Acne vulgaris in adolescents — branching viva

Opening — grade and name the disease

Open with the severity and the comedonal versus the inflammatory split, because the split drives the treatment. This 15-year-old has the open and the closed comedones, the inflammatory papules and pustules, and a few tender nodules on the jawline and the upper back — the moderate inflammatory acne vulgaris with some nodular disease. I grade on a reproducible scale and I record the proportion of the comedonal to the inflammatory lesions, and my first move is the psychosocial screen, because his withdrawal from swimming is the distress signal the lesion count hides. ^{[1] [9]}

Branch 1 — the topical ladder

Walk the examiner through your topical regimen. The foundation is the topical retinoid, because it fixes the microcomedone upstream. I use the adapalene 0.1 per cent as a thin film to the whole affected area at night, with the benzoyl peroxide 2.5 per cent by day, and I choose the adapalene over the tretinoin because the adapalene is photostable and combines safely with the benzoyl peroxide whereas the tretinoin is degraded by it. I counsel the dryness, the photosensitivity, and the sunscreen, and I review at six to eight weeks. ^{[1] [2]}

Branch 2 — the antibiotic stewardship

Explain when and how you add the oral antibiotic. For the many papules and pustules I add the oral doxycycline once daily for three months, but never alone — it travels with the topical retinoid and the benzoyl peroxide. The stewardship rule is one fellowship tests every year: never the antibiotic monotherapy, always pair it with the benzoyl peroxide to limit the resistance, cap the oral course at three to four months, and let the retinoid carry the maintenance. I never combine the topical erythromycin with the topical clindamycin, because the cross-resistance gives no added benefit. ^{[1] [7]}