Red Flags
- Acne fulminans (sudden severe nodulocystic with fever, arthralgia, malaise) — admit; oral steroid before isotretinoin; rare but serious[1]
- Pregnancy or planning pregnancy on isotretinoin — absolutely contraindicated; pregnancy prevention programme; switch to alternatives[1]
- Severe persistent psychological impact, suicidal ideation — mental health support; counsel about isotretinoin and mood (rare association)[1]
- Acne with virilising features (hirsutism, oligomenorrhoea, alopecia) in young women — investigate for PCOS, late-onset CAH, androgen-secreting tumour[1]
First-line treatment
Interventions
- General skin care[1]Gentle non-comedogenic cleanser BD; sunscreen SPF ≥30 daily (essential for PIH prevention); avoid harsh scrubs and over-cleansing; non-comedogenic cosmetics
- Mild acne — topical combination[1]Topical retinoid (adapalene, tretinoin) + benzoyl peroxide (BPO 2.5–5%); apply once daily at night; expect initial pustular flare and dryness; full effect 8–12 weeks
- Moderate acne — oral antibiotic + topical[1]Doxycycline 100 mg PO daily × 3 months max + topical retinoid + BPO; avoid antibiotic monotherapy (resistance); macrolide alternative if doxycycline contraindicated
- Severe/nodulocystic acne — isotretinoin[1]Oral isotretinoin 0.5–1 mg/kg/day to cumulative 120–150 mg/kg over 4–6 months; pregnancy prevention programme; LFT, lipids, FBC at baseline and 1–2 monthly
- Hormonal therapy in selected women[1]Combined oral contraceptive (containing drospirenone or norgestimate) ± spironolactone 50–100 mg daily; useful in adult women with hormonal pattern, PCOS, or contraindication to isotretinoin
- Post-inflammatory hyperpigmentation management[1]Strict sun protection; topical retinoid (adapalene); azelaic acid 15–20%; tranexamic acid topical; chemical peels (glycolic, salicylic, mandelic) at specialist; avoid hydroquinone monotherapy long-term
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Adapalene 0.1% gel (topical retinoid)[1] | Topical retinoid | Apply pea-sized amount once daily at night to affected areas | ≥9 years per local label | First-line topical for mild acne and maintenance; less irritation than tretinoin; safe in skin of colour; sun protection essential |
| Benzoyl peroxide 2.5–5% gel[1] | Topical antimicrobial | Apply once or twice daily | ≥12 years | Reduces P. acnes resistance when combined with antibiotic; bleaches fabric; mild irritation; combine with retinoid |
| Doxycycline (oral)[1] | Tetracycline antibiotic | 100 mg PO daily × 3 months maximum | ≥8 years: 1 mg/kg/day; ≥12 years: 100 mg daily | First-line oral antibiotic for moderate acne; photosensitivity — sunscreen counselling; oesophageal irritation — take with water and upright; combine with topical retinoid + BPO; never as monotherapy |
| Isotretinoin (oral)[1] | Oral retinoid | 0.5–1 mg/kg/day to cumulative 120–150 mg/kg over 4–6 months | Per dermatologist | Severe/nodulocystic or refractory acne; severe teratogenicity — pregnancy prevention programme; LFT/lipids monitoring; mucocutaneous side effects; counsel about mood |
| Spironolactone (women)[1] | Aldosterone antagonist | 50–100 mg PO daily titrated to 200 mg | — | Adult women with hormonal pattern; pregnancy contraindicated (anti-androgen feminisation of male fetus); potassium and BP monitoring |
Adapalene 0.1% gel (topical retinoid)[1]
Topical retinoid
- Adult
- Apply pea-sized amount once daily at night to affected areas
- Paediatric
- ≥9 years per local label
First-line topical for mild acne and maintenance; less irritation than tretinoin; safe in skin of colour; sun protection essential
Benzoyl peroxide 2.5–5% gel[1]
Topical antimicrobial
- Adult
- Apply once or twice daily
- Paediatric
- ≥12 years
Reduces P. acnes resistance when combined with antibiotic; bleaches fabric; mild irritation; combine with retinoid
Doxycycline (oral)[1]
Tetracycline antibiotic
- Adult
- 100 mg PO daily × 3 months maximum
- Paediatric
- ≥8 years: 1 mg/kg/day; ≥12 years: 100 mg daily
First-line oral antibiotic for moderate acne; photosensitivity — sunscreen counselling; oesophageal irritation — take with water and upright; combine with topical retinoid + BPO; never as monotherapy
Isotretinoin (oral)[1]
Oral retinoid
- Adult
- 0.5–1 mg/kg/day to cumulative 120–150 mg/kg over 4–6 months
- Paediatric
- Per dermatologist
Severe/nodulocystic or refractory acne; severe teratogenicity — pregnancy prevention programme; LFT/lipids monitoring; mucocutaneous side effects; counsel about mood
Spironolactone (women)[1]
Aldosterone antagonist
- Adult
- 50–100 mg PO daily titrated to 200 mg
- Paediatric
- —
Adult women with hormonal pattern; pregnancy contraindicated (anti-androgen feminisation of male fetus); potassium and BP monitoring
Safety-net
- Allow at least 8–12 weeks for treatment to show effect; do not switch prematurely or stack multiple irritants[1]
- Use sunscreen daily — sun exposure worsens post-inflammatory hyperpigmentation, the most common cosmetic concern in skin of colour[1]
- On isotretinoin: report mood changes, severe headache, abdominal pain, vision changes, or hearing changes immediately; absolute contraception[1]
Referral criteria
- Severe nodulocystic acne, scarring, or refractory to combined topical + oral antibioticDermatology for isotretinoin consideration[1]
- Acne fulminans or systemic featuresDermatology admission and pre-isotretinoin oral steroid[1]
- Suspected hyperandrogenism (hirsutism, oligomenorrhoea, virilisation)Endocrinology / gynaecology workup[1]
- Pregnancy planning while on isotretinoin or oral antibioticJoint dermatology and obstetric pre-conception clinic; switch to safer alternatives[1]
Clinical summary
Severity-graded topical, oral, and isotretinoin-based management of acne vulgaris in adolescents and adults; pigmentation considerations.