Acne clinical guideline
Addresses the management of adolescent and adult patients who present with acne vulgaris. The guideline discusses various acne treatments including:
Topical therapies
Systemic agents
Physical modalities
Lasers
Photodynamic therapy
In addition, the guideline covers:
Grading/classification system
Microbiologic and endocrinologic testing
Complementary/alternative therapies
The role of diet
This guideline does not examine the treatment of acne sequelae (e. g. scarring, post-inflammatory dyschromia).
The work group was comprised of 17 recognized acne experts, one general practitioner, one pediatrician, and one adult patient.
Acne Resource Center for patients
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Guideline highlights
Acne is very common among adolescents and young adults, but can persist into adulthood
Nearly 85% of teenagers are affected by acne at some point during their teenage years
In total, over 50 million people have acne in the United States
Permanent scarring, poor self-image, depression, and anxiety can result from acne
Pathogenesis
Understanding of acne pathogenesis is evolving, but may involve a combination of the following factors:
follicular hyperkeratinization
microbial colonization with P. acnes
sebum production
complex inflammatory mechanisms
neuroendocrine regulatory mechanisms
diet
genetic factors
non-genetic factors
Addresses the management of adolescent and adult patients who present with acne vulgaris. The acne treatments including:
topical therapies
systemic agents
physical modalities
lasers
photodynamic therapy
In addition, the guideline covers:
grading/classification system
microbiologic and endocrinologic testing
complementary/alternative therapies \
the role of diet
This guideline does not examine the treatment of acne sequelae (e. g. scarring, post-inflammatory dyschromia)
Disease burden & pathogenesis
Disease burden
Acne is very common among adolescents and young adults, but can persist into adulthood
Nearly 85% of teenagers are affected by acne at some point during their teenage years
In total, more than 50 million people have acne in the United States
Permanent scarring, poor self-image, depression, and anxiety can result from acne
The direct cost of acne is estimated to exceed $3 billion annually
Pathogenesis
Understanding of acne pathogenesis is evolving, but may involve a combination of the following factors:
Follicular hyperkeratinization
Microbial colonization with P. acnes
Sebum production
Complex inflammatory mechanisms
Neuroendocrine regulatory mechanisms
Diet
Genetic factors
Non-genetic factors
Grading and classification
An acne grading system may be helpful in patient care, but at present there is no universal system for grading and assessing severity of acne.
To facilitate therapeutic decisions and assess treatment response, clinicians can use a consistent method of grading and classifying acne using the following characteristics:
Number of acne lesions
Type of acne lesions
Disease severity
Anatomical sites
Scarring
Quality of Life (QOL)
Microbiologic and endocrinologic testing
Microbiologic testing
Routine testing is NOT recommended, though patients exhibiting acne-like lesions suggestive of gram negative folliculitis may benefit from microbiologic testing.
Endocrinologic testing
Routine testing is NOT recommended, though laboratory evaluation of acne patients with additional signs of androgen excess is recommended.
Topical therapies
Recommendations
Benzoyl peroxide alone or in combination with topical antibiotics for mild acne
Benzoyl peroxide in combination with topical retinoids or systemic antibiotic therapy for moderate to severe acne
Retinoids as monotherapy in primarily comedonal acne or in combination with topical or oral antimicrobials in mixed/primarily inflammatory acne
Topical dapsone 5% gel for inflammatory acne, particularly in adult females
Azelaic acid for post-inflammatory dyspigmentation
Other points of note
Benzoyl peroxide does not confer bacterial resistance
Topical antibiotics are NOT recommended as monotherapy due to risk of bacterial resistance
Combination therapy should be used in the majority of acne patients to target different aspects of acne pathogenesis
Patients should be counseled on pregnancy risks when starting a retinoid or if a female patient desires pregnancy
The topical therapy of acne in children under the age of 12 years with FDA-approved products has expanded
Benzoyl peroxide 2.5%/adapalene 1% gel – ages 9 and up
Tretinoin 0.05% micronized gel – ages 10 and up
The use of topical maintenance regimens after oral antibiotic therapy cannot be overemphasized
Topical therapies can accomplish continued efficacy months after discontinuation of systemic antibiotics
Systemic antibiotics
Systemic antibiotics are recommended for use in moderate to severe inflammatory acne that are resistant to topical therapies. They should be used in combination with a topical retinoid and benzoyl peroxide. Limiting antibiotic use to minimize antibiotic resistance is suggested.
Recommendations
Oral tetracycline, doxycycline, minocycline, erythromycin, azithromycin, trimethoprim/sulfamethoxazole (TMP/SMX), trimethoprim and cephalexin have been shown to be effective in the treatment of moderate and severe acne, and forms of inflammatory acne that are resistant to topical treatments.
