New dermatology guidelines recommend combination treatment for teens and adults with acne

A combination of two or more therapies is the best treatment option for the majority of patients with acne, according to new clinical guidelines, published online February 17, 2016 in the Journal of the American Academy of Dermatology.

Acne is one of the most common disorders treated by dermatologists and other health care providers, but clinical questions continue to arise in its treatment, according to dermatologist Andrea Zaenglein, MD, co-chair of the expert work group that developed the guidelines.

To provide evidence-based answers, the American Academy of Dermatology assembled the clinical work group, composed of about 20 acne experts, which developed the guidelines from a review of nearly 250 papers. From these, the workgroup gathered evidence to develop the current clinical treatment recommendations for teens and adults with acne.

The guidelines’ specific recommendations include:

Use a grading or classification scale. While there is no universally agreed-upon grading system to date, clinicians may find it helpful to use a consistent grading/classification scale (of acne lesions and disease severity) to make therapeutic decisions and assess response to treatment.

Avoid routine microbiologic or endocrinologic testing in most patients. Routine microbiologic testing is not recommended, although patients who exhibit acne-like lesions suggestive of Gram-negative folliculitis may benefit from it. Likewise, routine endocrinologic evaluation is not recommended for the majority of patients with acne, except for certain patients who have acne along with additional signs of androgen excess.

Use combination therapy for the majority of patients with acne. “Dermatologists have found that combining two or more treatments is the best option for the majority of patients,” said Dr. Zaenglein, who is also Professor of Dermatology and Pediatric Dermatology at Penn State Milton S. Hershey Medical Center, in Hershey, PA.

Benzoyl peroxide or a topical retinoid may be used as monotherapy for mild acne, but also may be combined with one another to create an effective treatment regimen. In preadolescent children, topical adapalene, tretinoin, or benzoyl peroxide can be safely used.

Systemic antibiotics are effective treatments for moderate to severe acne (and forms of inflammatory acne that are resistant to topical treatments), but systemic antibiotics are not recommended as monotherapy because of the risk of bacterial resistance; use them in combination with topical therapy, the guidelines say. Once the course of antibiotics is complete, patients should continue using topical treatments to manage their condition.

Consider oral isotretinoin in select cases. The guidelines recommend oral isotretinoin for severe nodular acne or moderate acne that does not respond to other therapy. Because isotretinoin carries a high risk of birth defects, women must be careful to prevent pregnancy while on it. Advise patients of the possible risks of oral isotretinoin and inflammatory bowel disease or depressive symptoms.

The guidelines include a number of additional points, such as:

• Estrogen-containing oral contraceptives, combined with other treatments, are effective and recommended to treat inflammatory acne in women.
  
• In-office modalities—including pulsed dye laser, glycolic acid peels, and salicylic acid peels—may improve acne, but are not recommended for routine treatment.
  
• Not enough evidence exists for the safety and efficacy of herbal and alternative therapies to recommend using them to treat acne.
  
• Dairy products and foods with a high glycemic index have been linked to acne, but not enough data are available to recommend dietary changes for acne patients.
  

The full text of the guidelines is available in the Journal of the American Academy of Dermatology. The guidelines also include supplementary tables with specific prescribing information for most acne treatments.