Bibliographic Source(s)

• Finnish Medical Society Duodecim. Acne. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2007 Apr 4 [Various].

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Lauharanta J. Acne. In: EBM Guidelines. Evidence-Based Medicine [CD-ROM]. Helsinki Finland: Duodecim Medical Publications Ltd.; 2007 Jan 4 [various].

Guideline Category

Treatment

Intended Users

Health Care Providers
Physicians

Guideline Objective(s)

Evidence-Based Medicine Guidelines collect summarize and update the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations.

Target Population

Patients with acne

Interventions and Practices Considered

Treatment

1. Skin cleansing with soap or antibacterial detergents
2. Treatment of comedonic acne with retinoic acid cream or solution adapalen gel or benzoyl peroxide cream or gel (3 to 10%)
3. Treatment of common acne with local antibiotics (e.g. clindamycin solution) ultraviolet light therapy combination of clindamycin and benzoyl peroxide and systemic treatment as indicated
4. Systemic antibiotics (tetracycline erythromycin)
5. Local treatment and light therapy used simultaneously with systemic treatment
6. Incision and drainage of pus-containing cysts with a large-caliber injection needle or narrow-tipped scalpel
7. Hormonal treatment for women: cyproterone acetate (an anti-androgen) + oestrogen
8. Treatment of scars by skin abrasion or laser therapy (by a dermatologist or a plastic surgeon)
9. Isotretinoin upon recommendation of a dermatologist
10. Consultation with or referral to a dermatologist

Note: Guideline developers considered several other treatment options. For a list of these see the "Major Recommendations" field below.

Major Outcomes Considered

• Efficacy of treatment
• Adverse effects of treatment

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

The evidence reviewed was collected from the Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). In addition the Cochrane Library and medical journals were searched specifically for original publications.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

1. Quality of Evidence: High

   Further research is very unlikely to change confidence in the estimate of effect

   • Several high-quality studies with consistent results
   • In special cases: one large high-quality multi-centre trial

2. Quality of Evidence: Moderate

   Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

   • One high-quality study
   • Several studies with some limitations

3. Quality of Evidence: Low

   Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

   • One or more studies with severe limitations

4. Quality of Evidence: Very Low

   Any estimate of effect is very uncertain.

   • Expert opinion
   • No direct research evidence
   • One or more studies with very severe limitations

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Major Recommendations

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Classification of Acne

• Comedonic acne (a. comedonicus See Picture 1 in the original guideline document)
  • Plenty of open or obstructed comedos but scant inflammatory changes
• Common acne (a. vulgaris) or pustular acne (See Pictures 2 & 3 in the original guideline document)
  • Pustules and comedos
• Cystic acne (a. Cystica See Pictures 4 & 5 in the original guideline document)
  • Cystic foci of infection that result in scars
• Acne conglobata
  • Multilobular inflammatory cysts containing volatile pus
  • Therapy-resistant scar forming
• Acne fulminans
  • An uncommon variant of acne in young men characterized by systemic symptoms (fever arthralgia skeletal foci of inflammation)
  • Systemic corticosteroids not antibiotics are the drugs of choice.
  • Refer patients with suspected acne fulminans to a dermatologist without delay. The painful disease is not well known and is often left untreated for a long time.

Treatment

Local Treatment

• Local treatment is usually sufficient for comedonic acne and mild common acne.
• Wash the skin with soap or antibacterial detergents.
• Comedonic acne can be treated with
  • Retinoic acid cream or solution (tretinoin [Purdy 2005] [A] isotretinoin[ [Purdy 2005] [B])
  • Adapalen gel (Purdy 2005) [C]
  • Benzoyl peroxide (3 to 10%)] (Purdy 2005) [A] cream or gel
  • All above drugs can be irritating at first. Use a low concentration of the active drug initially and advise the patient to wash the drug away after a few hours. The tolerance of the skin increases with time.
• Common acne can be treated with
  • Local antibiotics (e.g. clindamycin solution) (Purdy 2005) [A]
  • Combination gel containing benzoyl peroxide and clindamycin
  • Ultraviolet light therapy (as a course of 15 treatments added to other treatment) for widespread disease
• Consider systemic treatment if the effect of local treatment is unsatisfactory 2 to 3 months from the onset of treatment.

Systemic Treatment

• Antibiotics
  • Tetracycline (Garner et al. 2003) [B] and erythromycin (Purdy 2005) [A] are equally effective. The usual dose is 250 to 500 mg/day for a few months. Six months' treatment with tetracycline or erythromycin 1 g/day is more effective than a shorter treatment with a smaller dose. Do not use tetracyclines in children below 12 years of age.
  • Local treatment and light therapy can be used simultaneously with systemic treatment.
  • Local treatment is not sufficient in cystic acne and conglobate acne. Use systemic antibiotics or consider referral to a dermatologist. Pus-containing cysts can be drained by incising them with a large-caliber injection needle or narrow-tipped scalpel.
• Hormonal treatment for women
  • Cyproterone acetate (an anti-androgen) + oestrogen for 6 months reduce the excretion of sebaceous glands and alleviate acne.

