Acne Management: Guidelines From the American Academy of Dermatology

Michelle Nelson

KEY POINTS FOR PRACTICE

• Topical benzoyl peroxide or a retinoid, alone or in combination with a topical antibiotic, is effective treatment.

• For moderate to severe acne, oral doxycycline is recommended. Systemic antibiotics should not be used as monotherapy and should be combined with topical benzoyl peroxide and other topical drugs.

• Oral isotretinoin is strongly recommended for severe, scarring, or refractory acne or failure of other treatment.

• Intralesional corticosteroid injections should be considered for larger acne lesions, rapid resolution, or to minimize scarring.

From the AFP Editors

Acne vulgaris is a chronic inflammatory condition of pilosebaceous units of the skin affecting more than 50 million people in the United States, including 85% of adolescents. Risk factors include adolescent age, family history of acne, and oily skin type. The American Academy of Dermatology released updated guidelines for the management of acne.

EVALUATION

The Investigator Global Assessment system is the most used acne grading scale. Scoring depends on lesion type, count, and skin involvement.

MANAGEMENT

Topical treatments are the mainstay of treatment. Monotherapy, with the exception of antibiotic treatment, can be used, although the guideline recommends combination treatment with different mechanisms of action. Comedolytic and anti-inflammatory treatments can reduce lesions, whereas antibiotics can reduce colonization of the acne-causing bacteria Cutibacterium acnes (previously Propionibacterium acnes). Fixed-dose topical combinations of benzoyl peroxide and retinoids or antibiotics can improve adherence, although some (eg, erythromycin-benzoyl peroxide) require refrigeration.

TOPICAL TREATMENTS

Topical Retinoids

Topical retinoids are cornerstone treatments because of comedolytic and anti-inflammatory properties. The retinoids tretinoin, adapalene (Differin), tazarotene, and trifarotene (Aklief) are similarly effective. Adverse effects can include irritation, photosensitivity, burning sensation, dryness, erythema, exfoliation, peeling, and pain. Concurrent emollient use mitigates irritation. Adapalene, tazarotene, and trifarotene can be used concurrently with benzoyl peroxide; tretinoin degrades when benzoyl peroxide is present. Consider daily sunscreen use in patients using topical retinoids.

Benzoyl Peroxide

Available over the counter, benzoyl peroxide is a topical antimicrobial agent that is mildly comedolytic and reduces inflammatory and noninflammatory lesions. Adverse effects can include burning sensation, stinging, dryness, erythema, pain, peeling, irritation, fabric staining and bleaching, and, uncommonly, contact allergy. Lower concentrations may be better tolerated.

Topical Antibiotics

Erythromycin, clindamycin, minocycline (Zlixi, Amzeeq), and dapsone (Aczone) reduce inflammatory lesions but not noninflammatory lesions. Topical antibiotic monotherapy, which can result in antibiotic resistance, should be avoided.

Combination Therapy

Fixed-dose topical combinations of benzoyl peroxide, retinoids, or antibiotics can improve adherence. Adding benzoyl peroxide to topical antibiotic regimens prevents antibiotic resistance.

Clascoterone

Clascoterone (Winlevi) is a topical antiandrogen that inhibits sebum production and inflammation. Although effective, clascoterone is conditionally recommended because of high cost.

Salicylic Acid

Salicylic acid is a topical comedolytic agent available over the counter that is conditionally recommended because of limited evidence of benefit.

Azelaic Acid

Azelaic acid is a topical comedolytic, antibacterial, and anti-inflammatory agent that may be more useful in darker skin types or sensitive skin because it reduces hyperpigmentation associated with acne.