Acne Treatment in 2026: What the AAD Guidelines Recommend, From Benzoyl Peroxide to Doxycycline and Isotretinoin
Acne is one of the most common skin conditions in the United States, and also one of the most mistreated. Many people buy a new cleanser every month, stop a treatment after two weeks because it "isn't working", or take an antibiotic on its own for a year. Dermatologists now have a clear, evidence-based plan for what actually works.
The American Academy of Dermatology (AAD) updated its acne guidelines in 2024, the first major revision since 2016. The update contains 18 evidence-based recommendations and five good practice statements, and a 2025 summary in American Family Physician shows it is still the standard primary care doctors are following. This guide explains the main points in plain language: what is strongly recommended, what is only conditionally recommended, what the guideline does not support, and when to see a dermatologist.
The AAD guideline summary is available at: https://aad.org/news/updated-guidelines-acne-management
What Causes Acne
Acne starts in the hair follicle and sebaceous (oil) gland. Four things work together:
Excess sebum: oil production is driven by hormones called androgens, which rise at puberty and can stay high in some adults.
Clogged follicles: dead skin cells build up and plug the pore, forming blackheads and whiteheads.
Bacteria: Cutibacterium acnes (C. acnes) multiplies in the plugged follicle.
Inflammation: the immune response to the bacteria produces red bumps, pustules, and in severe cases nodules and cysts that can scar.
Each treatment works on one or more of these steps. That is why the guidelines favour combinations: a retinoid unplugs pores, benzoyl peroxide reduces bacteria, and an antibiotic or hormonal treatment can calm inflammation or oil production.
The Core Principle: Combine Treatments
The most important message in the guideline is that combining treatments with different actions works better than using one. Topical antibiotic monotherapy is specifically not recommended, because bacteria can become resistant. When a topical antibiotic is used, it should be paired with benzoyl peroxide, which helps prevent resistance. Fixed-dose combination products (for example a retinoid plus benzoyl peroxide in one tube) are recommended and make a routine easier to stick to.
Severity | Typical features | Usual starting approach |
Mild | Mostly blackheads and whiteheads, few inflamed spots | Topical retinoid plus benzoyl peroxide |
Moderate | Mix of comedones, papules, and pustules over a wider area | Combination topical therapy, with or without an oral antibiotic or spironolactone |
Severe | Nodules, cysts, widespread inflammation, scarring | Dermatology referral; isotretinoin, or aggressive combination therapy |
What the 2024 AAD Guideline Recommends
Treatment | Strength of recommendation | Role |
Topical benzoyl peroxide | Strong | Reduces acne-causing bacteria; also protects against antibiotic resistance |
Topical retinoids (adapalene, tretinoin, tazarotene, trifarotene) | Strong | Unclog pores and reduce inflammation; the foundation of therapy |
Topical antibiotics | Strong, but never alone | Use with benzoyl peroxide |
Fixed-dose topical combinations | Recommended | Retinoid + benzoyl peroxide, antibiotic + benzoyl peroxide, or retinoid + antibiotic |
Oral doxycycline | Strong | For moderate to severe acne, combined with topical treatment |
Oral isotretinoin | Strong | Severe acne, acne causing scarring or psychosocial burden, or acne that failed standard treatment |
Intralesional corticosteroid injection | Recommended as add-on | Large, painful nodules for faster relief |
Salicylic acid, azelaic acid | Conditional | Gentle exfoliation; azelaic acid also helps fade dark marks |
Clascoterone (Winlevi) | Conditional | Topical anti-androgen; conditional mainly because of cost |
Oral minocycline, sarecycline | Conditional | Alternative oral antibiotics |
Spironolactone, combined oral contraceptives | Conditional | Hormonal acne in women |
Conditional means the treatment is reasonable for most patients but the choice depends on individual factors such as cost, side effects, and other health conditions.
Doxycycline for Acne: What to Know
Doxycycline is the oral antibiotic the AAD strongly recommends for moderate to severe acne. It reduces both acne bacteria and inflammation.
Never use it alone. The guideline says systemic antibiotics should not be used as monotherapy; pair doxycycline with topical benzoyl peroxide and another topical treatment such as a retinoid.
Keep the course short. The AAD advises using oral antibiotics for the shortest time needed to get control and reviewing progress around 3 to 4 months, to limit antibiotic resistance. Once acne is controlled, topical treatment is usually continued to maintain results.
Protect your skin from the sun. Doxycycline makes skin more sensitive to sunlight, so use sunscreen and avoid tanning.
Protect your throat. Swallow tablets with a full glass of water and stay upright for a while afterwards, because doxycycline can irritate the oesophagus.
Watch the timing with minerals. Calcium, iron, magnesium, and antacids can reduce absorption, so keep them a few hours apart.
Who should avoid it: it is not used in pregnancy or in young children, because it can affect developing teeth and bones.
TheMedicineKart stocks doxycycline for patients with a valid prescription: [Doxycycline 100mg Tablets]. The dose and length of treatment should be set by your prescriber.
Hormonal Acne: Spironolactone, Birth Control and Clascoterone
Acne that flares around the jawline and chin, worsens before periods, or appears in adult women often has a hormonal driver. The guideline includes options that target it:
Spironolactone: a conditional recommendation for women. It blocks the effect of androgens on the skin. Doses of 50 to 100 mg daily are commonly used for acne. It must not be used in pregnancy, and contraception is advised while taking it.
Combined oral contraceptive pills: a conditional recommendation for women who also want contraception.
Clascoterone (Winlevi): the first FDA-approved topical treatment that addresses the hormonal cause of acne in both men and women; it is applied to the skin rather than taken by mouth.
