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.
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.
- 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 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.
- 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 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
[Alison Layton includes these – but I can’t find on the NICE website – I can only find the following:
NICE. Referral Advice.
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