Bibliographic Source(s)

• Strauss JS Krowchuk DP Leyden JJ Lucky AW Shalita AR Siegfried EC Thiboutot DM Van Voorhees AS Beutner KA Sieck CK Bhushan R American Academy of Dermatology/American Academy of Dermatology. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007 Apr;56(4):651-63. [180 references] PubMed

Guideline Status

This is the current release of the guideline.

Guideline Category

Evaluation
Management
Treatment

Intended Users

Physicians

Guideline Objective(s)

To address the management of adolescent and adult patients presenting with acne but not the consequences of disease including the scarring post-inflammatory erythema or postinflammatory hyperpigmentation

Target Population

Adolescents and adults with acne vulgaris i.e. open and/or closed comedones (blackheads and whiteheads) and inflammatory lesions including papules pustules or nodules

Interventions and Practices Considered

Classification/Evaluation

1. Use of consistent classification/grading scale
2. Microbiologic testing
3. Endocrinologic testing

Therapy

1. Topical therapy
   • Retinoids
   • Benzoyl peroxide
   • Topical antibiotics (erythromycin and clindamycin)
   • Salicylic acid
   • Other topical agents
   • Combination topical agents
2. Systemic antibiotics
   • Tetracyclines (minocycline doxycycline)
   • Macrolide antibiotics (erythromycin)
   • Trimethoprim-sulfamethoxazole
3. Hormonal agents
   • Estrogen-containing oral contraceptives
   • Anti-androgens (spironolactone cyproterone acetate and flutamide)
   • Oral corticosteroids
4. Isotretinoin
5. Miscellaneous therapy
   • Intralesional steroids
   • Chemical peels
   • Comedo removal
6. Complementary therapy
   • Herbal agents
   • Psychological approaches
   • Hypnosis/biofeedback
7. Dietary restrictions (not recommended)

Major Outcomes Considered

• Usefulness reliability and sensitivity of acne severity grading scales
• Usefulness of endocrinologic and microbiologic testing
• Number of lesions
• Severity of lesions
• Psychological and emotional improvement
• Adverse effects of treatment

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

A work group of recognized experts was convened to determine the audience for the guidelines define the scope of the guidelines and identify nine clinical questions to structure the primary issues in diagnosis and management.

An evidence-based model was used and some evidence was obtained by a vendor using a search of MEDLINE and EMBASE databases spanning the years 1970 through 2006. Only English-language publications were reviewed.

Number of Source Documents

300

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Evidence was graded using a three-point scale based on the quality of methodology as follows:

1. Good quality patient-oriented evidence
2. Limited quality patient-oriented evidence
3. Other evidence including consensus guidelines extrapolations from bench research opinion or case studies

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The available evidence was evaluated using a unified system called the Strength of Recommendation Taxonomy (SORT) developed by editors of the US family medicine and primary care journals (i.e. American Family Physician Family Medicine Journal of Family Practice and BMJ-USA). This strategy was supported by a decision of the Clinical Guidelines Task Force in 2005 with some minor modifications for a consistent approach to rating the strength of the evidence of scientific studies.

For each intervention within the Clinical Questions an effort was made to identify and present the best evidence regarding its use in the treatment of acne. Studies of clinical measurements of outcome were considered for analysis whether or not the clinical outcome was the primary outcome measured.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Clinical recommendations were developed on the best available evidence tabled in the guidelines and explained further in the companion document Guideline of Care for Acne Vulgaris Management Technical Report.

Rating Scheme for the Strength of the Recommendations

1. Recommendation based on consistent and good quality patient-oriented evidence.
2. Recommendation based on inconsistent or limited quality patient-oriented evidence.
3. Recommendation based on consensus opinion or case studies.

Cost Analysis

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

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

These guidelines have been developed in accordance with the American Academy of Dermatology (AAD)/American Academy of Dermatology Association "Administrative Regulations for Evidence-Based Clinical Practice Guidelines" which include the opportunity for review and comment by the entire AAD membership and final review and approval by the AAD Board of Directors.

Major Recommendations

Level of evidence grades (I-III) and strength of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

1. Systems for the Grading and Classification of Acne
   • Clinicians may find it helpful to use a consistent classification/grading scale (encompassing the numbers and types of acne lesions as well as disease severity) to facilitate therapeutic decisions and assess response to treatment.