The AAD work group also concluded that frequent routine blood tests are not a high-value practice for young, healthy patients taking spironolactone or isotretinoin. Your doctor may still decide on testing based on your own health.
If acne appears suddenly in an adult woman along with irregular periods or excess hair growth, ask about polycystic ovary syndrome (PCOS). Our guide to metformin explains one of the medicines sometimes used in PCOS: [Metformin (Glucophage): Complete 2026 Guide]
Isotretinoin: When Acne Needs the Strongest Treatment
Oral isotretinoin (once sold as Accutane) is the only treatment that can produce long-lasting remission in many people. The AAD strongly recommends it for:
Severe acne
Acne that is causing scarring or significant psychological distress
Acne that has not responded to standard topical and oral treatment
The guideline conditionally favours standard daily dosing over intermittent dosing, and considers standard isotretinoin and lidose-isotretinoin both acceptable.
Key safety points:
Pregnancy must be avoided. Isotretinoin causes serious birth defects, and prescribing in the United States runs through a monitored programme (iPLEDGE) that requires pregnancy prevention.
Dry lips, dry skin, and dry eyes are very common and usually manageable with moisturisers, lip balm, and sun protection.
Tell your prescriber about any low mood or unusual changes in how you feel while on treatment.
Do not share or use someone else's supply. This drug needs medical supervision.
What the Guideline Does Not Support
The AAD found too little evidence to recommend several popular options, including chemical peels, lasers and light-based devices, and microneedling for treating acne. It also made a conditional recommendation against adding broadband (intense pulsed) light to adapalene 0.3% gel. Evidence for dietary changes is still limited, so treat diet as an optional extra rather than a replacement for treatment.
Common Mistakes and Better Habits
Common mistake | Better approach |
Stopping after 2 to 3 weeks | Give a new routine 8 to 12 weeks before judging results |
Using only a topical antibiotic | Pair it with benzoyl peroxide; antibiotics alone are not recommended |
Using many products at once | Keep the routine simple: one retinoid, one benzoyl peroxide product, a gentle cleanser, and moisturiser with sunscreen |
Scrubbing harshly | Over-scrubbing irritates skin and worsens inflammation; wash gently twice a day |
Picking or squeezing | This raises the risk of scars and dark marks |
Taking an oral antibiotic for years | Aim for a short course, review at 3 to 4 months, and keep up topical treatment |
Ignoring dark marks left after spots clear | Azelaic acid and daily sunscreen help; see our hyperpigmentation guide |
For dark marks that remain after acne clears, see: [Hyperpigmentation and Dark Spots: Causes, Types and Treatment Guide]
Acne and rosacea can look alike, but they need different treatment. If your redness, flushing, and bumps appear mainly in the centre of the face in adulthood, read: [Ivermectin for Skin Conditions: Rosacea, Scabies and Dermatology Guide]
When to See a Dermatologist
You have nodules or deep cysts, or you are getting scars
You have dark marks that are not fading
Acne is affecting your mood, confidence, or daily life
You have used a consistent routine for 8 to 12 weeks with no improvement
Acne appeared suddenly as an adult, particularly with irregular periods
You are pregnant or planning pregnancy and need to review your treatments
A 2025 practice summary of the AAD guideline for primary care doctors is available at: https://www.aafp.org/afp/2025/1100/practice-guidelines-acne-management
Healio's report on the guideline update, including expert comments on clascoterone and sarecycline, is available at: https://cm.healio.com/news/dermatology/20240207/american-academy-of-dermatology-publishes-updated-care-guidelines-for-acne
Frequently Asked Questions
What is the best treatment for acne according to dermatologists?
There is no single best product. The AAD strongly recommends combining treatments with different actions: a topical retinoid (such as adapalene or tretinoin) to unclog pores plus benzoyl peroxide to reduce bacteria. For moderate to severe acne, oral doxycycline is strongly recommended alongside topical treatment, and isotretinoin is strongly recommended for severe, scarring, or treatment-resistant acne. Topical antibiotics should not be used alone.
Is doxycycline good for acne and how long should it be taken?
Yes. The AAD strongly recommends oral doxycycline for moderate to severe acne, but always combined with topical treatments such as benzoyl peroxide, never on its own. The guideline advises keeping antibiotic courses as short as possible and reviewing progress at around 3 to 4 months to reduce the risk of resistance. Doxycycline increases sun sensitivity, can irritate the oesophagus if swallowed without enough water, and is not used in pregnancy or young children.
What is hormonal acne and how is it treated?
Hormonal acne is driven by androgens increasing oil production. It often appears on the jawline and chin and may flare before periods. The AAD conditionally recommends spironolactone and combined oral contraceptives for women, and topical clascoterone for men and women. Spironolactone is commonly used at 50 to 100 mg daily and must not be taken during pregnancy. Sudden adult acne with irregular periods should prompt a check for PCOS.
When is isotretinoin recommended?
The AAD strongly recommends oral isotretinoin for severe acne, acne causing scarring or significant psychological distress, and acne that has failed standard topical or oral treatment. It causes serious birth defects, so pregnancy must be avoided and prescribing is monitored through the iPLEDGE programme. Dry skin and lips are very common. Tell your prescriber about any changes in mood while taking it.
How long does acne treatment take to work?
Most acne treatments need 8 to 12 weeks of consistent use before you can fairly judge results, and some people see a temporary flare in the first weeks of a retinoid. Stopping early is one of the most common reasons treatment appears to fail. If there is no improvement after 8 to 12 weeks of a consistent routine, a dermatologist can adjust the plan or add an oral or hormonal treatment.
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