Management of Acne Vulgaris

Publication Date: January 31, 2024
Last Updated: April 10, 2024

Topical Agents

When managing acne with topical medications, we recommend multimodal therapy combining multiple mechanisms of action. (U, CC)
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For patients with acne, we recommend benzoyl peroxide. (S, M )
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For patients with acne, we recommend topical retinoids. (S, M )
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For patients with acne, we recommend topical antibiotics. (S, M )
Remark: Topical antibiotic monotherapy is not recommended.
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For patients with acne, we conditionally recommend clascoterone. (C, H )
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For patients with acne, we conditionally recommend salicylic acid. (C, L )
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For patients with acne, we conditionally recommend azelaic acid. (C, M )
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For patients with acne, we recommend fixed dose combination topical antibiotic with benzoyl peroxide. (S, M )
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For patients with acne, we recommend fixed dose combination topical retinoid with topical antibiotic. (S, M )
Remark: Concomitant use of benzoyl peroxide is recommended to prevent the development of antibiotic resistance.
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For patients with acne, we recommend fixed dose combination topical retinoid with benzoyl peroxide. (S, M )
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Systemic antibiotics

For patients with acne, we recommend doxycycline. (S, M )
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For patients with acne, we conditionally recommend minocycline. (C, M )
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For patients with acne, we conditionally recommend sarecycline. (C, H )
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For patients with acne, we conditionally recommend doxycycline over azithromycin. (C, L )
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For patients with acne, we recommend limiting use of systemic antibiotics when possible to reduce the development of antibiotic resistance and other antibiotic associated complications. (U, CC)
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It is recommended that systemic antibiotics are used concomitantly with benzoyl peroxide and other topical therapy. (U, CC)
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Hormonal agents

For patients with acne, we conditionally recommend combined oral contraceptive pills. (C, M )
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For patients with acne, we conditionally recommend spironolactone. (C, M )
Remark: Potassium monitoring is not needed in healthy patients. However, consider potassium testing for those with risk factors for hyperkalemia (e.g., older age, medical comorbidities, medications).
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For patients with larger acne papules or nodules, we recommend intralesional corticosteroid injections as an adjuvant therapy. (U, CC)
Remark: Intralesional corticosteroid injections should be used judiciously for patients who are at risk of acne scarring and/or for rapid improvement in inflammation and pain. Using a lower concentration and volume of corticosteroid can minimize the risks of local corticosteroid adverse events.
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Isotretinoin

For patients with severe acne or for patients who have failed standard treatment with oral or topical therapy, we recommend isotretinoin. (U, CC)
Remark: Acne patients with psychosocial burden or scarring should be considered as having severe acne and to be candidates for isotretinoin. For patients undergoing treatment with isotretinoin, monitoring of LFTs and lipids should be considered, but CBC monitoring is not needed in healthy patients. Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease in acne patients undergoing treatment with isotretinoin. For persons of childbearing potential, pregnancy prevention is mandatory.
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For patients with severe acne, we conditionally recommend traditional daily dosing of isotretinoin over intermittent dosing of isotretinoin. (C, L )
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For patients prescribed isotretinoin, we conditionally recommend either standard isotretinoin or lidose-isotretinoin. (C, H )
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Physical modalities

For patients with acne, we conditionally recommend against adding pneumatic broadband light to adapalene 0.3% gel. (C, L )
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Algorithm

Algorithm: Management of Acne Vulgaris

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Recommendation Grading

Overview

Title

Management of Acne Vulgaris

Authoring Organization

American Academy of Dermatology

Publication Month/Year

January 31, 2024

Last Updated Month/Year

February 1, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The objective of this study was to provide evidence-based recommendations for the management of acne. This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

Target Patient Population

Patients with acne vulgaris

Target Provider Population

Dermatologists and other clinicians caring for patients with acne vulgaris

Inclusion Criteria

Male, Female, Adolescent, Adult, Child

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D013256 - Steroids, D013754 - Tetracyclines, D000152 - Acne Vulgaris, D000287 - Administration, Topical

Keywords

acne, acne vulgaris, acne management, topical antibiotics, antibiotics

Source Citation

Rachel V. Reynolds, Howa Yeung, Carol E. Cheng, Fran Cook-Bolden, Seemal R. Desai, Kelly Druby, Esther E. Freeman, Jonette E. Keri, Linda F. Stein Gold, Jerry K.L. Tan, Megha M. Tollefson, Jonathan S. Weiss, Peggy A. Wu, Andrea L. Zaenglein, Jung Min Han, John S. Barbieri, Guidelines of care for the management of acne vulgaris, Journal of the American Academy of Dermatology, 2024, ISSN 0190-9622, https://doi.org/10.1016/j.jaad.2023.12.017.

Methodology

Number of Source Documents
312
Literature Search Start Date
May 1, 2021
Literature Search End Date
November 1, 2022