Hidden triggers, red flags, and evidence-based management strategies to support adherence and treatment success…

It’s one of the first things teens notice in the mirror and one of the most common reasons they’ll walk through your door.

Affecting 9.4% of the global population, acne is the eighth most prevalent disease worldwide. Incidence is highest between ages 10 and 14, with cases peaking around 17, just as many teens are navigating their most pivotal developmental years.

While acne is common, its impact on adolescent patients can be physically, emotionally, and socially profound. Addressing this requires more than prescribing alone, it calls for careful consideration of developmental stage, social influences, and family dynamics.

Clinical considerations during acne assessment

Though primarily a dermatological condition, managing acne in adolescents involves recognising the wider psychological and lifestyle factors that shape both treatment outcomes and patient engagement.

Mental health: Acne is often linked to low self-esteem, anxiety, depression, and social withdrawal. Teens may not readily disclose emotional distress, so gentle questioning and observation are important. If you notice scabs and crusts, they may be picking at their acne. This ‘skin picking’ can signal underlying stress and contribute to scarring.

Lifestyle factors: Supplements that contain whey protein can worsen acne by stimulating insulin growth-like factor (IGF-1) which stimulates the oil gland. These are often used by gym-active teens, so it’s important to ask about supplement-use. Diets that are high in processed foods or high GI foods, such as white bread, chips or sweets, can also exacerbate inflammation. Poor sleep and stress can play a role as well.

Hormonal considerations: In older adolescent females, hormonal acne often presents as nodules along the lower face, jawline, and neck, with cyclical flares before menstruation. A family history of severe acne and signs of hyperandrogenism, such as hirsutism, may indicate hormonal involvement.

Skin type and pigmentation: Post-inflammatory hyperpigmentation (PIH) is a frequent concern in patients with skin of colour and may persist beyond active acne. Patients with skin of colour may also have increased risk of acne scarring. Minimising irritation with well-tolerated topicals is important for both clinical and emotional outcomes.

Skin type and pigmentation: Post-inflammatory hyperpigmentation (PIH) is a frequent concern in patients with skin of colour and may persist beyond active acne. Patients with skin of colour may also have increased risk of acne scarring. Minimising irritation with well-tolerated topicals is important for both clinical and emotional outcomes.

Treatment feasibility: Adherence can be affected by busy routines, shared care arrangements, or limited parental involvement. Asking about the teen’s daily habits and preferences supports a practical and sustainable treatment plan. Keeping the treatment plan simple, and suggesting strategies such as a reminder on their phone or ‘bundling’ acne cream with another habit (for example putting it by their toothbrush so they remember to use it when they brush their teeth) can improve adherence.

Follow-up: Regular review is key to assessing treatment response, managing side effects, and adjusting the plan as needed. It also reinforces the therapeutic relationship and ensures a clear path forward if first-line treatments are not effective.

Importance of developing a good rapport

Building rapport is central to effective acne care, particularly when working with adolescents.

Making an effort to connect with the teen and validate their feelings, while also offering hope, can go a long way.

It’s key to uncovering the emotional impact and addressing common misconceptions, as well as choosing a management approach that they can stick with.

Practice tip: Multi-step routines involving multiple active products are popular on social media, often resulting in irritated skin or dermatitis.
You may need to spend some time dispelling myths fuelled by social media, and point them toward reliable information such as
All About Acne and DermNet.

It’s also important to be upfront and realistic about the timeframes they can expect to see improvement, and what side effects might occur. At the same time, reassure them that although they might need to be patient, treatment can significantly improve their skin.

Treatment options

OTC treatments and when to escalate
Most patients will have tried OTC treatments before consulting a doctor. These typically include benzoyl peroxide, salicylic acid, or azelaic acid, which are readily available and affordable options. However, these agents often fail to provide sufficient control, particularly when acne persists or worsens. Consider prescription therapy for patients with few but persistent superficial lesions, despite OTC treatments.

Topical prescription therapies
Fixed-dose topical combinations are recommended as first-line options for the treatment of mild to moderate acne.

Adapalene combined with benzoyl peroxide
Adapalene combined with benzoyl peroxide offers both retinoid and antibacterial effects. It can be used long-term and is suitable alongside oral antibiotics since it does not contain a topical antibiotic. However, it can cause skin irritation, manifesting as dryness, itching, or peeling, and benzoyl peroxide may bleach household fabrics. Importantly, it is contraindicated during pregnancy due to the presence of the retinoid, adapalene.

Clindamycin combined with benzoyl peroxide
Clindamycin combined with benzoyl peroxide is another commonly used option. Unlike adapalene/benzoyl peroxide, this combination cannot be used with oral antibiotics due to the risk of antibiotic resistance. It also causes bleaching and may irritate the skin, but it is safe for use during pregnancy.

Clindamycin combined with tretinoin
A newer option is the combination of clindamycin and tretinoin, which pairs an antibiotic with a topical retinoid (tretinoin). This product is considered the least irritating of the three, making it a good choice for patients concerned about skin sensitivity. Like other retinoid-containing products, it is not suitable for pregnant patients or when oral antibiotics are being used concurrently.

Practice tip: To minimise irritation, topical treatments should be applied two to three times per week initially, with frequency increased as tolerated. Patients should avoid using multiple active skincare products alongside prescription treatments and instead use a gentle cleanser and moisturiser. They should also be advised that visible results may take several weeks.

Progressing to systemic therapy
For patients with moderate to severe inflammatory acne, or when lesions extend to areas like the chest or back where topical treatment is impractical, oral antibiotics are appropriate. These agents reduce acne-causing bacteria and suppress inflammatory cytokines, helping to prevent long-term scarring.

Oral antibiotics should never be used as monotherapy. They must be combined with topical benzoyl peroxide to prevent resistance. The recommended treatment duration is limited to three months, and oral and topical antibiotics should never be used together.

Doxycycline is the preferred first-line oral antibiotic, typically prescribed at 100 mg daily. For patients with severe inflammation, a loading regimen of 100 mg twice daily for two weeks may be considered, followed by a reduction to the standard dose.

In patients unable to tolerate tetracyclines, trimethoprim-sulfamethoxazole (Bactrim DS) is an alternative. Minocycline is considered second-line due to its greater risk of adverse effects. Other antibiotics, such as lymecycline, azithromycin, and cephalexin, are used less frequently and are generally third-line options.

When to refer

Referral is warranted when acne progresses to severe forms, fails to respond to appropriate therapies, or causes significant psychological distress.

Early referral is also advised when there are signs of scarring, as timely intervention can prevent permanent damage.

Key points:

• Managing acne in adolescents is a multifaceted process that goes beyond prescribing decisions, requiring attention to mental health, diet, hormonal influences and real-world barriers to adherence.
• Clear, empathetic communication helps uncover emotional distress, correct misinformation, and set realistic expectations, all of which are essential for adolescent engagement and adherence.
• Start with topical combinations for mild to moderate cases; escalate to short-course oral antibiotics for more extensive or inflammatory acne, always paired with topical agents.
• Refer early for severe, scarring, or unresponsive acne, or when hormonal features are present, particularly in older adolescent females.

For trusted patient resources on acne see All About Acne and DermNet.