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. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]
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.
Copyright © 2024 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.
Abbreviations used
- AAD (American Academy of Dermatology)
- BP (benzoyl peroxide)
- COC (combined oral contraceptive)
- EE (ethinyl estradiol)
- FDA (Food and Drug Administration)
- IBD (inflammatory bowel disease)
- IGA (Investigator Global Assessment)
- MD (mean difference)
- RCT (randomized controlled trial)
- RR (risk ratio)
- US (United States)
- 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.1,2 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.3 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.4
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.5-7 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
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.9 Acne affects approximately 85% of teenagers but can occur in most age groups and can persist into adulthood.10 The burden of acne, as measured by disability-adjusted life years, ranked second among all skin diseases in 2013.11 Over 50 million people in the US have acne.12 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 2013.1 Acne has important impact on emotional functioning, social functioning, relationships, leisure activities, daily activities, sleep, school, and work.13,14 The health-related quality of life impact of acne is comparable to that of chronic conditions such as asthma, psoriasis, and arthritis.15,16 Acne is associated with increased risks of stigmatization, bullying, depression, anxiety, poor self-esteem, and suicidal ideation.17-20Multifactorial 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.21
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.22 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.23-29
*
While there is no universally accepted acne grading system in clinical settings, the IGA is most commonly used in the US30 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.31 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.32 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.33 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.34 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.35
Beyond signs and symptoms, core acne outcomes measures should also include domains such as satisfaction with appearance, extent of scars/dark marks, satisfaction with treatment received, long-term acne control, adverse events, and health-related quality of life. Acne quality-of-life measures provide a more comprehensive and holistic perspective on the burden of acne on patients’ lives and may not correlate well with clinical acne severity.36 While multiple dermatology-specific and acne-specific health-related quality-of-life measures are available as research tools, shorter measures also exist for use in routine clinical practice.37,38
Beyond signs and symptoms, core acne outcomes measures should also include domains such as satisfaction with appearance, extent of scars/dark marks, satisfaction with treatment received, long-term acne control, adverse events, and health-related quality of life. Acne quality-of-life measures provide a more comprehensive and holistic perspective on the burden of acne on patients’ lives and may not correlate well with clinical acne severity.36 While multiple dermatology-specific and acne-specific health-related quality-of-life measures are available as research tools, shorter measures also exist for use in routine clinical practice.37,38
Microbiological and endocrine testing
C. acnes (formerly Propionibacterium acnes) is a Gram-positive anaerobic rod primarily implicated in acne pathogenesis, with some strains likely pathogenic while others commensal in the skin microbiome.39,40 C. acnes has specific culture requirements that prevent growth in routine bacterial culture. Staphylococcus epidermidis, Staphylococcus aureus, and Malassezia species have also been identified in acne lesions, although causal relationships remain to be demonstrated.41-45While some C. acnes species have developed resistance to antibiotics46,47 and certain strains are more strongly associated with acne, routine microbiologic and/or antibiotic susceptibility testing is not indicated for patients with acne since it does not affect management. Patients presenting with eruptive uniform pustules to nodules in periorificial areas, particularly in settings of prolonged tetracycline treatment, may benefit from lesion culture to diagnose Gram-negative folliculitis. Treatment with isotretinoin or another antibiotic may be required. Microbiologic testing may also be considered for patients presenting with monomorphic truncal papules and pustules to diagnose pityrosporum folliculitis.
Routine endocrinologic testing is not indicated for most patients with acne. Patients who present with acne and clinical signs or symptoms of hyperandrogenism, such as hirsutism, oligomenorrhea or amenorrhea, androgenic alopecia, infertility, polycystic ovaries, clitoromegaly, and truncal obesity may warrant further endocrine testing for hyperandrogenism. Polycystic ovarian syndrome is a common cause of hyperandrogenism, characterized by ovulatory dysfunction or polycystic ovaries on ultrasonography. Tests for serum total and/or free testosterone, dehydroepiandrosterone sulfate, androstenedione, luteinizing hormone, follicle-stimulating hormone may be considered.50-54 For women with hyperandrogenism, screening for nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency by 17-hydroxyprogesterone levels may be indicated.50 Serum growth hormone, insulin-like growth factor, sex hormone-binding globulin, free androgen index, lipid panel, insulin, prolactin, estrogen, and progesterone may also be abnormal in some patients with severe acne.51,54-57 Patients with abnormal endocrine testing or in whom there is a persistent concern for underlying endocrine disorder should be evaluated by an endocrinologist.
Acne management
Treatment options available for acne include topical therapies (available over the counter or as prescriptions), systemic antibiotics, hormonal agents, oral isotretinoin, physical modalities, complementary and alternative medicine, and dietary and environmental interventions. Given the diversity of treatment options for acne, shared decision-making is important to individualize acne care based on the potential treatment benefits and risks, the severity, extent, and region of acne involvement, treatment costs, patient preferences, and other factors (Fig 1).
Fig 1 Management of acne vulgaris.
