American Academy of Dermatology releases new guidelines of care for management of acne vulgaris

The guidelines, published in the Journal of the American Academy of Dermatology, identified important evidence gaps on the use of endocrinology and microbiology testing in acne, the use of systemic antibiotics beyond tetracycline-class antibiotics, complementary and alternative therapies, physical modalities, cost-effectiveness of acne treatments, and dietary interventions for the treatment of acne.

For developing the guidelines, Rachel V. Reynolds, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, and colleagues performed Systematic reviews to evaluate the effectiveness and safety of acne treatments approved by the United States Food and Drug Administration (FDA) from May 2021 to November 2022.

The reviews evaluated the data under the scope of nine clinical questions. The AAD work group consisted of 9 board-certified dermatologists, 3 board-certified pediatric dermatologists, 1 patient representative, and 1 staff liaison.

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

This guideline presents 18 evidence-based recommendations and five good practice statements. Strong recommendations are made for topical retinoids, benzoyl peroxide, oral doxycycline, and topical antibiotics.

Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard topical or oral therapy. Conditional recommendations are made for salicylic acid, topical clascoterone, and azelaic acid, as well as for oral minocycline, sarecycline, spironolactone, and combined oral contraceptive pills.

"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," the guideline stated.

Topical agents

• When managing acne with topical medications, multimodal therapy combining multiple mechanisms of action is recommended.
• For patients with acne, benzoyl peroxide is recommended.
• For patients with acne, topical retinoids are recommended.
• For patients with acne, topical antibiotics are recommended. Topical antibiotic monotherapy is not recommended.
• For patients with acne, clascoterone is conditionally recommended.
• For patients with acne, salicylic acid is conditionally recommended.
• For patients with acne, azelaic acid is conditionally recommended.
• For patients with acne, a fixed-dose combination topical antibiotic with benzoyl peroxide is recommended.
• For patients with acne, a fixed-dose combination of topical retinoid with topical antibiotics is recommended.
• For patients with acne, a fixed-dose combination of topical retinoid with benzoyl peroxide is recommended.

Systemic Antibiotics

• For patients with acne, doxycycline is recommended.
• For patients with acne, minocycline is conditionally recommended.
• For patients with acne, sarecycline is conditionally recommended.
• For patients with acne, doxycycline over azithromycin is conditionally recommended.
• For patients with acne, limiting the use of systemic antibiotics is recommended, when possible, to reduce the development of antibiotic resistance and other antibiotic-associated complications.
• It is recommended that systemic antibiotics are used concomitantly with benzoyl peroxide and other topical therapy.

Hormonal agents

• For patients with acne, combined oral contraceptive pills are conditionally recommended.
• For patients with acne, spironolactone is conditionally recommended.
• For patients with larger acne papules or nodules, intralesional corticosteroid injections as an adjuvant therapy are recommended.

Isotretinoin

• For patients with severe acne or for patients who have failed standard treatment with oral or topical therapy, isotretinoin is recommended.
• For patients with severe acne, traditional daily dosing of isotretinoin is conditionally recommended over intermittent dosing of isotretinoin.
• For patients prescribed isotretinoin, either standard isotretinoin or lidose-isotretinoin is conditionally recommended.

Physical Modalities

• For patients with acne, the group conditionally recommends against adding pneumatic broadband light to adapalene 0.3% gel.

"These guidelines identified important evidence gaps on the use of microbiology and endocrinology testing in acne, the use of systemic antibiotics beyond tetracycline-class antibiotics, physical modalities, complementary and alternative therapies, dietary interventions for the treatment of acne, and cost-effectiveness of acne treatments," the AAD work group members concluded.

They added, “[Randomized controlled trials] with long-term follow-up and comparative effectiveness research are necessary to examine and compare patient-centered acne treatment outcomes.”

Reference:

Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. Published online January 30, 2024. doi:10.1016/j.jaad.2023.12.017