Here is a longer, more detailed rewrite:A person should consider seeing a dermatologist if they develop cysts, nodules, or deep, painful acne, as these forms of acne often require specialized treatment to prevent scarring and long-term skin damage. Professional care is also recommended for individuals experiencing late-onset or persistent acne.
Late-onset acne occurs in adults who may never have dealt with acne during their teenage years but suddenly begin to develop breakouts. This type of acne can be linked to factors such as hormonal changes, stress, or underlying medical conditions, and a dermatologist can help identify the cause and recommend appropriate treatment.
Persistent acne, on the other hand, refers to acne that continues from adolescence into adulthood or returns after appearing to improve. Because persistent acne can be frustrating and may not respond well to over-the-counter products, a dermatologist can provide tailored therapies to manage symptoms effectively and prevent further complications.
The American Academy of Dermatology (AAD) has issued updated guidelines for the clinical management of patients with acne vulgaris, which have been published in the Journal of the American Academy of Dermatology.
Systematic reviews to evaluate the effectiveness and safety of acne treatments approved by the United States Food and Drug Administration (FDA) were performed from May 2021 to November 2022. The reviews evaluated the data under the scope of 9 clinical questions. The AAD work group comprised 9 board-certified dermatologists, 3 board-certified pediatric dermatologists, 1 staff liaison, and 1 patient representative.
A variety of acne grading systems are available, with none universally accepted in clinical settings. The most frequently used grading system in the US is the Investigator Global Assessment (IGA), which is characterized by good agreement between clinician and patient ratings. Core acne outcomes measures should include signs and symptoms, satisfaction with appearance and treatment, extent of scars/dark marks, long-term acne control, adverse events, and health-related quality of life. Routine microbiologic, antibiotic susceptibility, and endocrine testing is generally not indicated in most patients with acne.
Acne management includes treatments such as topical therapies, systemic antibiotics, hormonal agents, oral isotretinoin, physical modalities, complementary and alternative medicine, and dietary and environmental interventions. The AAD guidelines encourage shared decision-making to individualize care based on the potential treatment benefits and risks, acne severity and location, costs, patient preferences, and other factors.
Topical Therapies
Topical therapies, including prescription and over-the-counter medicines, are common treatments for acne. Topical agents, excluding topical antibiotics, may be used as initial therapy and maintenance as monotherapy or combined with other topical or oral agents. Options include topical retinoids, benzoyl peroxide, antibiotics, clascoterone, salicylic acid, and azelaic acid. In a good practice statement regarding the use of topical therapies for acne, the AAD work group recommends the use of multimodal therapy combining multiple mechanisms of action to optimize efficacy and lower the risk of antibiotic resistance.
A strong recommendation was made for the use of topical retinoids for patients with acne. Among topical retinoids, tretinoin, adapalene, tazarotene, and trifarotene are approved by the FDA for acne treatment in the US, and data do not suggest superiority of 1 topical retinoid over another. The use of benzoyl peroxide and topical antibiotics is strongly recommended for acne. Topical antibiotic monotherapy is not recommended owing to the potential for antibiotic resistance.
The work group strongly recommends the use of fixed-dose topical combinations therapy with benzoyl peroxide plus topical retinoid, benzoyl peroxide plus topical antibiotic, or topical retinoid plus topical antibiotic for acne treatment. To prevent antibiotic resistance, concomitant treatment with benzoyl peroxide is recommended for patients receiving combination therapy with a topical retinoid plus topical antibiotic.
Conditional recommendations were made for clascoterone, salicylic acid, and azelaic acid.
Topical azelaic acid, benzoyl peroxide, erythromycin, and clindamycin are not likely to cause fetal harm. In addition, salicylic acid can be used during pregnancy if the exposure area and treatment duration are limited. Use of topical therapies other than topical retinoids is preferred in pregnant women, and topical minocycline is not recommended during pregnancy or lactation. Data on the use of topical benzoyl peroxide, retinoids, antibiotics, and their combinations during pregnancy are insufficient.
Systemic Antibiotics
In patients with moderate to severe acne, systemic antibiotics are frequently used, including oral tetracycline-class antibiotics such as doxycycline, minocycline, and sarecycline. Tetracycline-class antibiotics are contraindicated during pregnancy, lactation, and in children aged younger than 9 years during tooth development.
In a pair of good practice statements, the AAD work group recommends limiting the use of systemic antibiotics, when possible, to reduce the risk for antibiotic resistance and other antibiotic-associated complications. Systemic antibiotics should be used concomitantly with benzoyl peroxide and other topical therapies. Oral antibiotics should not be used as monotherapy for acne, and systemic antibiotic use should be limited to the shortest duration possible, typically no longer than 3 to 4 months.
Doxycycline use is strongly recommended for the treatment of acne, and taking the drug with food and adequate fluids in an upright position may lower the risk for gastrointestinal side effects. A conditional recommendation was made for the use of doxycycline rather than azithromycin for acne owing to an increased risk for antibiotic resistance with increasing use of azithromycin. Conditional recommendations were made for minocycline and sarecycline. Although sarecycline is generally well tolerated, with a low incidence of side effects and a high certainty of benefits vs risks, the AAD work group gave it a conditional recommendation owing to concerns about its high cost.
