Acne Guidelines: Whats's New?

By: Beth Williams, MSN, FNP-C

In January, the American Academy of Dermatology (AAD) updated its acne vulgaris management guidelines¹. They thoroughly examined the literature and produced recommendations based on existing evidence, incorporating newly approved treatments since their 2016 guidelines². This gives providers an excellent basis for treating patients with acne.

The document is a worthwhile read and includes a useful decision tree. We’ve identified some highlights within the document that you may find helpful in examining your management of patients (ages 9+) with acne.

First, the AAD recommends using the Investigator’s Global Assessment (IGA)³ (or a similar grading tool). With the IGA instrument, acne severity is ranked from 0 (‘clear’) to 4 (‘severe’). This helps providers gauge initial acne severity and response to treatment. Tracking the patient’s satisfaction with their appearance, treatment, and quality of life is also essential.

Next, they concluded that topical retinoids, benzoyl peroxide (BP), topical antibiotics and fixed-dose topical combinations are demonstratively effective, as well as oral doxycycline and oral isotretinoin¹.

Topical therapies are quite effective for acne management and are the mainstay for any acne regimen, and topical retinoids are the foundation for treatment. They normalize skin cell turnover and suppress inflammation⁴. No research suggests that one is superior to another, so they should be prescribed based on your patient’s tolerance and response to treatment¹.

Additionally, BP continues to be a cornerstone of acne treatment. It’s an antimicrobial that reduces the formation of inflammatory and noninflammatory comedones. There has been no reported C. acnes resistance – which separates it considerably from the antibiotics on the list¹.

Combination drugs (BP/retinoid, BP/topical antibiotic, retinoid/topical antibiotic) are also recommended. Individual component vs the fixed-dose combination costs should be explored as there may be significant discrepancies depending on the regimen¹.

Moving onto antibiotics (topical and oral) here’s the biggest takeaway – avoid monotherapy! Combining topical antibiotics with BP is advised to enhance efficacy and limit drug resistance¹. Regarding oral antibiotics it’s important to note that only doxycycline is strongly recommended. The AAD advises doxycycline if a patient has moderate-to-severe acne, has failed other treatments, and is using concomitantly with BP and other topicals (particularly retinoids)¹. They caution providers to limit treatment to 3-4 months, and to heed the usual warnings with doxycycline (i.e., gastrointestinal upset, esophagitis, phototoxicity, avoidance in pregnancy/lactation) regardless of dosage (which can range in once or twice daily dosing from 20mg to 100mg)1,5.

Despite limited research demonstrating its effectiveness and mechanism of action, oral isotretinoin is strongly recommended for severe acne, acne causing psychosocial burden/scarring, or acne failing standard treatments¹. Dermatologists have been using this drug for decades, noting remarkable success.
On a final note, the group did release some Good Practice Statements which may not have robust evidence, but have notable benefits and limited harm. We’ve included a chart below for your review.