Linking To And Excerpting From The Journal Of The American Academy Of Dermatology’s “Guidelines of care for the management of acne vulgaris”

Posted on September 27, 2025 by Tom Wade MD

Today, I review, link to, and excerpt from the Journal Of The American Academy Of Dermatology‘s Guidelines of care for the management of acne vulgaris.*

*Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024 May;90(5):1006.e1-1006.e30. doi: 10.1016/j.jaad.2023.12.017. Epub 2024 Jan 30.

All that follows is from the above resource.

Abstract

Background: Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older.

Objective: The objective of this study was to provide evidence-based recommendations for the management of acne.

Methods: A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations.

Results: This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

Limitations: Analysis is based on the best available evidence at the time of the systematic review.

Conclusions: These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Keywords: Acne; Cutibacterium acnes; acne vulgaris; adapalene; antiandrogens; antibiotics; azelaic acid; azithromycin; benzoyl peroxide; clascoterone; clindamycin; contraceptives; corticosteroids; diet and acne; doxycycline; erythromycin; grading and classification of acne; guidelines; hormonal therapy; isotretinoin; light therapies; microbiological and endocrine testing; minocycline; retinoids; salicylic acid; sarecycline; spironolactone; tazarotene; treatment; tretinoin; trifarotene.

PubMed Disclaimer

Abbreviations used

  1. AAD (American Academy of Dermatology)
  2. BP (benzoyl peroxide)
  3. COC (combined oral contraceptive)
  4. EE (ethinyl estradiol)
  5. FDA (Food and Drug Administration)
  6. IBD (inflammatory bowel disease)
  7. IGA (Investigator Global Assessment)
  8. MD (mean difference)
  9. RCT (randomized controlled trial)
  10. RR (risk ratio)
  11. US (United States)
  12. VTE (venous thromboembolism)
Capsule Summary
• The American Academy of Dermatology’s 2016 guidelines for the management of acne vulgaris are updated with a systematic review, which resulted in 18 evidence-based recommendations and 5 good practice statements.
• Strong recommendations are made for topical benzoyl peroxide, retinoids, and/or antibiotics and their fixed-dose combinations, and for oral doxycycline. Oral isotretinoin is strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne failing standard treatment with oral or topical therapy.
• Conditional recommendations are made for the use of topical clascoterone, salicylic acid, azelaic acid, oral minocycline, sarecycline, combined oral contraceptives, and spironolactone.
• Using topical therapies combining multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with benzoyl peroxide and other topical therapies, and adjuvant intralesional corticosteroid injections are recommended as good clinical practices.

Scope and objectives

Acne vulgaris is one of the most common skin conditions diagnosed and treated by dermatologists in the United States (US) and worldwide., These guidelines aim to provide evidence-based recommendations to guide the clinical management of acne vulgaris for adults, adolescents, and preadolescents aged 9 years or older from the perspectives of US and Canadian dermatologists, clinicians who treat acne, and patients. These guidelines update the 2016 American Academy of Dermatology guidelines of care for the management of acne. We examine evidence based on a systematic review of the literature on acne grading and classification, laboratory testing, and treatment using topical therapies, systemic antibiotics, hormonal agents, oral isotretinoin, physical modalities, complementary and alternative medicine, and dietary and environmental interventions. These guidelines focus on acne treatments that are available, approved by the US Food and Drug Administration (FDA), and commonly used in the US. Acneiform eruptions and medication-induced acne are not addressed. Diagnosis and treatment of infantile acne, mid-childhood acne in children under the age of 9 years, and acne-induced hyperpigmentation and scarring are beyond of the scope of these guidelines.