2. Microbiologic and Endocrinologic Testing

   Microbiologic Testing

   • Routine microbiologic testing is unnecessary in the evaluation and management of patients with acne.
   • Those who exhibit acne-like lesions suggestive of gram-negative folliculitis may benefit from microbiologic testing.

   Recommendation	Strength of Recommendation	Level of Evidence	References
   Microbiologic testing	B	II	Cove Cunliffe & Holland 1980; Bojar et al. 1995; Eady et al. 1989; Harkaway et al. 1992

   Endocrinologic Testing

   • Routine endocrinologic evaluation (e.g. for androgen excess) is not indicated for the majority of patients with acne. Laboratory evaluation is indicated for patients who have acne and additional signs of androgen excess. In young children this may be manifested by body odor axillary or pubic hair and clitoromegaly. Adult women with symptoms of hyperandrogenism may present with recalcitrant or late-onset acne infrequent menses hirsutism male or female pattern alopecia infertility acanthosis nigricans and truncal obesity.

   Recommendation	Strength of Recommendation	Level of Evidence	References
   Endocrinologic testing	A	I	Lawrence et al. 1981; Lucky et al. "Predictors" 1997

3. Topical Therapy
   • Topical therapy is a standard of care in acne treatment.
   • Topical retinoids are important in acne treatment.
   • Benzoyl peroxide and combinations with erythromycin or clindamycin are effective acne treatments.
   • Topical antibiotics (e.g. erythromycin and clindamycin) are effective acne treatments. However the use of these agents alone can be associated with the development of bacterial resistance.
   • Salicylic acid is moderately effective in the treatment of acne.
   • Azelaic acid has been shown to be effective in clinical trials but its clinical use compared to other agents has limited efficacy according to experts.
   • Data from peer-reviewed literature regarding the efficacy of sulfur resorcinol sodium sulfacetamide aluminum chloride and zinc are limited.
   • Employing multiple topical agents that affect different aspects of acne pathogenesis can be useful. However it is the opinion of the work group that such agents not be applied simultaneously unless they are known to be compatible.

4. Systemic Antibiotics
   • Systemic antibiotics are a standard of care in the management of moderate and severe acne and treatment-resistant forms of inflammatory acne.
   • Doxycycline and minocycline are more effective than tetracycline and there is evidence that minocycline is superior to doxycycline in reducing Propionibacterium acnes.
   • Although erythromycin is effective use should be limited to those who cannot use the tetracyclines (i.e. pregnant women or children under 8 years of age because of the potential for damage to the skeleton or teeth). The development of bacterial resistance is also common during erythromycin therapy.
   • Trimethoprim-sulfamethoxazole and trimethoprim alone are also effective in instances where other antibiotics cannot be used.
   • Bacterial resistance to antibiotics is an increasing problem.
   • The incidence of significant adverse effects with antibiotic use is low. However adverse effect profiles may be helpful for each systemic antibiotic used in the treatment of acne.

5. Hormonal Agents
   • Estrogen-containing oral contraceptives can be useful in the treatment of acne in some women.
   • Oral antiandrogens such as spironolactone and cyproterone acetate can be useful in the treatment of acne. While flutamide can be effective hepatic toxicity limits its use. There is no evidence to support the use of finasteride.
   • There are limited data to support the effectiveness of oral corticosteroids in the treatment of acne. There is a consensus of expert opinion that oral corticosteroid therapy is of temporary benefit in patients who have severe inflammatory acne.
   • In patients who have well-documented adrenal hyperandrogenism low-dose oral corticosteroids may be useful in treatment of acne.

6. Isotretinoin
   • Oral isotretinoin is approved for the treatment of severe recalcitrant nodular acne.
   • It is the unanimous opinion of the acne work-group that oral isotretinoin is also useful for the management of lesser degrees of acne that are treatment-resistant or for the management of acne that is producing either physical or psychological scarring.
   • Oral isotretinoin is a potent teratogen. Because of its teratogenicity and the potential for many other adverse effects this drug should be prescribed only by those physicians knowledgeable in its appropriate administration and monitoring.
   • Female patients of child-bearing potential must only be treated with oral isotretinoin if they are participating in the approved pregnancy prevention and management program (iPLEDGE*).
   • Mood disorders depression suicidal ideation and suicides have been reported in patients taking this drug. However a causal relationship has not been established.

