Acne Vulgaris Guidelines

Updated: Aug 27, 2020
  • Author: Jaggi Rao, MD, FRCPC; Chief Editor: William D James, MD  more...
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Guidelines Summary

In 2016, the American Academy of Dermatology (AAD) issued new evidence-based guidelines for treatment of both adolescents and adults. Recommended treatments include topical therapy, antibiotics, isotretinoin, and oral contraceptives. [33] The key recommendations include the following:

  • Benzoyl peroxide or combinations with erythromycin or clindamycin as monotherapy for mild acne; benzoyl peroxide with a topical retinoid or systemic antibiotic therapy for moderate-to-severe acne

  • Topical antibiotics (eg, erythromycin, clindamycin) are not recommended as monotherapy because of the risk of bacterial resistance

  • Topical retinoids as monotherapy in primarily comedonal acne, or in combination with topical or oral antimicrobials for mixed or primarily inflammatory acne

  • Topical adapalene, tretinoin, and benzoyl peroxide can be safely used to treat acne in preadolescent children

  • Topical dapsone 5% gel for inflammatory acne, particularly in adult females

  • Systemic antibiotics are recommended for moderate and severe acne and forms of inflammatory acne that are resistant to topical treatments; doxycycline and minocycline are both more effective than tetracycline

  • Topical therapy with benzoyl peroxide or a retinoid should be used with systemic antibiotics and for maintenance after completion of systemic antibiotic therapy

  • Monotherapy with systemic antibiotics is not recommended

  • Systemic antibiotic use should be limited to the shortest possible duration; to minimize the development of bacterial resistance, reevaluation at 3-4 months

  • Use of oral erythromycin and azithromycin should be limited to those who cannot use the tetracyclines (ie, pregnant women or children aged < 8 y); erythromycin use should be restricted because of its increased risk of bacterial resistance

  • Isotretinoin is recommended for severe acne or moderate acne that does not respond to other therapy; low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medication-related adverse effects, but intermittent dosing is not recommended; all patients treated with isotretinoin must adhere to the iPLEDGE risk management program; patients should receive routine monitoring of liver function tests, serum cholesterol, and triglycerides at baseline and again until response to treatment is established, but routine monitoring of complete blood count is not recommended; patients should be educated about the potential risks and monitored for any indication of inflammatory bowel disease and depressive symptoms

  • Combined oral contraceptives (COC) containing estrogen are effective for treatment of inflammatory acne in females; physicians should follow the World Health Organization (WHO) recommendations for COC usage eligibility

  • Despite the lack of published data, relying on available evidence, experience, and expert opinion, the guidelines support the use of spironolactone in select women

In 2015, as part of the Choosing Wisely® initiative from the American Board of Internal Medicine Foundation (ABIM), the AAD released recommendations regarding low-value care that cautioned against the routine use of microbiologic testing in the evaluation and management of acne. The AAD concluded that determining the type of bacteria present in acne lesions was unnecessary because it did not alter the management of typical acne presentations. [78]

Canadian clinical practice guidelines for acne treatment have been updated; the following is a summary of their recommendations [79, 80] :

  • Comedonal acne - Topical retinoids or benzoyl peroxide; fixed-dose combinations adapalene–benzoyl peroxide and clindamycin–benzoyl peroxide; or the combination of clindamycin 1.2% and tretinoin 0.025% (as a gel); and, for women, consider combined oral contraceptives

  • Localized mild-to-moderate papulopustular acne - Benzoyl peroxide as monotherapy; topical retinoids as monotherapy; the fixed-dose combination of clindamycin 1% and benzoyl peroxide 5% and the fixed-dose combination of adapalene 0.1% and benzoyl peroxide 2.5% (as gels); or the combination of clindamycin 1.2% and tretinoin 0.025% gel

  • More extensive moderate papulopustular acne - Addition of systemic antibiotics to the topical medications above, as recommended for mild-to-moderate papulopustular acne

  • More extensive moderate papulopustular acne in women - Addition of combined oral contraceptives to the topical medications above, as recommended for mild-to-moderate papulopustular acne

  • Severe acne - Oral isotretinoin or systemic antibiotics in combination with benzoyl peroxide, with or without topical retinoids

  • Oral isotretinoin - Should only be prescribed by physicians with experience in prescribing and monitoring the drug; strict pregnancy precautions must be followed

The American Academy of Pediatrics has endorsed the recommendations of the American Acne and Rosacea Society for the diagnosis and treatment of pediatric acne. [25] The evidence-based guidelines used age and pubertal status to delineate classification, diagnosis, evaluation, and management, as well as special concerns such as the psychosocial effects of acne, treatment adherence, and dietary considerations.

The following are among recommendations presented for adolescent, preadolescent, infant, and neonatal acne [25] :

  • Benzoyl peroxide is generally safe and effective as monotherapy or when used in topical combination products for mild acne (level A)

  • Topical retinoids may be used either as monotherapy or in combination with other products and in therapeutic regimens for all types and severities of acne in children and adolescents of all ages (level A)

  • Oral antibiotics may be used for moderate-to-severe inflammatory acne for any age (except for tetracycline in children < 8 years) (level B)

  • Hormonal therapy with combination oral contraceptives may be used as second-line therapy in pubertal females with moderate-to-severe acne (level A)

  • Isotretinoin is recommended for severe, scarring, and/or refractory acne in adolescents (level A)

In June 2014, FDA announced that "rare but serious and potentially life-threatening" reactions can occur with over-the-counter acne medications. [81] It advised healthcare professionals to instruct consumers to stop using these products and seek emergency medical attention immediately if they experience hypersensitivity reactions such as swelling of the eyes, face, lips, or tongue; difficulty breathing; throat tightness; feelings of faintness; or hives or itching. These reactions may occur within minutes to a day or longer after using the product. The FDA is uncertain whether the reactions are caused by the active ingredient (ie, benzoyl peroxide, salicylic acid), inactive ingredients, or a combination of both. For more information, see Serious Allergic Reactions Possible With Acne Products, FDA Says.