AAD Guidelines for Management of Acne Vulgaris
Summary:
Acne vulgaris (AV) is a multifactorial chronic inflammatory skin disease that affects an estimated 50 million people in the United States, including approximately 85% of teenagers. While AV is not life threatening in and of itself, it is associated with significant physical and psychological morbidity and healthcare costs. The American Academy of Dermatology (AAD) has released guidelines for managing acne in adolescents and adults.
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Classification and Grading:
- Currently no universal classification or grading system in recommended
- Despite this, acne is typically divided into mild, moderate and severe categories to help guide treatment and monitor for improvement with therapies
Mild Acne
- Typically limited to scattered comedones without scarring or nodules
- First line treatment includes: Benzoyl peroxide (BP) | Topical retinoid | Topical combination (BP +/- Retinoid +/- antibiotic)
Moderate Acne
- Visually obvious nodules, papules and comedones
- First line treatment includes: Topical combination therapy | Oral antibiotic + BP + retinoid | Oral antibiotic + topical antibiotic + BP + retinoid
Severe Acne
- Extensive and prominent nodules, papules and comedones with associated scarring
- First line treatment includes: Oral antibiotic + topical therapy | Oral isotretinoin
Further Testing:
Microbiologic testing
- Not recommend in the absence of suspicion for gram negative folliculitis
- Gram negative folliculitis is a rare condition with uniform and eruptive pustules in the perioral and perinasal regions, typically in the setting of prolonged tetracycline use
- Endocrinologic testing
- Not recommended in the absence of signs of hyperandrogenism
- Signs of excess androgen in post-pubertal females include: Irregular periods | Hirsutism| Infertility | PCOS | Androgenic alopecia
Topical Therapies:
Benzoyl Peroxide
- Assists with prevention of bacterial resistance and increases efficacy of antibiotics, should be initiated when antibiotics are used
- Available as cleanser, foams, gels and creams
Antibiotics
- Not recommended as monotherapy due to risk of bacterial resistance
- Clindamycin 1% solution or gel is currently the preferred topical antibiotic for
acne therapy - Erythromycin may also be used
Retinoids
- Vitamin A derivatives
- Includes: Adapalene | Tretinoin | Tazarotene
- Tretinoin inactivated by the coadministration of Benzoyl Peroxide so they should be applied at different times of day
- Use limited by side effects such as drying, peeling and photosensitivity
- Sunscreen recommended to assist with increased photosensitivity
Azelaic Acid
- Good for treatment of post-inflammatory hyperpigmentation
Dapsone
- 5% gel recommended for inflammatory acne
- In studies found to work better in women than in men
Salicylic Acid
- Available over the counter in wash off and leave on formulations
- Limited data on efficacy
Systemic Antibiotics:
- Antibiotic use should be limited to shortest possible duration (ideally no more than 3 to 4 months) to reduce risk of antibiotic resistance
- Switching to topical antibiotics is recommended following oral antibiotic course for maintenance therapy
- Not recommended as monotherapy
Tetracyclines
- First line oral antibiotic class
- Includes: Doxycycline | Minocycline | Tetracycline
- Toxicities include: Photosensitivity | GI distress | Pigment deposition (with minocycline)
Macrolides
- Should be limited to patients unable to take tetracyclines (e.g., pregnant patients)
- Includes: Azithromycin | Erythromycin
Trimethoprim +/- Sulfamethoxazole
- Generally, not recommended and should be limited to those unable to take tetracyclines or macrolides
Beta lactams/Cephalosporins
- Limited data, but used occasionally for patients unable to tolerate any of the above
Hormonal Agents:
Combined oral contraceptives
- Not recommended for certain patients: Pregnant| Breast feeding within 6 weeks of delivery | HTN | Age > 35 and smoker | Diabetes with end organ damage | DM for > 20 years | History of VTE | Heart disease | Prior stroke | Migraines | Liver disease
- Otherwise, estrogen containing OCPs are effective for menstruating people with inflammatory acne
- 4 combined OCPs approved by FDA for acne therapy: Ethinyl estradiol/norgestimate | Ethinyl estradiol/norethindrone acetate/ferrous fumarate | Ethinyl estradiol/drospirenone | Ethinyl estradiol/drospirenone/levomefolate
- Work via an antiandrogen effect
- May take several months to take effect on acne
Spironolactone
- Aldosterone receptor antagonist that decreases testosterone production
- Recommended for females; male patients had unwanted side effects such as gynecomastia
- Effect (and side effects) are dose dependent
- Side effects include: Hyperkalemia | Diuresis | Menstrual irregularities | Breast enlargement | Fatigue | Dizziness
Flutamide
- Nonsteroidal selective androgen receptor blocker used in the treatment of prostate cancer; use for acne is not FDA approved
- High rates of side effects including: Decreased libido | GI distress | Breast tenderness | Hot flashes | Headaches
Oral corticosteroids
- Can help temporarily for patients with severe inflammatory acne while initiating other therapies
- Low dose oral corticosteroids (e.g., Prednisone 5 to 15 mg/day) also recommended for patients with proven adrenal hyperandrogenism
- Long term use not recommended
Isotretinoin:
- Recommended for severe nodular acne or acne associated with scarring and significant psychosocial distress
- Low dose isotretinoin can be used when side effects limit conventional dosing
- Should be taken with food
- Routine monitoring recommended of: CBC | LFTs | Cholesterol | Triglycerides
- Pregnancy category X: Patients of childbearing age need to be counseled on contraceptive methods
- Significant side effects, most commonly: Dry skin | Cheilitis | Dry eyes | Peeling
- Patients should be counseled on risks including| Possible development of IBD | Mood changes (e.g., depression, SI) | Agranulocytosis | Elevated LFTs | Elevated triglycerides
Miscellaneous and Alternative Therapies:
Chemical peels
- Limited evidence for efficacy of routine use of physical modalities
- Multiple treatments necessary and results not long lasting
Intralesional steroids
- Effective for treatment of single nodules
Tea tree oil, herbal remedies
- Data limited to support use
Role of Diet:
At this time, no dietary changes are recommended for the management of acne
Glycemic index
- High glycemic index diets may be associated with acne
Dairy
- Some emerging data shows dairy intake may influence acne
Primary Sources – Learn More:
Journal of American Academy of Dermatology: Guidelines of Care for the Management of Acne Vulgaris

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