   *Because of the teratogenic effects of isotretinoin on the fetus the FDA and the manufacturers have approved a new risk management program for isotretinoin. Prescribers patients pharmacies drug wholesalers and manufacturers in the United States are required to register and comply with the iPLEDGE program. This program requires mandatory registration of all patients receiving this drug. Detailed information can be found on the iPLEDGE web site (www.ipledgeprogram.com).

7. Miscellaneous Therapy
   • Intralesional corticosteroid injections are effective in the treatment of individual acne nodules.
   • There is limited evidence regarding the benefit of physical modalities including glycolic acid peels and salicylic acid peels.

8. Complementary Therapy
   • Herbal and alternative therapies have been used to treat acne. Although these products appear to be well tolerated very limited data exist regarding the safety and efficacy of these agents.

9. Dietary Restriction
   • Dietary restriction (either specific foods or food classes) has not been demonstrated to be of benefit in the treatment of acne.

Definitions:

Levels of Evidence

1. Good quality patient-oriented evidence
2. Limited quality patient-oriented evidence
3. Other evidence including consensus guidelines extrapolations from bench research opinion or case studies

Strength of Recommendations

1. Recommendation based on consistent and good quality patient-oriented evidence.
2. Recommendation based on inconsistent or limited quality patient-oriented evidence.
3. Recommendation based on consensus opinion or case studies.

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Allen BS Smith JG Jr. Various parameters for grading acne vulgaris. Arch Dermatol 1982 Jan;118(1):23-5. PubMed



• Bassett IB Pannowitz DL Barnetson RS. A comparative study of tea-tree oil versus benzoylperoxide in the treatment of acne. Med J Aust 1990 Oct 15;153(8):455-8. PubMed



• Becker LE Bergstresser PR Whiting DA Clendenning WE Dobson RL Jordan WP Abell E LeZotte LA Pochi PE Shupack JL Sigafoes RB Stoughton RB Voorhees JJ. Topical clindamycin therapy for acne vulgaris. A cooperative clinical study. Arch Dermatol 1981 Aug;117(8):482-5. PubMed



• Belknap BS. Treatment of acne with 5% benzoyl peroxide gel or 0.05% retinoic acid cream. Cutis 1979 Jun;23(6):856-9. PubMed



• Bernstein JE Shalita AR. Topically applied erythromycin in inflammatory acne vulgaris. J Am Acad Dermatol 1980 Apr;2(4):318-21. PubMed



• Bett DG Morland J Yudkin J. Sugar consumption in acne vulgaris and seborrhoeic dermatitis. Br Med J 1967 Jul 15;3(5558):153-5. PubMed



• Blaney DJ Cook CH. Topical use of tetracycline in the treatment of acne: a double-blind study comparing topical and oral tetracycline therapy and placebo. Arch Dermatol 1976 Jul;112(7):971-3. PubMed



• Bojar RA Hittel N Cunliffe WJ Holland KT. Direct analysis of resistance in the cutaneous microflora during treatment of acne vulgaris with topical 1% nadifloxacin and 2% erythromycin. Drugs 1995;49 Suppl 2:164-7. PubMed



• Chalker DK Lesher JL Jr Smith JG Jr Klauda HC Pochi PE Jacoby WS Yonkosky DM Voorhees JJ Ellis CN Matsuda-John S et al.. Efficacy of topical isotretinoin 0.05% gel in acne vulgaris: results of a multicenter double-blind investigation. J Am Acad Dermatol 1987 Aug;17(2 Pt 1):251-4. PubMed



• Chalker DK Shalita A Smith JG Jr Swann RW. A double-blind study of the effectiveness of a 3% erythromycin and 5% benzoyl peroxide combination in the treatment of acne vulgaris. J Am Acad Dermatol 1983 Dec;9(6):933-6. PubMed



• Christian GL Krueger GG. Clindamycin vs placebo as adjunctive therapy in moderately severe acne. Arch Dermatol 1975 Aug;111(8):997-1000. PubMed



• Christiansen JV Gadborg E Ludvigsen K Meier CH Norholm A Pedersen D Rasmussen KA Reiter H Reymann F Sylvest B Unna P Wehnert R Holm P. Topical tretinoin vitamin A acid (Airol) in acne vulgaris. A controlled clinical trial. Dermatologica 1974;148(2):82-9. PubMed



• Cook CH Centner RL Michaels SE. An acne grading method using photographic standards. Arch Dermatol 1979 May;115(5):571-5. PubMed



• Cove JH Cunliffe WJ Holland KT. Acne vulgaris: is the bacterial population size significant. Br J Dermatol 1980 Mar;102(3):277-80. PubMed



