Management of Acne Vulgaris

Publication Date: May 1, 2016

Recommendations

Grading and classification of acne

Clinicians may find it helpful to use a consistent grading/classification scale (encompassing the numbers and types of acne lesions as well as disease severity, anatomic sites, and scarring) to facilitate therapeutic decisions and assess response to treatment. (B)
Currently, no universal acne grading/classifying system can be recommended.
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Microbiologic testing

Routine microbiologic testing is not recommended in the evaluation and management of patients with acne. (B)
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Those who exhibit acne-like lesions suggestive of Gram-negative folliculitis may benefit from microbiologic testing. (B)
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Endocrinologic testing

Routine endocrinologic evaluation (eg, for androgen excess) is not recommended for the majority of patients with acne. (B)
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Laboratory evaluation is recommended for patients who have acne and additional signs of androgen excess. (B)
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Topical therapies

Benzoyl peroxide

Benzoyl peroxide or combinations with erythromycin or clindamycin are effective acne treatments and are recommended as monotherapy for mild acne, or in conjunction with a topical retinoid, or systemic antibiotic therapy for moderate to severe acne. (A)
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Benzoyl peroxide is effective in the prevention of bacterial resistance and is recommended for patients on topical or systemic antibiotic therapy. (A)
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Topical antibiotics

Topical antibiotics (eg, erythromycin and clindamycin) are effective acne treatments, but are not recommended as monotherapy because of the risk of bacterial resistance. (A)
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Topical retinoids

Topical retinoids are important in addressing the development and maintenance of acne and are recommended as monotherapy in primarily comedonal acne, or in combination with topical or oral antimicrobials in patients with mixed or primarily inflammatory acne lesions. (A)
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Combination therapy

Using multiple topical agents that affect different aspects of acne pathogenesis can be useful. Combination therapy should be used in the majority of patients with acne. (A)
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Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in the management of preadolescent acne in children. (A)
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Azelaic acid is a useful adjunctive acne treatment and is recommended in the treatment of postinflammatory dyspigmentation. (A)
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Topical dapsone 5% gel is recommended for inflammatory acne, particularly in adult females with acne. (A)
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There is limited evidence to support recommendations for sulfur, nicotinamide, resorcinol, sodium sulfacetamide, aluminum chloride, and zinc in the treatment of acne. (D)
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Systemic antibiotics

Systemic antibiotics are recommended in the management of moderate and severe acne and forms of inflammatory acne that are resistant to topical treatments. ()
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Doxycycline and minocycline are more effective than tetracycline, but neither is superior to each other. (A)
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Although oral erythromycin and azithromycin can be effective in treating acne, its use should be limited to those who cannot use the tetracyclines (ie, pregnant women or children <8 years of age). Erythromycin use should be restricted because of its increased risk of bacterial resistance. (A)
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Trimethoprim-sulfamethoxazole and trimethoprim use should be restricted to patients who are unable to tolerate tetracyclines or in treatment-resistant patients. (B)
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Use of systemic antibiotics, other than the tetracyclines and macrolides, is discouraged because there are limited data for their use in acne. Trimethoprim-sulfamethoxazole and trimethoprim use should be restricted to patients who are unable to tolerate tetracyclines or in treatment-resistant patients (A)
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Systemic antibiotic use should be limited to the shortest possible duration. Re-evaluate at 3-4 months to minimize the development of bacterial resistance. Monotherapy with systemic antibiotics is not recommended. (A)
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Concomitant topical therapy with benzoyl peroxide or a retinoid should be used with systemic antibiotics and for maintenance after completion of systemic antibiotic therapy. (A)
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Hormonal agents

Estrogen-containing combined oral contraceptives are effective and recommended in the treatment of inflammatory acne in females. (A)
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Spironolactone is useful in the treatment of acne in select females. (B)
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Oral corticosteroid therapy can be of temporary benefit in patients who have severe inflammatory acne while starting standard acne treatment. (B)
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In patients who have well documented adrenal hyperandrogenism, low-dose oral corticosteroids are recommended in treatment of acne. (B)
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Use of flutamide in the treatment of acne is discouraged except where benefit warrants the risk. (C)
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Isotretinoin

Oral isotretinoin is recommended for the treatment of severe nodular acne. (A)
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Oral isotretinoin is appropriate for the treatment of moderate acne that is treatment-resistant or for the management of acne that is producing physical scarring or psychosocial distress. (A)
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Low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medication-related side effects. Intermittent dosing of isotretinoin is not recommended. (A)
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Routine monitoring of liver function tests, serum cholesterol, and triglycerides at baseline and again until response to treatment is established is recommended. Routine monitoring of complete blood count is not recommended. (B)
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All patients treated with isotretinoin must adhere to the iPLEDGE risk management program. (A)
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Females of child-bearing potential taking isotretinoin should be counseled regarding various contraceptive methods including user-independent forms. (A)
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Prescribing physicians also should monitor their patients for any indication of inflammatory bowel disease and depressive symptoms and educate their patients about the potential risks with isotretinoin. (A)
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Miscellaneous therapies and physical modalities

There is limited evidence to recommend the use and benefit of physical modalities for the routine treatment of acne, including pulsed dye laser, glycolic acid peels, and salicylic acid peels. (B)
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Intralesional corticosteroid injections are effective in the treatment of individual acne nodules. (C)
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Complementary and alternative therapies

Herbal and alternative therapies have been used to treat acne. Although most of these products appear to be well tolerated, limited data exist regarding the safety and efficacy of these agents to recommend their use in acne. (B)
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Role of diet in acne

Given the current data, no specific dietary changes are recommended in the management of acne. (B)
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Emerging data suggest that high glycemic index diets may be associated with acne. (B)
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Limited evidence suggests that some dairy, particularly skim milk, may influence acne. (B)
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Recommendation Grading

Disclaimer

Overview

Title

Management of Acne Vulgaris

Authoring Organization

Publication Month/Year

May 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline addresses the management of adolescent and adult patients who present with acne vulgaris (AV). This document will discuss various acne treatments, including topical therapies, systemic agents, and physical modalities, including lasers and photodynamic therapy. In addition, grading/classification system, microbiology and endocrinology testing, complementary/alternative therapies, and the role of diet will be reviewed.

Target Patient Population

Patients with acne vulgaris

Inclusion Criteria

Female, Male, Adolescent, Adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D013256 - Steroids, D013754 - Tetracyclines, D000152 - Acne Vulgaris, D000287 - Administration, Topical

Keywords

acne vulgaris, acne management, topical antibiotics, antibiotics

Methodology

Number of Source Documents
315
Literature Search Start Date
May 1, 2006
Literature Search End Date
September 1, 2014