Other points of note
Tetracyclines (tetracycline, doxycycline, minocycline) are the preferred systemic antibiotics
Oral erythromycin and azithromycin use should be limited to those who cannot use tetracyclines:
Pregnant women
Children under 8 years of age
Trimethoprim-sulfamethoxazole and trimethoprim use should be restricted to patients unable to tolerate tetracyclines or in treatment-resistant patients
Use of all other systemic antibiotics is discouraged
Monotherapy with systemic antibiotics is NOT recommended
When prescribing systemic antibiotics, the issue of bacterial resistance remains a major concern
The Centers for Disease Control (CDC) has stressed antibiotic stewardship
Limit antibiotic use to the shortest possible duration, typically three months, to minimize the development of bacterial resistance.
Concomitant topical therapy with benzoyl peroxide and/or a retinoid should be used with systemic antibiotics, as well as for maintenance after completion of systemic antibiotic therapy
Limiting systemic antibiotic use is urged due to reported associations of inflammatory bowel disease, pharyngitis, Clostridium difficile infection, and induction of Candida vulvovaginitis.
Hormonal agents
Oral contraceptives may improve acne for many women. They could be used alone or in combination with other acne treatments.
Recommendations
Estrogen-containing combined oral contraceptives for inflammatory acne in females
Currently four FDA-approved combined oral contraceptives for the treatment of acne
Acne reduction with these agents can take time
Other points of note
Spironolactone can be useful in the treatment of acne in select females, though evidence of its efficacy is limited
Oral corticosteroid therapy can be of temporary benefit in patients who have severe inflammatory acne while starting standard acne treatment
Long-term adverse effects of corticosteroids prohibit use as a primary therapy for acne
Isotretinoin
Recommendations
Oral isotretinoin is recommended for the treatment of severe nodular acne.
Other points of note
Oral isotretinoin is appropriate for the treatment of moderate acne that is treatment-resistant or for the management of acne that is producing physical scarring and/or psychosocial distress
Low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medication-related side effects
Intermittent dosing of isotretinoin is NOT recommended
Routine monitoring of liver function tests, serum cholesterol and triglycerides at baseline and again until response to treatment is established is recommended
Routine monitoring of complete blood count is NOT recommended
Every woman of child-bearing potential taking isotretinoin should be carefully counseled regarding various contraceptive methods that are available and the specific requirements of the iPLEDGE system at each clinic visit
Patient-independent forms of birth control, including long acting reversible contraceptives, should be considered whenever appropriate
Prescribing physicians also should monitor their patients for any indication of inflammatory bowel disease and depressive symptoms and educate their patients about the potential risks with isotretinoin
Physical modalities and miscellaneous therapies
There is limited evidence to recommend the use and benefit of physical modalities for the routine treatment of acne including:
Comedo removal
Pulsed dye laser
Potassium titanyl phosphate (KTP) laser
Fractionated and non-fractionated infrared lasers
Fractionated CO2 laser
Photodynamic therapy (PDT)
Glycolic acid peels
Salicylic acid peels
Intralesional corticosteroid injections are effective in the treatment of larger individual acne nodules.
Complementary/alternative therapies
Herbal and alternative therapies have been reported to have value in treating acne:
Tea tree oil
Topical and oral ayurvedic compounds
Oral barberry extract
Gluconolactone solution
Although most of these products appear to be well tolerated, very limited data exist regarding the safety and efficacy of these agents to recommend their use in acne.
Role of diet in acne
No specific dietary changes are recommended in the management of acne
Emerging data suggests that high glycemic index (GI) diets may be associated with acne
Limited evidence suggests that some dairy, particularly skim milk, may influence acne
Research and knowledge gaps in acne
Topics | Identified research gaps |
---|---|
General |
|
Pathogenesis |
|
Grading and classification |
|
Topical therapies |
|
Systemic antibiotics |
|
Hormonal agents |
|
Isotretinoin |
|
Physical modalities |
|
Role of diet in acne |
|
Treatment algorithm for adolescents and young adults
First line treatment options | |||
---|---|---|---|
Mild | Benzoyl peroxide (BP) | Topical retinoid | Topical combination therapy*:
|
Moderate | Topical combination therapy*:
| Oral antibiotic + topical retinoid + BP | Oral antibiotic + topical retinoid + BP + topical antibiotic |
Severe | Oral Antibiotic + topical combination therapy:
| Oral isotretinoin |
* May be prescribed as a fixed combination product or as separate component.
Alternative options | ||||
---|---|---|---|---|
Mild | Add topical retinoid or BP (if not on already) | Consider alternate retinoid | Consider topical dapsone | |
Moderate | Consider alternate combination therapy | Consider change in oral antibiotic | Add combined oral contraceptive or oral spironolactone (females) | Consider oral isotretinoin |
Severe | Consider change in oral antibiotic | Add combined oral contraceptive or oral spironolactone (females) | Consider oral isotretinoin | |