Guidelines for acne vulgaris treatment

Management of Acne: A Report from a Global Alliance to Improve Outcomes in Acne

Key consensus recommendations:

Acne pathophysiology should influence treatment, which should target as many factors as possible.

Retinoids

Most patients with acne benefit from a retinoid – with a topical agent as part of conventional therapy, or oral isotretinoin for treatment-resistant cases.
Topical retinoids have multiple anti-acne actions, and should be primary treatment for most forms of acne vulgaris.

  • Use early for best results.
  • Should be applied to the entire affected area.
  • Combine with antimicrobial therapy when inflammatory lesions are present.
  • Essential part of maintenance therapy.

Antimicrobials plus topical retinoid therapy

  • Antimicrobial therapy plus topical retinoid therapy is significantly better than antimicrobials alone.
  • Combination therapy allows targeting of different pathophysiologic factors.
  • Topical retinoid therapy is likely to enhance penetration of antimicrobial agents.
  • Add topical retinoids early—at the onset of therapy—for greatest and fastest results.
  • Maintain success by continuing with topical retinoid.

Combination therapy

  • Should be used when inflammatory lesions are present.
  • Speeds clearing and provides greater resolution of both inflammatory lesions and comedones
  • Topical retinoid should be started at the initiation of antimicrobial therapy
  • Antibiotic should be discontinued when inflammatory lesions resolve adequately.
  • If this is not possible, then switch to a combination agent with benzoyl peroxide plus an antibiotic.
  • Continue use of topical retinoid to maintain remission of new acne lesions when antibiotic therapy is discontinued.

Antimicrobial therapy

  • Antimicrobial therapy primary affects inflammatory lesions.
  • Oral and topical antibiotics should not usually be used as monotherapy.
  • Antibiotics are generally well tolerated, but are associated with rare instances of severe adverse events (minocycline).
  • Antibiotics should be combined with topical retinoids to enhance efficacy against comedones and inflammatory acne lesions.
  • Benzoyl peroxide alone significantly improves inflammatory acne.
  • Topical benzoyl peroxide or azaleic acid treatment may be added to antibiotics to reduce the potential of developing P acnesresistance.

Hormonal therapy

  • Excellent choice for women who need oral contraception for gynaecologic reasons.
  • Use early in female patients with moderate to severe acne or with seborrhea/acne/hirsutism/alopecia (SAHA) symptoms.
  • Useful as a component of combination therapy in women with or without endocrine abnormalities.
  • Sometimes used in women with late-onset acne.

Oral retinoids

  • Oral isotretinoin is the mainstay of therapy for severe acne.
  • Targets all pathophysiologic factors in acne.
  • May achieve dramatic results even in severe disease.
  • Now used more frequently in moderate, nonresponsive acne.
  • Side-effects are common, but usually manageable.
  • Education is vital (side-effects, teratogenicity, adverse psychiatric events, monitoring).
  • Variable rate of recurrence; retreatment may be necessary.
  • (Ref: Cunliffe WJ and Gollnick H, H. Management of acne. A report from a global alliance to improve outcomes in acne. Am Acad Dermatol 2003; 49 (1): S1-S37)

Use of isotretinoin
Advice on the safe introduction and continued use of isotretinoin in acne in the UK 2010.

ref: Goodfield, MJD, Cox, NH, Bowser A et al. BJD 2010; 162: 1172-1179

Clinical Knowledge Summary
Acne vulgaris management

NICE referral advice
http:/www.nice.org.uk/nice-eb/pdf/NICE_GP_Referral_cues_4.pdf
[Alison Layton includes these – but I can’t find on the NICE website – I can only find the following:
NICE. Referral Advice.

US guidelines
American Academy of Dermatologists: Guidelines of care for acne vulgaris management.

Ref: Strauss JS, Krowchuk DP, Leyden JJ et al.  Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007; 56: 651-663