TOPIC 1: Acne Vulgaris (FEATURED READING) – Guidelines of Care for the Management of Acne Vulgaris
OFFICIAL ABP TOPIC:
Acne Vulgaris (FEATURED READING) – Guidelines of Care for the Management of Acne Vulgaris
BACKGROUND
Acne vulgaris is a chronic inflammatory skin disease affecting the pilosebaceous unit. It is one of the most common skin conditions, affecting approximately 85% of teenagers and over 50 million people in the US. Acne has a significant impact on quality of life, with psychosocial effects comparable to other chronic diseases like asthma and arthritis.
ASSESSMENT/EVALUATION
Acne severity is commonly assessed using grading scales such as the Investigator Global Assessment (IGA). The IGA is a 5-point scale ranging from 0 (clear) to 4 (severe).
|
IGA Score |
Severity |
Description |
|
|
0 |
Clear |
No inflammatory or noninflammatory lesions |
|
|
1 |
Almost Clear |
Rare noninflammatory lesions with no more than 1 small inflammatory lesion |
|
|
2 |
Mild |
Some noninflammatory lesions with no more than a few inflammatory lesions |
|
|
3 |
Moderate |
Many noninflammatory lesions and may have some inflammatory lesions, but not more than 1 nodular lesion |
|
|
4 |
Severe |
Numerous or extensive inflammatory lesions, with more than 1 nodular lesion |
Routine microbiological testing is not indicated for acne as it does not affect management. Endocrinologic testing is also not routinely indicated unless patients present with signs of hyperandrogenism.
MANAGEMENT/TREATMENT
Mild acne can typically be managed with only topical therapies, while moderate to severe acne may be treated with a combination of topical therapies, systemic antibiotics, and hormonal agents. Oral isotretinoin is strongly recommended for severe or refractory acne. The key recommendations are summarized below.
TOPICAL THERAPIES
Topical therapies are the mainstay of acne treatment for mild to moderate acne. Multimodal topical therapy combining multiple mechanisms of action is recommended.
- Benzoyl peroxide (strong recommendation): Antimicrobial, mildly comedolytic. Available in various concentrations and formulations.
- Topical retinoids (strong recommendation):Comedolytic, anti-inflammatory. Normalize follicular keratinization.
- Tretinoin
- Adapalene
- Tazarotene
- Trifarotene
- Topical antibiotics (strong recommendation): Anti-inflammatory, antibacterial against C. acnes. Use in combination with benzoyl peroxideto reduce resistance.
- Erythromycin
- Clindamycin
- Fixed-dose combinations of benzoyl peroxide, retinoids, and antibiotics are available and can increase adherence.
- Clascoterone (conditional recommendation): Topical antiandrogen, reduces sebum production. Conditionally recommended due to concerns about the high current cost of treatment that may impact equitable acne treatment access.
- Azelaic acid (conditional recommendation): Mildly comedolytic, antimicrobial, anti-inflammatory. May help with post-inflammatory hyperpigmentation. Particularly helpful for patients with sensitive or darker skin types due to its lightening effect on dyspigmentation.
- Salicylic acid (conditional recommendation): Comedolytic. Available over the counter. Recommended based on evidence from a randomized controlled trial showing a 25% greater reduction in inflammatory lesions compared to vehicle at 12 weeks.
SYSTEMIC ANTIBIOTICS
Oral antibiotics are commonly added on for moderate to severe acne. To minimize antibiotic resistance:
- Limit antibiotic use when possible
- Use concomitantly with topical benzoyl peroxide
- Limit antibiotic courses to 3-4 months
Recommended oral antibiotics:
- Doxycycline (strong recommendation):
- Minocycline: Conditionally recommended based on moderate certainty evidence and concerns about rare potential adverse effects, including vertigo, autoimmune hepatitis, skin hyperpigmentation, drug-induced lupus, and hypersensitivity syndrome.
- Sarecycline: Conditionally recommended based on high certainty evidence and concerns about the high current cost of treatment that may impact equitable acne treatment access.
HORMONAL AGENTS
- Combined oral contraceptives (COCs): Conditionally recommended for females with mild to moderate acne who also desire contraception. Reduces androgen production, increases sex hormone-binding globulin. Potential risks include: increased risk of venous thromboembolism, stroke, and myocardial infarction, especially in patients with risk factors like smoking, hypertension, and migraine.
- Spironolactone:Conditionally recommended based on moderate certainty evidence. It is an androgen receptor blocker that reduces sebum production.
- Use caution in patients at risk for hyperkalemia (renal insufficiency, taking other medications that increase potassium).
- Routine potassium monitoring is not needed in healthy patients.
- Intralesional corticosteroids (e.g., triamcinolone) can be used as adjuvant therapy for large inflammatory lesions.
ORAL ISOTRETINOIN
Isotretinoin is strongly recommended for severe acne, acne causing scarring or psychosocial distress, or acne not responding to other therapies. It is anti-inflammatory, reduces sebum production, and normalizes follicular keratinization.
Monitoring of liver function tests and lipids should be considered. Pregnancy prevention is mandatory through enrollment in the iPLEDGE system. Two methods of contraception are required for patients who can become pregnant.
CONTRAINDICATIONS & PRECAUTIONS
Topical retinoids, oral tetracycline antibiotics, isotretinoin, and spironolactone are contraindicated in pregnancy and should be avoided during breastfeeding.