• Dai WS LaBraico JM Stern RS. Epidemiology of isotretinoin exposure during pregnancy. J Am Acad Dermatol 1992 Apr;26(4):599-606. PubMed



• Dobson RL Belknap BS. Topical erythromycin solution in acne. Results of a multiclinic trial. J Am Acad Dermatol 1980 Nov;3(5):478-82. PubMed



• Doshi A Zaheer A Stiller MJ. A comparison of current acne grading systems and proposal of a novel system. Int J Dermatol 1997 Jun;36(6):416-8. PubMed



• Eady EA Cove JH Holland KT Cunliffe WJ. Erythromycin resistant propionibacteria in antibiotic treated acne patients: association with therapeutic failure. Br J Dermatol 1989 Jul;121(1):51-7. PubMed



• Ellerbroek WC. Hypotheses toward a unified field theory of human behavior with clinical application to acne vulgaris. Perspect Biol Med 1973 Winter;16(2):240-62. PubMed



• Fulton JE Jr Plewig G Kligman AM. Effect of chocolate on acne vulgaris. JAMA 1969 Dec 15;210(11):2071-4. PubMed



• Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ. Comparative efficacy of oral erythromycin versus oral tetracycline in the treatment of acne vulgaris. A double-blind study. J Am Acad Dermatol 1986 Feb;14(2 Pt 1):183-6. PubMed



• Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW Lucky AW Reed BR Siegfried EC Thiboutot DM Wheeland RG American Academy of Dermatology. American Academy of Dermatology Consensus Conference on the safe and optimal use of isotretinoin: summary and recommendations [published erratum appears in J Am Acad Derm 2004;51:348]. J Am Acad Dermatol 2004 Jun;50(6):900-6. [4 references] PubMed



• Goulden V Clark SM McGeown C Cunliffe WJ. Treatment of acne with intermittent isotretinoin. Br J Dermatol 1997 Jul;137(1):106-8. PubMed



• Gratton D Raymond GP Guertin-Larochelle S Maddin SW Leneck CM Warner J Collins JP Gaudreau P Bendl BJ. Topical clindamycin versus systemic tetracycline in the treatment of acne. Results of a multiclinic trial. J Am Acad Dermatol 1982 Jul;7(1):50-3. PubMed



• Greenwood R Brummitt L Burke B Cunliffe WJ. Acne: double blind clinical and laboratory trial of tetracycline oestrogen-cyproterone acetate and combined treatment. Br Med J (Clin Res Ed) 1985 Nov 2;291(6504):1231-5. PubMed



• Grimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups. Dermatol Surg 1999 Jan;25(1):18-22. PubMed



• Harkaway KS McGinley KJ Foglia AN Lee WL Fried F Shalita AR Leyden JJ. Antibiotic resistance patterns in coagulase-negative staphylococci after treatment with topical erythromycin benzoyl peroxide and combination therapy. Br J Dermatol 1992 Jun;126(6):586-90. PubMed



• Hersle K. Trimethoprim-sulphamethoxazole in acne vulgaris. A double-blind study. Dermatologica 1972;145(3):187-91. PubMed



• Hjorth N Graupe K. Azelaic acid for the treatment of acne. A clinical comparison with oral tetracycline. Acta Derm Venereol Suppl (Stockh) 1989;143:45-8. PubMed



• Hughes H Brown BW Lawlis GF Fulton JE Jr. Treatment of acne vulgaris by biofeedback relaxation and cognitive imagery. J Psychosom Res 1983;27(3):185-91. PubMed



• Jones EL Crumley AF. Topical erythromycin vs blank vehicle in a multiclinic acne study. Arch Dermatol 1981 Sep;117(9):551-3. PubMed



• Kim SW Moon SE Kim JA Eun HC. Glycolic acid versus Jessner's solution: which is better for facial acne patients? A randomized prospective clinical trial of split-face model therapy. Dermatol Surg 1999 Apr;25(4):270-3. PubMed



• Lalla JK Nandedkar SY Paranjape MH Talreja NB. Clinical trials of ayurvedic formulations in the treatment of acne vulgaris. J Ethnopharmacol 2001 Nov;78(1):99-102. PubMed



• Lawrence DM Katz M Robinson TW Newman MC McGarrigle HH Shaw M Lachelin GC. Reduced sex hormone binding globulin and derived free testosterone levels in women with severe acne. Clin Endocrinol (Oxf) 1981 Jul;15(1):87-91. PubMed