Methods

The American Academy of Dermatology (AAD) and Evidinno, Inc., conducted a series of focused and systematic reviews from May 2021 to November 2022 (see Detailed Methods in Supplementary Materials, available via Mendeley at https://data.mendeley.com/datasets/z2bmdwwdf9/2) to determine the effectiveness and safety of treatments currently available and approved in the US for the management of acne vulgaris in adults, adolescents, and preadolescents aged 9 years or older based on the 9 clinical questions with prespecified patient, intervention, comparator, and outcome and study eligibility criteria (Table I and Supplementary Tables I-VII, available via Mendeley at https://data.mendeley.com/datasets/z2bmdwwdf9/2). The Work Group consisted of 9 board-certified dermatologists (including 1 methodologist and 1 measure representative and medical writer), 3 board-certified pediatric dermatologists, 1 staff liaison, and 1 patient representative. The work group employed the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. This approach incorporates benefits and harms, patient values and preferences, resource use, and certainty of evidence as key factors in the evidence to decision framework (Supplementary Table X, available via Mendeley at https://data.mendeley.com/datasets/z2bmdwwdf9/2). Strength of recommendation and strength of the supporting evidence were expressed as shown in Table II. A strong recommendation means that the work group believes that the benefits clearly outweigh risks and burden (or that the risks and burden clearly outweigh the benefits), and a conditional recommendation means that the work group believes that the benefits are closely balanced with risks and burden. A conditional recommendation implies that we believe most people would want the recommended course of action.
Table IClinical questions and scope
Clinical questions
CQ 1. What systems are most commonly used for the grading and classification of acne vulgaris in adults, adolescents, and preadolescents (≥9 y)?
CQ 2. What is the role of microbiological and endocrine testing in evaluating acne vulgaris in adults, adolescents, and preadolescents (≥9 y)?
CQ 3. What are the effectiveness and safety of topical agents in the treatment of acne vulgaris in adults, adolescents, and preadolescents (≥9 y), including:•Retinoids (adapalene, tazarotene, tretinoin, and trifarotene)•Benzoyl peroxide•Topical antibiotics (erythromycin, clindamycin, dapsone, and minocycline)•Alpha hydroxy acid (glycolic acid)•Beta hydroxy acid (salicylic acid)•Azelaic acid•Topical antiandrogen (clascoterone)•Others (sulfur/sulfacetamide sodium and resorcinol)•Combinations of topical agents
CQ 4. What are the effectiveness and safety of systemic antibiotics in the treatment of acne vulgaris in adults, adolescents, and preadolescents (≥9 y), including:•Tetracyclines (doxycycline, minocycline, sarecycline)•Macrolides (azithromycin, clarithromycin, and erythromycin)•Penicillins (amoxicillin and ampicillin)•Cephalosporin (cephalexin)•Trimethoprim/sulfamethoxazole•Other (dapsone)
CQ 5.a. What are the effectiveness and safety of hormonal agents in the treatment of acne vulgaris in adults, adolescents, and preadolescents (≥9 y), including:•Combined contraceptive agents (estrogen and progestin)•Aldosterone receptor antagonist (spironolactone)•Oral corticosteroids (prednisolone and prednisone)•Intralesional corticosteroid (triamcinolone)
CQ 5.b. For patients on spironolactone, how often and for how long should potassium level be monitored?
CQ 6.a. What are the effectiveness and safety of isotretinoin in the treatment of acne vulgaris in adults, adolescents, and preadolescents (≥9 y)?
CQ 6.b. For patients on isotretinoin, how often and for how long should lipids, liver enzymes, creatine kinase, and blood count levels be monitored?
CQ 7. What are the effectiveness and safety of physical modalities for the treatment of acne vulgaris in adults, adolescents, and preadolescents (≥9 y), including:•Chemical peels (alpha hydroxy acid: glycolic acid, lactic acid, madelic acid; beta hydroxy acid: salicylic acid)•Comedo extraction•Lasers•Photodynamic/light therapy (blue light therapy, red light therapy, ALA, and IPL)
CQ 8. What are the effectiveness and safety of complementary/alternative therapies in the treatment of acne vulgaris in adults, adolescents, and preadolescents (≥9 y), including:•Botanicals/plant-derived agents (tea tree oil, green tea, and witch hazel)•Vitamin oral formulation (zinc, niacinamide, pantothenic acid)•Vitamin topical formulation (zinc and niacinamide)
CQ 9. What are the effectiveness and safety of diet in the treatment of acne vulgaris in adults, adolescents, and preadolescents (≥9 y), including:•Low-glycemic diet•Low-dairy diet•Low-whey diet•Omega-3 and chocolate
ALA, Aminolevulinic acid; IPL, intense pulsed light; US, United States.
Table IIStrength of recommendation and certainty of evidence
Strength of recommendation Wording Implication5-7
Strong recommendation for the use of an intervention “We recommend…” Benefits clearly outweigh risk and burdens; recommendation applies to most patients in most circumstances.
Strong recommendation against the use of an intervention “We recommend against…” Risk and burden clearly outweigh benefits; recommendation applies to most patients in most circumstances.
Good practice statement “We recommend…” Guidance was viewed by the Work Group as imperative to clinical practice and developed when the supporting evidence was considerable but indirect, and the certainty surrounding an intervention’s impact was high with the benefits clearly outweighing the harms (or vice versa). Good Practice Statements are strong recommendations as the certainty surrounding the impact of the recommended intervention is high. Implementation of these strong recommendations is considered to clearly result in beneficial outcomes.7
Conditional recommendation for the use of an intervention “We conditionally recommend…” Benefits are closely balanced with risks and burden; recommendation applies to most patients, but the most appropriate action may differ depending on the patient or other stakeholder values.
Conditional recommendation against the use of an intervention “We conditionally recommend against…” Risks and burden closely balanced with benefits; recommendation applies to most patients, but the most appropriate action may differ depending on the patient or other stakeholder values
Certainty of evidence Wording Implication5,6
High “high certainty evidence” Very confident that the true effect lies close to that of the estimate of the effect.
Moderate “moderate certainty evidence” Moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low “low certainty evidence” Confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect
Very low “very low certainty evidence” The estimate of effect is very uncertain; the true effect may be substantially different from the estimate of effect