These antibiotics are also indicated for community-acquired infections, including pneumonia and urinary tract infections; broad use for acne is not recommended. The AAD work group did not make recommendations comparing certain systemic antibiotics directly against each other or against topical treatments as the evidence was insufficient.
Hormonal Agents
The FDA has approved 4 combined oral contraceptives (COCs) for the treatment of acne in women who desire oral contraception: norgestimate/ethinyl estradiol (EE), norethindrone acetate/EE/ferrous fumarate, drospirenone/EE, and drospirenone/EE/ levomefolate. COCs are conditionally recommended for the treatment of acne. Clinicians may consider combining COCs with other acne therapies early in treatment to promote a faster treatment response. Potential adverse effects of COCs include venous thromboembolism, myocardial infarction, stroke, breast cancer, and cervical cancer, among others.
A conditional recommendation was provided for the use of spironolactone for acne. Common side effects include diuresis, breast tenderness, breast enlargement, gynecomastia, fatigue, headache, and dizziness. Spironolactone should not be used during pregnancy. The utility of potassium monitoring was determined to be low in patients without risk factors for hyperkalemia (eg, older age, medical comorbidities, medications). The AAD work group issued a good practice statement regarding intralesional corticosteroid injection as an adjuvant treatment in patients who have larger acne papules or nodules. Intralesional corticosteroid injections should be used judiciously in patients with a risk for acne scarring and/or for rapid improvement in inflammation and pain.
The AAD work group did not provide a recommendation on the use of oral corticosteroids, flutamide, or metformin for acne treatment as evidence was insufficient. Long-term adverse effects of oral corticosteroids prohibit their use as a primary treatment for acne.
Isotretinoin
Since 1982, oral isotretinoin has been the only FDA-approved treatment for patients with severe recalcitrant nodular acne vulgaris; however, clinical trial data regarding its efficacy in routine dermatology practice are limited and of low quality. A good practice statement was provided for the use of isotretinoin in patients with severe acne or those for whom standard treatment with oral or topical therapy has failed. Patients with acne and a related psychosocial burden and/or scarring may be candidates for isotretinoin.
Isotretinoin is commonly used in patients who have mild to moderate acne that is refractory to other topical and oral therapies or who relapse quickly after discontinuation of oral antibiotics. Laboratory monitoring during isotretinoin use should include liver function tests, a fasting lipid panel, and a pregnancy test in patients with pregnancy potential. Complete blood count monitoring is not necessary.
Among patients with pregnancy potential, pregnancy prevention is mandatory with isotretinoin treatment, owing to the risk of fetal congenital malformations; all patients who receive isotretinoin must enroll in and adhere to iPLEDGE, the current FDA-mandated Risk Evaluation and Mitigation Strategy aimed at preventing isotretinoin exposure during pregnancy. The AAD work group also advises clinicians to monitor patients for depression, anxiety, suicidal ideation/suicidality, and other neuropsychiatric adverse effects. Treatment decisions should be personalized based on individual responses to this drug.
Conditional recommendations were made for the use of daily dosing vs intermittent dosing of isotretinoin and for treatment with either standard isotretinoin or lidose-isotretinoin.
The AAD work group did not directly compare traditional dosage vs low-dosage isotretinoin regimens, isotretinoin with systemic antibiotics with or without topical therapies, or isotretinoin alone vs isotretinoin administered in combination with topical agents as evidence was insufficient.
Physical Modalities
After review, the AAD work group found that the evidence was insufficient to make a recommendation for the use of acne lesion/comedo extraction, chemical peels, laser and light-based devices, microneedle radiofrequency devices, or photodynamic therapy with aminolevulinic acid for patients with acne. A conditional recommendation was provided against the addition of pneumatic broadband light therapy to treatment with adapalene 0.3% gel.
Complementary/Alternative Therapies
Complementary and alternative therapies include botanical or plant-derived agents and vitamins. The AAD work group did not provide a recommendation regarding the use of topical tea tree oil, topical green tea, topical witch hazel, oral pantothenic acid, oral or topical zinc, and oral or topical niacinamide in patients with acne as evidence was insufficient.
Diet
There were conflicting research findings regarding low-glycemic-load diet as a treatment for acne. The evidence was insufficient to recommend the use of a low dairy diet, low whey diet, omega-3 fatty acids, or chocolate for acne treatment.
AAD Review Limitations and Conclusions
Limitations in the development of the current AAD guidelines include analysis based on the best available evidence at the time of the systematic review, as well as the work group’s review of English-language studies — which may have excluded relevant data published in other languages — and randomized controlled trials only — which may have limited identification of long-term follow-up data.
The AAD work group members concluded, “These guidelines identified important evidence gaps on the use of microbiology and endocrinology testing in acne, the use of systemic antibiotics beyond tetracycline-class antibiotics, physical modalities, complementary and alternative therapies, dietary interventions for the treatment of acne, and cost-effectiveness of acne treatments.” They added, “[Randomized controlled trials] with long-term follow-up and comparative effectiveness research are necessary to examine and compare patient-centered acne treatment outcomes.”