• Lehmann HP Robinson KA Andrews JS Holloway V Goodman SN. Acne therapy: a methodologic review. J Am Acad Dermatol 2002 Aug;47(2):231-40. [17 references] PubMed



• Lehucher-Ceyrac D Weber-Buisset MJ. Isotretinoin and acne in practice: a prospective analysis of 188 cases over 9 years. Dermatology 1993;186(2):123-8. PubMed



• Lesher JL Jr Chalker DK Smith JG Jr Guenther LC Ellis CN Voorhees JJ Shalita AR Klauda HC. An evaluation of a 2% erythromycin ointment in the topical therapy of acne vulgaris. J Am Acad Dermatol 1985 Mar;12(3):526-31. PubMed



• Levine RM Rasmussen JE. Intralesional corticosteroids in the treatment of nodulocystic acne. Arch Dermatol 1983 Jun;119(6):480-1. PubMed



• Lewis-Jones MS Finlay AY. The Children's Dermatology Life Quality Index (CDLQI): initial validation and practical use. Br J Dermatol 1995 Jun;132(6):942-9. PubMed



• Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME. Efficacy of a low-dose oral contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the treatment of moderate acne: A randomized placebo-controlled trial. J Am Acad Dermatol 2002 Sep;47(3):399-409. PubMed



• Leyden JJ Shalita AR Saatjian GD Sefton J. Erythromycin 2% gel in comparison with clindamycin phosphate 1% solution in acne vulgaris. J Am Acad Dermatol 1987 Apr;16(4):822-7. PubMed



• Lookingbill DP Chalker DK Lindholm JS Katz HI Kempers SE Huerter CJ Swinehart JM Schelling DJ Klauda HC. Treatment of acne with a combination clindamycin/benzoyl peroxide gel compared with clindamycin gel benzoyl peroxide gel and vehicle gel: combined results of two double-blind investigations. J Am Acad Dermatol 1997 Oct;37(4):590-5. PubMed



• Lucky AW Biro FM Simbartl LA Morrison JA Sorg NW. Predictors of severity of acne vulgaris in young adolescent girls: results of a five-year longitudinal study. J Pediatr 1997 Jan;130(1):30-9. PubMed



• Lucky AW Cullen SI Jarratt MT Quigley JW. Comparative efficacy and safety of two 0.025% tretinoin gels: results from a multicenter double-blind parallel study. J Am Acad Dermatol 1998 Apr;38(4):S17-23. PubMed



• Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ. Effectiveness of norgestimate and ethinyl estradiol in treating moderate acne vulgaris. J Am Acad Dermatol 1997 Nov;37(5 Pt 1):746-54. PubMed



• McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ Hunter JR Dinan BJ Jick H. An observational study of isotretinoin recipients treated for acne in a health maintenance organization. Arch Dermatol 1991 Mar;127(3):341-6. PubMed



• Miller JA Wojnarowska FT Dowd PM Ashton RE O'Brien TJ Griffiths WA Jacobs HS. Anti-androgen treatment in women with acne: a controlled trial. Br J Dermatol 1986 Jun;114(6):705-16. PubMed



• Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ. Sequential antibiotic therapy for acne promotes the carriage of resistant staphylococci on the skin of contacts. J Antimicrob Chemother 1996 Nov;38(5):829-37. PubMed



• Mills O Jr Thornsberry C Cardin CW Smiles KA Leyden JJ. Bacterial resistance and therapeutic outcome following three months of topical acne therapy with 2% erythromycin gel versus its vehicle. Acta Derm Venereol 2002;82(4):260-5. PubMed



• Mills OH Jr Kligman AM Pochi P Comite H. Comparing 2.5% 5% and 10% benzoyl peroxide on inflammatory acne vulgaris. Int J Dermatol 1986 Dec;25(10):664-7. PubMed



• Muhlemann MF Carter GD Cream JJ Wise P. Oral spironolactone: an effective treatment for acne vulgaris in women. Br J Dermatol 1986 Aug;115(2):227-32. PubMed



• Nader S Rodriguez-Rigau LJ Smith KD Steinberger E. Acne and hyperandrogenism: impact of lowering androgen levels with glucocorticoid treatment. J Am Acad Dermatol 1984 Aug;11(2 Pt 1):256-9. PubMed



