Acne Fulminans Guidelines

Updated: Jun 15, 2022
  • Author: Ryszard Zaba, MD, PhD; 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 acne vulgaris treatment of both adolescents and adults. Recommended treatments include topical therapy, antibiotics, isotretinoin, and oral contraceptives. [31] 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. [32]

Flowchart for the management of acne fulminans patients is also available. [33]