Acne Scars

• Consider treatment of scars by skin abrasion or laser therapy (Jordan Cummins & Burls 1998; Health Technology Assessment Database [HTA]-998502 2001) [D] only after the activity of the disease has totally subsided.
• Scars can be treated either by a dermatologist or a plastic surgeon.

Indications for Specialist Consultation

• Severe forms of acne (a. cystica conglobata fulminans)
• If ordinary treatment fails the dermatologist can consider isotretinoin. However it has considerable teratogenicity. A program called iPLEDGE has been set up to make sure that pregnant women do not take isotretinoin and that women do not become pregnant while taking isotretinoin: see http://www.nlm.nih.gov/medlineplus/print/druginfo/medmaster/a681043.html

Related Resources

Cochrane Reviews

• There is not enough data to evaluate the effectiveness of spironolactone as treatment of acne (Farquhar et al. 2003) [C].

Other Evidence Summaries

• Azelaic acid may be effective in reducing inflammatory lesions and comedones in patients with acne vulgaris (Purdy 2005) [C].
• Topical erythromycin appears to be effective in reducing inflammatory lesions in patients with acne vulgaris (Purdy 2005) [A].
• Topical tetracycline appears to be effective in reducing acne severity but it causes skin discolouration (Purdy 2005) [B].
• Oral doxycycline is as effective as oral minocycline and oral erythromycin in reducing lesions in patients with acne vulgaris (Purdy 2005) [A].

Definitions:

Levels of Evidence

1. Quality of Evidence: High

   Further research is very unlikely to change confidence in the estimate of effect

   • Several high-quality studies with consistent results
   • In special cases: one large high-quality multi-centre trial

2. Quality of Evidence: Moderate

   Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

   • One high-quality study
   • Several studies with some limitations

3. Quality of Evidence: Low

   Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

   • One or more studies with severe limitations

4. Quality of Evidence: Very Low

   Any estimate of effect is very uncertain.

   • Expert opinion
   • No direct research evidence
   • One or more studies with very severe limitations

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Farquhar C Lee O Toomath R Jepson R. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev 2005;(4):CD000194.



• Garner SE Eady EA Popescu C Newton J Li WA. Minocycline for acne vulgaris: efficacy and safety. Cochrane Database Syst Rev 2003;(1):CD002086. [143 references] PubMed



• Jordan R Cummins C Burls A. Laser resurfacing of the skin for improvement of facial acne scarring. Birmingham: Department of Public Health and Epidemiology University of Birmingham. DPHE Report No. 11. West Midlands (Great Britain): Department and Evaluation Service Department of Public Health and Epidemiology (DPHE); 1998. 51 p.



• Purdy S. What are the effects of topical treatments in people with acne vulgaris?. Clin Evid 2005;13:2042-59.



• The Health Technology Assessment Database Database no: HTA-998502. In: The Cochrane Library [database online]. Issue 1. Oxford: Update Software; 2001 

Type of Evidence supporting the Recommendations

Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are. The type of supporting evidence is identified and graded for select recommendations (see the "Major Recommendations" field).

Potential Benefits

Effective treatment of acne

Potential Harms

Adverse Effects of Medication

• Retinoic acid cream or solution adapalen gel and benzoyl peroxide (3 to 10%) can be irritating at first. The tolerance of the skin increases with time.
• Isotretinoin has considerable teratogenicity

Contraindications

Tetracyclines should not be used in children below 12 years of age.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Bibliographic Source(s)

• Finnish Medical Society Duodecim. Acne. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2007 Apr 4 [Various].

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Finnish Medical Society Duodecim

Guideline Committee

Editorial Team of EBM Guidelines

Composition of Group that Authored the Guideline

Primary Author: Jorma Lauharanta

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Lauharanta J. Acne. In: EBM Guidelines. Evidence-Based Medicine [CD-ROM]. Helsinki Finland: Duodecim Medical Publications Ltd.; 2007 Jan 4 [various].

Guideline Availability

This guideline is included in a CD-ROM titled "EBM Guidelines. Evidence-Based Medicine" available from Duodecim Medical Publications Ltd PO Box 713 00101 Helsinki Finland; e-mail: info@ebm-guidelines.com; Web site: www.ebm-guidelines.com.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This summary was completed by ECRI on December 17 2002. The information was verified by the guideline developer as of February 7 2003. This summary was updated by ECRI on March 29 2004 and again on September 29 2004. This summary was updated by ECRI on June 19 2006 following the U.S. Food and Drug Administration (FDA) advisory on Accutane and generic isotretinoin. This NGC summary was updated by ECRI on August 7 2006. This summary was updated by ECRI on November 14 2006 following the updated FDA advisory on iPLEDGE. This NGC summary was updated by ECRI on February 27 2007 and most recently on November 9 2007.

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This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

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