Topical therapies
Topical therapies are the mainstay of acne treatment: they may be used for acne initial treatment and maintenance as monotherapy (except topical antibiotics) or used in combination with other topical or oral agents. Commonly used topical therapies include topical retinoids, benzoyl peroxide (BP), antibiotics, clascoterone, salicylic acid, and azelaic acid. When managing acne with topical therapies, multimodal therapy combining multiple mechanisms of actions is recommended as a good practice statement to optimize efficacy and to reduce the risk of antibiotic resistance.
Topical retinoids
Topical retinoids are vitamin A derivatives and serve as the cornerstone of acne treatment since they are comedolytic and anti-inflammatory, improve dyspigmentation, and enable maintenance of acne clearance. Four types of topical retinoids, including topical tretinoin,58 adapalene,59 tazarotene,60,61 and trifarotene,62 are FDA-approved for acne treatment in the US. Each retinoid binds to a different set of retinoic acid receptors and confers modest differences in activity, tolerability and efficacy.
We recommend topical retinoids for acne treatment based on moderate certainty evidence from 20 studies (Table III and Supplementary Table XII, available via Mendeley at https://data.mendeley.com/datasets/z2bmdwwdf9/2).59,62-64,71-81,153-155 Compared to vehicle at 12 weeks, a greater proportion of patients treated with topical retinoids achieved IGA success in 4 RCTs (risk ratio [RR], 1.57 [1.21, 2.04]).59,63,64,71 Topical retinoid use may be limited by side effects, including increased risk of burning sensation, dryness, erythema, exfoliation, peeling, and pain. Treatment-emergent adverse events leading to discontinuation at 12 weeks were low (1.4%) in 3 RCTs.63,80,155 Existing comparative effectiveness data do not suggest superiority of one topical retinoid against another, with efficacy and tolerability differing by specific concentrations and formulations.153,156-159 Irritation may be particularly common at higher concentrations, which may be mitigated by reduced frequency of use and concurrent emollients use.160-163 Some tretinoin formulations should be applied in the evening due to its photolabile nature and should not be applied with BP to avoid oxidation and inactivation; topical tretinoin microsphere formulations, adapalene, and tazarotene lack similar restrictions. Topical retinoids may cause photosensitivity; concurrent daily sunscreen use can reduce sunburn risks. Adapalene 0.1% gel is available over the counter while other topical retinoids are available by prescription only.
No. Recommendation Strength Certainty of evidence Evidence Topical agents 1.1 When managing acne with topical medications, we recommend multimodal therapy combining multiple mechanisms of action. Good practice statement 1.2 For patients with acne, we recommend benzoyl peroxide. Strong Moderate 63-70 1.3 For patients with acne, we recommend topical retinoids. Strong Moderate 59,60,62-64,71-83 1.4 For patients with acne, we recommend topical antibiotics
Remark: Topical antibiotic monotherapy is not recommended.Strong Moderate 66,68,69,71,79,84-92 1.5 For patients with acne, we conditionally recommend clascoterone. Conditional∗ High 93,94 1.6 For patients with acne, we conditionally recommend salicylic acid. Conditional Low 95 1.7 For patients with acne, we conditionally recommend azelaic acid. Conditional Moderate 96-98 1.8 For patients with acne, we recommend fixed dose combination topical antibiotic with benzoyl peroxide Strong Moderate 66,68,69,99-106 1.9 For patients with acne, we recommend fixed dose combination topical retinoid with topical antibiotic.
Remark: Concomitant use of benzoyl peroxide is recommended to prevent the development of antibiotic resistance.Strong Moderate 71,79,99,107,108 1.10 For patients with acne, we recommend fixed dose combination topical retinoid with benzoyl peroxide. Strong Moderate 63,64,99,109-113 Systemic antibiotics 2.1 For patients with acne, we recommend doxycycline. Strong Moderate 114-118 2.2 For patients with acne, we conditionally recommend minocycline. Conditional Moderate 114,119-122 2.3 For patients with acne, we conditionally recommend sarecycline. Conditional∗ High 123-125 2.4 For patients with acne, we conditionally recommend doxycycline over azithromycin. Conditional Low 126-129 2.5 For patients with acne, we recommend limiting use of systemic antibiotics when possible to reduce the development of antibiotic resistance and other antibiotic associated complications. Good practice statement 2.6 It is recommended that systemic antibiotics are used concomitantly with benzoyl peroxide and other topical therapy. Good practice statement Hormonal agents 3.1 For patients with acne, we conditionally recommend combined oral contraceptive pills. Conditional† Moderate 130-139 3.2 For patients with acne, we conditionally recommend spironolactone.
Remark: Potassium monitoring is not needed in healthy patients. However, consider potassium testing for those with risk factors for hyperkalemia (e.g., older age, medical comorbidities, medications).Conditional Moderate 140-147 3.3 For patients with larger acne papules or nodules, we recommend intralesional corticosteroid injections as an adjuvant therapy.
Remark: Intralesional corticosteroid injections should be used judiciously for patients who are at risk of acne scarring and/or for rapid improvement in inflammation and pain. Using a lower concentration and volume of corticosteroid can minimize the risks of local corticosteroid adverse events.Good practice statement Isotretinoin 4.1 For patients with severe acne or for patients who have failed standard treatment with oral or topical therapy, we recommend isotretinoin.
