the evening
or
trifarotene topical: (0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
-- AND --
benzoyl peroxide topical: (2.5% to 10%) children ≥12 years of age and adults: apply to the affected area(s) once to three times daily
topical benzoyl peroxide
Treatment recommended for ALL patients in selected patient group
Concomitant use of topical benzoyl peroxide with combination therapy (topical retinoid plus a topical antibiotic) is recommended to prevent the development of antibiotic resistance.[36]
Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[46]
[ ]
Should be used until improvement is noted, then use can be gradually tapered and discontinued.
Primary options
benzoyl peroxide topical: (2.5% to 10%) children ≥12 years of age and adults: apply to the affected area(s) once to three times daily
oral isotretinoin
Treatment for patients with moderate to severe acne (i.e. grade 3: moderate severity; up to many non-inflammatory lesions and may have some inflammatory lesions, but no more than one small nodular lesion to grade 4: severe severity; many non-inflammatory and inflammatory lesions, but no more than a few nodular lesions), or patients who are unresponsive to other treatments, includes the use of oral isotretinoin.[34][36]
For patients with moderate to severe acne, or acne unresponsive to other treatments, a course of oral isotretinoin for 15-20 weeks is the recommended treatment of choice.[35][36][67][68]
[ ]
[Evidence C] In practice treatment is started at the recommended dose and then uptitrated based on adverse effects. Treatment should continue until the patient is acne free for 2-3 months (usually about 5-8 months total), as this appears to be a better predictor of relapse than daily or cumulative dose and allows for individualised treatment regimens.[69][70] Some patients may require a repeat course of isotretinoin.
In the UK, oral isotretinoin should only be considered once adequate courses of standard treatment with systemic antibiotics and topical therapy have failed.[34] For people under 18 years of age prescribed isotretinoin, additional oversight is required.[34] Two independent prescribers need to agree the initiation of oral isotretinoin in patients under 18 years; access to counseling of people about potential mental health and sexual function side effects; assessment of mental health and sexual function before starting treatment and monitoring of mental health and sexual function during treatment; guidance on roles and responsibilities for healthcare professionals; use of regulatory risk minimisation materials.[34][76]
Adverse effects can be severe, and regular monitoring during treatment with isotretinoin is required. Severe headaches, decreased night vision, significant liver enzyme or lipid elevations, or signs of adverse psychiatric events necessitate prompt discontinuation. Elevated serum cholesterol, triglycerides, and transaminases have been reported in some patients taking oral isotretinoin. Laboratory monitoring during isotretinoin treatment should include liver function tests, and a fasting lipid panel, but full blood count monitoring is not required.[36]
Isotretinoin is teratogenic; all women should have a pregnancy test before starting the drug and subsequently monthly while taking it.[36] In the US, isotretinoin can only be prescribed through the iPledge risk management programme. iPledge system (for isotretinoin prescribing) Opens in new window
Results from studies investigating whether isotretinoin increases the incidence of depression and/or suicidal ideation are conflicting; signs and symptoms of depression should be monitored during and after treatment.[36][71][72] Depressive symptoms often improve after treatment with isotretinoin, as well as with other therapies, as the acne symptoms improve.[73][74]
Lidose and micronised formulations of isotretinoin improve oral bioavailability, pharmacological bioactivity, and increase efficacy in patients who are unwilling/unable to take regular isotretinoin with a high fat/calorie meal.[75]
In the UK, oral corticosteroid therapy may be used in conjunction with isotretinoin, or prior to initiating isotretinoin, to treat the systemic and cutaneous manifestations of acne fulminans and for prevention and treatment of isotretinoin-induced acne flare.[34]
Primary options
isotretinoin: children ≥12 years of age: 0.5 to 1 mg/kg/day orally given in 2 divided doses; adults: 0.5 to 2 mg/kg/day orally given in 2 divided doses
OR
isotretinoin lidose: children ≥12 years of age: 0.5 to 1 mg/kg/day orally given in 2 divided doses; adults: 0.5 to 2 mg/kg/day orally given in 2 divided doses
OR
isotretinoin micronized: children ≥12 years of age: 0.4 to 0.8 mg/kg/day orally given in 2 divided doses; adults: 0.4 to 1.6 mg/kg/day orally given in 2 divided doses
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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