18 evidence-based recommendations + 5 good practice statements for adults, adolescents, and preadolescents ≥9 years — American Academy of Dermatology · J Am Acad Dermatol 2024;90:1006.e1-30
Baseline Evaluation — All Patients
Assess before selecting therapy
Complete at every visit — informs therapeutic decision-making and tracks treatment response
Severity (IGA scale)
Use Investigator Global Assessment (IGA): 0 clear → 1 almost clear → 2 mild → 3 moderate → 4 severe. Assess lesion types, counts, extent, scarring, dyspigmentation.
QOL & Psychosocial
Assess impact on daily activities, social functioning, sleep, and emotional wellbeing. Psychosocial burden or scarring risk → consider isotretinoin regardless of severity grade.
Testing (Not Routine)
Microbiological and endocrine testing NOT routinely indicated. Consider endocrine testing only if signs of hyperandrogenism (hirsutism, oligomenorrhea, PCOS). Culture only if Gram-negative folliculitis suspected.
Step 1 — Select Clinical Pathway
What is the primary management question?
Choose the pathway that matches the current clinical need — each generates evidence-based recommendations with dosing
🧴 Topical Therapy
Mild to moderate acne — selecting or optimising topical agents. Covers all recommended topicals including retinoids, benzoyl peroxide, antibiotics, and combinations
💊 Systemic Antibiotics
Moderate to severe acne — selecting oral antibiotic therapy. Doxycycline, minocycline, sarecycline with antibiotic stewardship guidance
⚧ Hormonal Therapy
Female patients with acne — combined oral contraceptives or spironolactone. Includes contraindication screening and monitoring guidance
⚡ Isotretinoin
Severe, scarring, or refractory acne — isotretinoin candidacy, iPLEDGE requirements, monitoring, formulation choice, and dosing strategy
Step 2 — Topical Treatment Goal (Table III #1.1–1.10)
What is the treatment objective?
Select the scenario that best describes the current clinical need for topical therapy
Starting first topical regimen
No current prescription topical treatment — selecting initial therapy
Optimising — adding to existing regimen
Currently using one or more topical agents, adding a complementary mechanism to improve response
Fixed-dose combination products
Seeking a single product combining multiple agents to simplify adherence
Special topical agents
Considering clascoterone, salicylic acid, or azelaic acid — conditional recommendations and specific use cases
Additional patient considerations
Step 2 — Antibiotic Selection (Table III #2.1–2.6)
Systemic antibiotic clinical scenario
Oral tetracycline-class antibiotics for moderate to severe acne — limit use to shortest duration possible and combine with BP + topical therapy
First antibiotic course needed
No prior systemic antibiotic for acne — selecting initial oral antibiotic alongside topical therapy
Switching antibiotic
Prior antibiotic ineffective, not tolerated, or resistance suspected — selecting alternative
Ready to de-escalate / stop antibiotic
Acne controlled — antibiotic stewardship guidance on tapering and transitioning to maintenance topical therapy
Contraindications to consider
Step 2 — Hormonal Therapy Profile (Table III #3.1–3.2)
Female patient profile for hormonal therapy
Hormonal agents treat acne through anti-androgenic effects. COC and spironolactone are conditionally recommended.
Combined oral contraceptive (COC)
Patient desires oral contraception OR has hormonal/androgenic acne pattern — COC is conditionally recommended for acne in females
Spironolactone
Aldosterone receptor antagonist — anti-androgenic acne treatment. Not FDA-approved for acne but conditionally recommended with moderate certainty
Contraindications / safety screening
Step 2 — Isotretinoin Candidacy (Table III #4.1–4.3)
Select the primary indication for isotretinoin
Oral isotretinoin is the only FDA-approved treatment for severe recalcitrant nodular acne — also appropriate beyond this indication
Severe or nodular/cystic acne
Nodules, cysts, or conglobate acne — strongly recommended (good practice statement)