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The AAD’s new guidelines for the care and management of acne vulgaris include several updates for dermatologists, including an increased emphasis on oral antibiotic stewardship and recommendations for use.
Andrea L. Zaenglein, M.D.The American Academy of Dermatology (AAD) released its “Guidelines of care for the management of acne vulgaris,” published online February 15 in the Journal of the American Academy of Dermatology.1
“The Academy is dedicated to promoting and encouraging dermatology research and the application of these findings to improving patient care. This includes the development of rigorous, evidence-based guidelines of care for dermatologic conditions,” says guidelines’ workgroup cochair Andrea L. Zaenglein, M.D., professor of dermatology and pediatric dermatology at PennState Health Milton S. Hershey Medical Center, Hershey, Penn.
“Our goal is to revisit the data at least every five years … to review any new evidence that could affect the guideline's recommendations. Officially, any guidelines is only good for five years,” Dr. Zaenglein says.
Bethanee J. Schlosser, M.D, Ph.D.Workgroup member Bethanee J. Schlosser, M.D, Ph.D., tells Dermatology Times that the most recent acne guidelines emphasize appropriate stewardship of oral antibiotics, including their recommended course, the importance of maintenance therapy and what defines maintenance therapy.
“In general, not just in dermatology, the Centers for Disease Control and Prevention has clearly been emphasizing throughout medicine that we want to be using the right antibiotic, for the right patient, for the right indication, for the right duration of time, to avoid development of antibiotic resistance,” says Dr. Schlosser, assistant professor, director, Women's Skin Health Program, department of dermatology, Northwestern University Feinberg School of Medicine, Chicago. “When you look across the board, dermatology is a significant percentage of antibiotic prescriptions, and acne accounts for a significant proportion of that.”
The guidelines recommend using oral antibiotics in patients with moderate-to-severe inflammatory acne. In essence, according to Dr. Schlosser, oral antibiotics are not meant for most patients with mild inflammatory acne, and these drugs are not appropriate for patients with comedonal acne.
The workgroup made a more specific recommendation that patients on antibiotics should be re-evaluated at three to four months to determine their continued need for the antibiotic. Although, the workgroup does acknowledge that there are select groups of patients that may require and benefit from a more prolonged course of oral antibiotics. Those are patients who are not eligible for other forms of therapy, including patients who may not be eligible combination oral contraceptives; patients who may not be candidates for oral isotretinoin due to other health issues; and patients who may not be able to tolerate topical agents.
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“Oral antibiotics should never be used as monotherapy for patients with acne,” Dr. Schlosser says. “… for patients that have moderate-to-severe inflammatory acne, dermatologists should still be using a topical retinoid in addition to the oral antibiotic.”
Dermatologists treating acne patients should advocate for benzoyl peroxide use in any patient who is on either a topical or an oral antibiotic. The data show that benzoyl peroxide used in conjunction with antibiotics decreases antibiotic resistance, according to Dr. Schlosser.
Acne tends to be a chronic disease, making adherence to therapy important for maintaining outcomes.
Products that contain two agents, whether an antibiotic and benzoyl peroxide or benzoyl peroxide and a topical retinoid, have greater utility and some improved adherence compared to individual agents, alone, according to the guidelines.
The guidelines, however, do not recommend one specific product over another.
Dermatologists might wonder what they should give patients post antibiotic treatment to maintain outcomes. According to the guidelines, there are several studies that have shown that even patients with moderate-to-severe inflammatory acne who have been on oral antibiotics, in conjunction with a topical retinoid and benzoyl peroxide, for three months, maintain results when they continue with just the topicals.
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Based on the workgroup’s recommendations, Dr. Zaenglein says she will look closely at how long she keeps her patients on antibiotics for acne.
“It used to be that acne patients were kept on antibiotics for more than a year. Now we know that with a good maintenance routine with a retinoid and topical antimicrobial, like benzoyl peroxide, many of these patients will be able to limit the use of antibiotics to just a few months,” Dr. Zaenglein says.
The Academy’s guidelines are driven by evidence and data; not necessarily on practice patterns, according to Dr. Schlosser.
“Based on the data, it is a little surprising … but there’s very little evidence to support the utilization of topical sulfur or topical sodium sulfacetamide in the treatment of acne,” Dr. Schlosser says.