• Olson WH Lippman JS Robisch DM. The duration of response to norgestimate and ethinyl estradiol in the treatment of acne vulgaris. Int J Fertil Womens Med 1998 Nov-Dec;43(6):286-90. PubMed



• Paranjpe P Kulkarni PH. Comparative efficacy of four Ayurvedic formulations in the treatment of acne vulgaris: a double-blind randomised placebo-controlled clinical evaluation. J Ethnopharmacol 1995 Dec 15;49(3):127-32. PubMed



• Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG Windhorst DB Cheripko J. Isotretinoin versus placebo in the treatment of cystic acne. A randomized double-blind study. J Am Acad Dermatol 1982 Apr;6(4 Pt 2 Suppl):735-45. PubMed



• Pepall LM Cosgrove MP Cunliffe WJ. Ablation of whiteheads by cautery under topical anaesthesia. Br J Dermatol 1991 Sep;125(3):256-9. PubMed



• Pochi PE Bagatell FK Ellis CN Stoughton RB Whitmore CG Saatjian GD Sefton J. Erythromycin 2 percent gel in the treatment of acne vulgaris. Cutis 1988 Feb;41(2):132-6. PubMed



• Pochi PE Shalita AR Strauss JS Webster SB Cunliffe WJ Katz HI Kligman AM Leyden JJ Lookingbill DP Plewig G et al.. Report of the Consensus Conference on Acne Classification. Washington D.C. March 24 and 25 1990. J Am Acad Dermatol 1991 Mar;24(3):495-500. [12 references] PubMed



• Potter RA. Intralesional triamcinolone and adrenal suppression in acne vulgaris. J Invest Dermatol 1971 Dec;57(6):364-70. PubMed



• Prince RA Busch DA Hepler CD Feldick HG. Clinical trial of topical erythromycin in inflammatory acne. Drug Intell Clin Pharm 1981 May;15(5):372-6. PubMed



• Rubinow DR Peck GL Squillace KM Gantt GG. Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin. J Am Acad Dermatol 1987 Jul;17(1):25-32. PubMed



• Schutte H Cunliffe WJ Forster RA. The short-term effects of benzoyl peroxide lotion on the resolution of inflamed acne lesions. Br J Dermatol 1982 Jan;106(1):91-4. PubMed



• Shalita AR Chalker DK Griffith RF Herbert AA Hickman JG Maloney JM Miller BH Tschen EH Chandraratna RA Gibson JR Lew-Kaya DA Lue JC Sefton J. Tazarotene gel is safe and effective in the treatment of acne vulgaris: a multicenter double-blind vehicle-controlled study. Cutis 1999 Jun;63(6):349-54. PubMed



• Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J Powala C Ashley R. Effects of subantimicrobial-dose doxycycline in the treatment of moderate acne. Arch Dermatol 2003 Apr;139(4):459-64. PubMed



• Smith EB Padilla RS McCabe JM Becker LE. Benzoyl peroxide lotion (20 percent) in acne. Cutis 1980 Jan;25(1):90-2. PubMed



• Smith JG Jr Chalker DK Wehr RF. The effectiveness of topical and oral tetracycline for acne. South Med J 1976 Jun;69(6):695-7. PubMed



• Stoughton RB Cornell RC Gange RW Walter JF. Double-blind comparison of topical 1 percent clindamycin phosphate (Cleocin T) and oral tetracycline 500 mg/day in the treatment of acne vulgaris. Cutis 1980 Oct;26(4):424-5 429. PubMed



• Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM Lowe NJ Jones TM Stewart DM Jarratt MT Katz I Pariser DM Pariser RJ Tschen E Chalker DK Rafal ES Savin RP Roth HL Chang LK Baginski DJ Kempers S McLane J Eberhardt D Leach EE Bryce G Hong J. A randomized trial of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in patients with severe recalcitrant nodular acne. J Am Acad Dermatol 2001 Aug;45(2):187-95. PubMed



• Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM Lowe NJ Jones TM Stewart DM Jarratt MT Katz I Pariser DM Pariser RJ Tschen E Chalker DK Rafal ES Savin RP Roth HL Chang LK Baginski DJ Kempers S McLane J Eberhardt D Leach EE Bryce G Hong J. Safety of a new micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne: A randomized trial comparing micronized isotretinoin with standard isotretinoin. J Am Acad Dermatol 2001 Aug;45(2):196-207. PubMed



• Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD. A randomized controlled trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for acne treatment. Fertil Steril 2001 Sep;76(3):461-8. PubMed