Definition

Acne vulgaris is a chronic, inflammatory skin disease of the pilosebaceous unit. Acne primarily presents with open or closed comedones, papules, pustules, or nodules on the face or trunk and may result in pain, erythema, hyperpigmentation, or scars.

Introduction/background

Acne vulgaris is a common skin condition affecting 9.4% of the global population in 2010, representing the eighth most prevalent disease globally. Acne affects approximately 85% of teenagers but can occur in most age groups and can persist into adulthood. The burden of acne, as measured by disability-adjusted life years, ranked second among all skin diseases in 2013. Over 50 million people in the US have acne. In the US, more than 5.1 million Americans sought medical treatment for acne, leading to $846 million in medical costs and $398 million in lost productivity for patients and caregivers in 2013. Acne has important impact on emotional functioning, social functioning, relationships, leisure activities, daily activities, sleep, school, and work., The health-related quality of life impact of acne is comparable to that of chronic conditions such as asthma, psoriasis, and arthritis., Acne is associated with increased risks of stigmatization, bullying, depression, anxiety, poor self-esteem, and suicidal ideation.
Multifactorial pathogenesis of acne involves follicular hyperkeratinization, microbial colonization with Cutibacterium acnes, sebum production, complex inflammatory mechanisms involving both innate and acquired immunity, neuroendocrine mechanisms, and genetic and nongenetic factors. Risk factors for acne development include increasing age during adolescence, family history of acne, and oily skin type.

Acne grading and classification

Numerous acne clinical grading and classification systems have been used in research and clinical settings to assess overall acne disease severity, lesion number and morphologies, affected anatomic sites, and associated secondary changes such as dyspigmentation and scarring. Consistent use of an acne grading and classification system may help facilitate therapeutic decision-making and assess treatment response in clinical practice. Available grading systems include the Investigator Global Assessment (IGA), Leeds revised acne grading system, Global Acne Grading System, Global Acne Severity Scale, and Comprehensive Acne Severity Scale, among others.
While there is no universally accepted acne grading system in clinical settings, the IGA is most commonly used in the US and demonstrates good agreement between clinician and patient ratings. The definition of IGA scales varied over time and will require harmonization efforts to facilitate use and future meta-analyses. The IGA scale has been used in many randomized controlled trials (RCTs) for acne treatments and proposed as a cohesive framework upon which to establish an ideal acne grading system. An ideal acne grading system should measure the types of primary acne lesions, number of lesions, and extent and region of skin involvement and should feature strong psychometric properties, ability to categorize severity via descriptive text or photographs, ease of use, and stakeholder acceptance. Stakeholders from the International Dermatology Outcomes Measures and the American Academy of Dermatology reached consensus on a 5-point ordinal scale (ranging from 0-4: clear, almost clear, mild, moderate, and severe) to quantify severity of acne and other inflammatory dermatoses in routine clinical practice. Descriptors of this scale remain to be standardized and validated for use in facial and truncal acne. Acne severity may also be measured via digital photography, as is increasingly used in clinical practice and trials, as well as fluorescent photography, polarized light photography, video microscopy, and multispectral imaging modalities.
This entry was posted in Acne Vulgaris Management Guidelines, Journal Of The American Academy Of Dermatology. Bookmark the permalink.