Remark: Acne patients with psychosocial burden or scarring should be considered as having severe acne and to be candidates for isotretinoin. For patients undergoing treatment with isotretinoin, monitoring of LFTs and lipids should be considered, but CBC monitoring is not needed in healthy patients. Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease in acne patients undergoing treatment with isotretinoin. For persons of childbearing potential, pregnancy prevention is mandatory.Good practice statement 4.2 For patients with severe acne, we conditionally recommend traditional daily dosing of isotretinoin over intermittent dosing of isotretinoin. Conditional Low 148-150 4.3 For patients prescribed isotretinoin, we conditionally recommend either standard isotretinoin or lidose-isotretinoin. Conditional High 151 Physical modalities 5.1 For patients with acne, we conditionally recommend against adding pneumatic broadband light to adapalene 0.3% gel. Conditional Low 152 Table IIIRecommendation for the management of acne vulgaris in adults, adolescents, and preadolescents (≥9 years)
No. Recommendation Strength Certainty of evidence Evidence Topical agents 1.1 When managing acne with topical medications, we recommend multimodal therapy combining multiple mechanisms of action. Good practice statement 1.2 For patients with acne, we recommend benzoyl peroxide. Strong Moderate 63-70 1.3 For patients with acne, we recommend topical retinoids. Strong Moderate 59,60,62-64,71-83 1.4 For patients with acne, we recommend topical antibiotics
Remark: Topical antibiotic monotherapy is not recommended.Strong Moderate 66,68,69,71,79,84-92 1.5 For patients with acne, we conditionally recommend clascoterone. Conditional∗ High 93,94 1.6 For patients with acne, we conditionally recommend salicylic acid. Conditional Low 95 1.7 For patients with acne, we conditionally recommend azelaic acid. Conditional Moderate 96-98 1.8 For patients with acne, we recommend fixed dose combination topical antibiotic with benzoyl peroxide Strong Moderate 66,68,69,99-106 1.9 For patients with acne, we recommend fixed dose combination topical retinoid with topical antibiotic.
Remark: Concomitant use of benzoyl peroxide is recommended to prevent the development of antibiotic resistance.Strong Moderate 71,79,99,107,108 1.10 For patients with acne, we recommend fixed dose combination topical retinoid with benzoyl peroxide. Strong Moderate 63,64,99,109-113 Systemic antibiotics 2.1 For patients with acne, we recommend doxycycline. Strong Moderate 114-118 2.2 For patients with acne, we conditionally recommend minocycline. Conditional Moderate 114,119-122 2.3 For patients with acne, we conditionally recommend sarecycline. Conditional∗ High 123-125 2.4 For patients with acne, we conditionally recommend doxycycline over azithromycin. Conditional Low 126-129 2.5 For patients with acne, we recommend limiting use of systemic antibiotics when possible to reduce the development of antibiotic resistance and other antibiotic associated complications. Good practice statement 2.6 It is recommended that systemic antibiotics are used concomitantly with benzoyl peroxide and other topical therapy. Good practice statement Hormonal agents 3.1 For patients with acne, we conditionally recommend combined oral contraceptive pills. Conditional† Moderate 130-139 3.2 For patients with acne, we conditionally recommend spironolactone.
Remark: Potassium monitoring is not needed in healthy patients. However, consider potassium testing for those with risk factors for hyperkalemia (e.g., older age, medical comorbidities, medications).Conditional Moderate 140-147 3.3 For patients with larger acne papules or nodules, we recommend intralesional corticosteroid injections as an adjuvant therapy.
Remark: Intralesional corticosteroid injections should be used judiciously for patients who are at risk of acne scarring and/or for rapid improvement in inflammation and pain. Using a lower concentration and volume of corticosteroid can minimize the risks of local corticosteroid adverse events.Good practice statement Isotretinoin 4.1 For patients with severe acne or for patients who have failed standard treatment with oral or topical therapy, we recommend isotretinoin.
Remark: Acne patients with psychosocial burden or scarring should be considered as having severe acne and to be candidates for isotretinoin. For patients undergoing treatment with isotretinoin, monitoring of LFTs and lipids should be considered, but CBC monitoring is not needed in healthy patients. Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease in acne patients undergoing treatment with isotretinoin. For persons of childbearing potential, pregnancy prevention is mandatory.Good practice statement 4.2 For patients with severe acne, we conditionally recommend traditional daily dosing of isotretinoin over intermittent dosing of isotretinoin. Conditional Low 148-150 4.3 For patients prescribed isotretinoin, we conditionally recommend either standard isotretinoin or lidose-isotretinoin. Conditional High 151 Physical modalities 5.1 For patients with acne, we conditionally recommend against adding pneumatic broadband light to adapalene 0.3% gel. Conditional Low 152 ∗ Conditional recommendations were made for clascoterone and sarecycline due to high current cost of treatment that may impact equitable acne treatment access.† Conditional recommendation was made for combined oral contraceptive pills due to the variability in patient values and preferences related to contraception and hormonal medications.