• Tschen EH Katz HI Jones TM Monroe EW Kraus SJ Connolly MA Levy SF. A combination benzoyl peroxide and clindamycin topical gel compared with benzoyl peroxide clindamycin phosphate and vehicle in the treatment of acne vulgaris. Cutis 2001 Feb;67(2):165-9. PubMed



• Wang CM Huang CL Hu CT Chan HL. The effect of glycolic acid on the treatment of acne in Asian skin. Dermatol Surg 1997 Jan;23(1):23-9. PubMed



• Zouboulis CC Derumeaux L Decroix J Maciejewska-Udziela B Cambazard F Stuhlert A. A multicentre single-blind randomized comparison of a fixed clindamycin phosphate/tretinoin gel formulation (Velac) applied once daily and a clindamycin lotion formulation (Dalacin T) applied twice daily in the topical treatment of acne vulgaris. Br J Dermatol 2000 Sep;143(3):498-505. PubMed

Type of Evidence supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Potential Benefits

Appropriate management of acne vulgaris

Potential Harms

Topical Antibiotics

The use of topical antibiotics alone can be associated with the development of bacterial resistance.

Oral Antibiotics

• A major problem affecting antibiotic therapy of acne has been bacterial resistance which has been increasing. Resistance has been seen with all antibiotics but is most common with erythromycin.
• The use of oral antibiotics for the treatment of acne may be associated with adverse effects. Vaginal candidiasis may complicate the use of all oral antibiotics. Doxycycline can be associated with photosensitivity. Minocycline has been associated with pigment deposition in the skin mucous membranes and teeth particularly among patients receiving long-term therapy and/or higher doses of the medication. Pigmentation occurs most often in acne scars anterior shins and mucous membranes. Autoimmune hepatitis a systemic lupus erythematosus-like syndrome and serum sickness-like reactions occur rarely with minocycline.

Hormonal Agents

• While flutamide can be effective hepatic toxicity limits its use.
• Spironolactone may cause hyperkalemia particularly when higher doses are prescribed or when there is cardiac or renal compromise. It occasionally causes menstrual irregularity.

Isotretinoin

• Oral isotretinoin is a potent teratogen.
• Side effects include those of the mucocutaneous musculoskeletal and ophthalmic systems as well as headaches and central nervous system effects. Most of the adverse effects are temporary and resolve after the drug is discontinued.
• While hyperostosis premature epiphyseal closure and bone demineralization have been observed with prolonged use of higher dose retinoids in the usual course of acne treatment these findings have not been identified. Therefore it is the unanimous opinion of the acne work group that routine screening for these issues is not required. Laboratory monitoring during therapy should include triglycerides cholesterol transaminase and complete blood counts.
• Changes in mood suicidal ideation and suicide have been reported sporadically in patients taking isotretinoin. While these events have been seen a causal relationship has not been established. Nonetheless patients must be made aware of this possibility and treating physicians should monitor patients for psychiatric adverse effects.

Intralesional Steroids

Systemic absorption of steroids may occur. Adrenal suppression was observed in one study. The injection of intralesional steroids may be associated with local atrophy.

Qualifying Statements

• Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient.
• This report reflects the best available data at the time the report was prepared but caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness

Bibliographic Source(s)

• Strauss JS Krowchuk DP Leyden JJ Lucky AW Shalita AR Siegfried EC Thiboutot DM Van Voorhees AS Beutner KA Sieck CK Bhushan R American Academy of Dermatology/American Academy of Dermatology. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007 Apr;56(4):651-63. [180 references] PubMed

Adaptation

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

Source(s) of Funding

American Academy of Dermatology operational funds and member volunteer time supported the development of this guideline.

Guideline Committee

American Academy of Dermatology Work Group
American Academy of Dermatology Clinical Guidelines Task Force

Composition of Group that Authored the Guideline

Work Group Members: John S. Strauss MD Chair Department of Dermatology Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City; Daniel P. Krowchuk MD Departments of Pediatrics and Dermatology Wake Forest University School of Medicine Brenner Children's Hospital Winston-Salem; James J. Leyden MD Department of Dermatology University of Pennsylvania Hospital Philadelphia; Anne W. Lucky MD Division of Pediatric Dermatology Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine Cincinnati; Alan R. Shalita MD Department of Dermatology State University of New York Downstate Medical Center Brooklyn; Elaine C. Siegfried MD Department of Dermatology St Louis University School of Medicine St Louis; Diane M. Thiboutot MD Department of Dermatology Pennsylvania State University College of Medicine Milton S. Hershey Medical Center Hershey; Abby S. Van Voorhees MD Department of Dermatology University of Pennsylvania Hospital Philadelphia; Karl A. Beutner MD PhD Anacor Pharmaceuticals Inc Palo Alto; Carol K. Sieck RN MSN American Academy of Dermatology Schaumburg; Reva Bhushan PhD American Academy of Dermatology Schaumburg