The same is true for antibiotics in the penicillin family, including cephalosporins. Although, the workgroup notes, these antibiotics can be used in select populations, such as those who are pregnant or who have allergies to other classes of antibiotics, which may have greater utility and greater efficacy in acne, such as the tetracycline class.
Cochrane database reviews comparing combination oral contraceptive pills for the treatment of acne have yielded no clear winner, according to Dr. Schlosser.
“But we do know that combination oral contraceptive pills are better than placebo, based on the data,” she says. “And they do help in terms of not just facial acne, but there’s a study that also shows benefit for truncal acne.”2
The guidelines continue to recommend that acne patients being considered for hormonal therapy be appropriately selected and screened for concomitant morbidities and risk factors, including if they have a family or personal history of blood clotting disorders, hypertension, stroke, etc.
Isotretinoin is widely accepted as standard of care and has solid evidence for select patients who have nodulocystic disease or who have moderate-to-severe inflammatory acne that is recalcitrant to treatment with other agents.
“Obviously, we want to be appropriately selecting patients based on their personal risk factors,” Dr. Schlosser says. “There is controversy about the potential association with [isotretinoin and] inflammatory bowel disease, as well as mood changes or depressive symptoms. There have been some suggestions … but the evidence is not conclusive. But we still advocate that all dermatologists discuss potential associations with their patients and review potential side effects of the medicine. Then, monitor their patients throughout the entire treatment course. Of course, it’s imperative that patients be counseled about the birth defect potential of the medication, and that all prescribers adhere to the strict requirements of the iPLEDGE system.”
In-office procedures, including laser treatments and chemical peels, have been shown to offer slight improvements in acne, according to Dr. Schlosser.
“But the guidelines actually don’t recommend those procedures for routine acne treatment, and that’s simply because there is not enough data out there to suggest their benefit over other topical modalities, like topical retinoids,” she says. “[Physical modalities] may have some adjunctive benefit for select patients, but they wouldn’t necessarily replace other treatments.”
Diet’s role in acne remains controversial but represents an exciting area of research.
“I think the emerging data on diet and acne is fascinating. And while we don’t have the rigorous data required yet to make specific recommendations to patients, I look forward to seeing what emerges over the next few years,” Dr. Zaenglein says.
The role of a high glycemic diet in acne is particularly interesting, according to Dr. Zaenglein.
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“We have good, preliminary evidence that especially in those with known abnormal glucose metabolism (metabolic syndrome), changes in diet can result in notable improvement in acne as well as their cholesterol, insulin levels and other metabolic parameters. Longer term, prospective studies are needed, however, prior to making specific dietary recommendations to acne patients with normal metabolic profiles,” Dr. Zaenglein says.
There is also research to suggest dairy - particularly skim milk - could be linked to acne. But this data, too, is inadequate to make a sweeping recommendation, Dr. Schlosser says.
Although it’s not emphasized in the guidelines, Dr. Schlosser says dermatologists should make sure their acne patients are being treated appropriately for their acne severity.
“We don’t want practitioners to shy away from using oral agents if patients have adequate degree of severity in terms of their inflammatory acne. For instance, we don’t want someone with moderate inflammatory acne, with mild scarring, to just be treated with a topical agent because the practitioner is hesitant to utilize an oral agent,” she says. “It’s important to emphasize that patients should be treated as aggressively as needed for the severity of their acne.”
Disclosures: Dr. Zaenglein served on the advisory boards for Anacor Pharmaceuticals, Galderma Laboratories, Promius Pharmaceuticals, and Valeant Pharmaceuticals International, receiving honoraria. She also served as consultant for Ranbaxy Laboratories Limited, receiving honoraria. Dr. Schlosser reports no relevant disclosures.
1. Work Group:, Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, Bowe WP, Graber EM, Harper JC, Kang S, Keri JE, Leyden JJ, Reynolds RV, Silverberg NB, Stein Gold LF, Tollefson MM, Weiss JS, Dolan NC, Sagan AA, Stern M, Boyer KM, Bhushan R. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 Feb 15.
2. Palli MB, Reyes-Habito CM, Lima XT, Kimball AB. A single-center, randomized double-blind, parallel-group study to examine the safety and efficacy of 3mg drospirenone/0.02 mg ethinyl estradiol compared with placebo in the treatment of moderate truncal acne vulgaris. J Drugs Dermatol. 2013;12: 633-637.