Acne Vulgaris: Diagnosis and Treatment

 

Am Fam Physician. 2019 Oct 15;100(8):475-484.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/acne/.

Author disclosure: No relevant financial affiliations.

Acne vulgaris is the most prevalent chronic skin disease in the United States, affecting nearly 50 million people per year, mostly adolescents and young adults. Potential sequelae of acne, such as scarring, dyspigmentation, and low self-esteem, may result in significant morbidity. Typical acne lesions involve the pilosebaceous follicles and the interrelated processes of sebum production, Cutibacterium acnes (previously called Propionibacterium acnes) colonization, and inflammation. Acne may be classified as mild, moderate, or severe based on the number and type of skin lesions. Multiple treatment agents and formulations are available, with each agent targeting a specific area within acne pathogenesis. Treatment selection is based on disease severity, patient preference, and tolerability. Topical retinoids are indicated for acne of any severity and for maintenance therapy. Systemic and topical antibiotics should be used only in combination with benzoyl peroxide and retinoids and for a maximum of 12 weeks. Isotretinoin is used for severe, recalcitrant acne. Because of the risk of teratogenicity, patients, pharmacists, and prescribers must register with the U.S. Food and Drug Administration–mandated risk management program, iPledge, before implementing isotretinoin therapy. There is limited evidence for physical modalities (e.g., laser therapy, light therapy, chemical peels) and complementary therapies (e.g., purified bee venom, low-glycemic-load diet, tea tree oil); therefore, further study is required.

Acne vulgaris is the most prevalent chronic skin disease in the United States, affecting nearly 50 million people.1 Acne is most common in adolescents and young adults but may persist into the 30s and 40s at a cost of $3 billion. Sequelae of acne include scarring, dyspigmentation, depression, anxiety, and low self-esteem. Specific estimates of prevalence for psychiatric comorbidities vary, and further study is needed.2,3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Topical retinoids should be used as monotherapy for mild comedonal acne and in combination with other topical or oral agents for moderate to severe inflammatory acne.1,14,17,2022

B

Limited patient-oriented evidence from randomized controlled trials and expert consensus

Topical retinoids should be used for maintenance therapy once treatment goals are achieved and oral agents are discontinued.1,17,2023

C

Narrative reviews and expert consensus

Systemic antibiotics should be used for treatment of moderate to severe inflammatory acne.1,23

B

Systematic review of heterogenous studies

Oral isotretinoin should be used for treatment of severe nodular acne or refractory acne in adults and adolescents.1,29

B

Systematic review and meta-analysis of nonrandomized trials

Combined oral contraceptives should be considered for menarchal females unresponsive or intolerant to past therapies, for temporal association of acne outbreaks with menses, or for females with signs and symptoms of hyperandrogenism (acne, hirsutism, oligomenorrhea).1,34

A

Cochrane review of randomized controlled trials with consistent findings


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Topical retinoids should be used as monotherapy for mild comedonal acne and in combination with other topical or oral agents for moderate to severe inflammatory acne.1,14,17,2022

B

Limited patient-oriented evidence from randomized controlled trials and expert consensus

Topical retinoids should be used for maintenance therapy once treatment goals are achieved and oral agents are discontinued.1,17,2023

C

Narrative reviews and expert consensus

Systemic antibiotics should be used for treatment of moderate to severe inflammatory acne.1,23

B

Systematic review of heterogenous studies

Oral isotretinoin should be used for treatment of severe nodular acne or refractory acne in adults and adolescents.1,29

B

Systematic review and meta-analysis of nonrandomized trials

Combined oral contraceptives should be considered for menarchal females unresponsive or intolerant to past therapies, for temporal association of acne outbreaks with menses, or for females with signs and symptoms of hyperandrogenism (acne, hirsutism, oligomenorrhea).1,34

A

Cochrane review of randomized controlled trials with consistent findings


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go

The Authors

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LINDA K. OGÉ, MD, is an associate professor of clinical family medicine and section chief in the Department of Family Medicine at Louisiana State University Health Sciences Center - University Hospital and Clinics, Lafayette....

ALAN BROUSSARD, MD, is an assistant professor of clinical family medicine in the Department of Family Medicine at Louisiana State University Health Sciences Center - University Hospital and Clinics and is assistant program director of the Family Medicine Residency Program.

MARILYN D. MARSHALL, MD, is an assistant professor of clinical family medicine in the Department of Family Medicine at Louisiana State University Health Sciences Center - University Hospital and Clinics and is program director of the Family Medicine Residency Program.

Address correspondence to Linda K. Ogé, MD, 2390 West Congress St., Lafayette, LA 70506 (email: loge@lsuhsc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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