Task Force Members: Karl A. Beutner MD PhD Chair; Mark A. Bechtel MD; Michael E. Bigby MD; Craig A. Elmets MD; Steven R. Feldman MD PhD; Joel M. Gelfand MD; Brad P. Glick DO MPH; Cindy F. Hoffman DO; Judy Y. Hu MD; Jacqueline M. Junkins-Hopkins MD; Jeannine L. Koay MD; Gary D. Monheit MD; Abrar A. Qureshi MD MPH; Ben M. Treen MD; Carol K. Sieck RN MSN

Financial Disclosures/Conflicts of Interest

Each of the following Work Group Members have served as a consultant received research support or clinical research grants from the following companies:

Dr. Strauss was a consultant and investigator for Roche Laboratories receiving honoraria and grants and a consultant for Medicis receiving honoraria.

Dr. Krowchuk has no relevant conflicts of interest to disclose.

Dr. Leyden was a consultant for Stiefel and SkinMedica receiving honoraria; served on the Advisory Board and was a consultant for Galderma and Obaj receiving honoraria; was on the Advisory Board and was a consultant and investigator for Connetics Collagenex Allergan and Medicis receiving honoraria.

Dr. Lucky was an investigator for Connetics Dow Galderma Healthpoint Johnson & Johnson QLT and Stiefel receiving grants and an investigator and consultant for Berlex receiving grants and honoraria.

Dr. Shalita was a consultant investigator stockholder and speaker for Allergan receiving grants and honoraria; a consultant for Bradley/Doak receiving honoraria; served on the Advisory Board and was a consultant for Collagenex receiving honoraria; was a consultant and investigator for Connetics receiving grants and honoraria; an Advisory Board member consultant investigator and speaker for Galderma receiving grants and honoraria; a consultant speaker and stockholder for Medicis receiving honoraria; an Advisory Board member for Ranbaxy receiving honoraria; and a consultant investigator and speaker for Stiefel receiving grants and honoraria.

Dr. Siegfried was an investigator for Atrix receiving salary.

Dr. Thiboutot served on the Advisory Board and was an investigator and speaker for Allergan and Galderma receiving honoraria; was on the Advisory Board and was a consultant and investigator for Collagenex receiving honoraria; was on the Advisory Board and was an investigator for Connetics Dermik and QLT receiving honoraria; and was a consultant investigator and speaker for Intendis receiving honoraria.

Dr. Van Voorhees served on the Advisory Board and was an investigator and speaker for Amgen receiving grants and honoraria; was an investigator for Astellas Bristol Myers Squibb and GlaxoSmithKline receiving grants; was an Advisory Board Member and investigator for Genentech and Warner Chilcott receiving grants and honoraria; was on the Advisory Board for Centocor receiving honoraria; was a speaker for Connetics receiving honoraria; and was a stockholder of Merck owning stock and stock options.

Dr. Beutner was an employee of Anacor receiving salary and stock options and a stockholder of Dow Pharmaceutical Sciences receiving stock.

Ms. Sieck and Dr. Bhushan have no relevant conflicts of interest to disclose.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from American Academy of Dermatology Association Web site.

Print copies: Available from the AAD PO Box 4014 Schaumburg IL 60168-4014 Phone: (847) 330-0230 ext. 333; Fax: (847) 330-1120; Web site: www.aad.org.

Availability of Companion Documents

The following is available:

• Guidelines of care for acne vulgaris management. Technical report. American Academy of Dermatology Association. 2007. 69 p.

Electronic copies: Not available at this time.

Print copies: Available from the AAD PO Box 4014 Schaumburg IL 60168-4014 Phone: (847) 330-0230 ext. 333; Fax: (847) 330-1120; Web site: www.aad.org.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on July 25 2007. The information was verified by the guideline developer on August 2 2007.

COPYRIGHT STATEMENT

The American Academy of Dermatology Association places no restriction on the downloading use or reproduction of its guidelines.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.