Shaw JC.

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.Canadian clinical practice guidelines for acne treatment have been updated; the following is a summary of their recommendationsComedonal 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 contraceptivesLocalized 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% gelMore extensive moderate papulopustular acne - Addition of systemic antibiotics to the topical medications above, as recommended for mild-to-moderate papulopustular acneMore extensive moderate papulopustular acne in women - Addition of combined oral contraceptives to the topical medications above, as recommended for mild-to-moderate papulopustular acneSevere acne - Oral isotretinoin or systemic antibiotics in combination with benzoyl peroxide, with or without topical retinoidsOral isotretinoin - Should only be prescribed by physicians with experience in prescribing and monitoring the drug; strict pregnancy precautions must be followedThe American Academy of Pediatrics has endorsed the recommendations of the American Acne and Rosacea Society for the diagnosis and treatment of pediatric acne.The following are among recommendations presented for adolescent, preadolescent, infant, and neonatal acneBenzoyl 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.Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, et al. Oral trimethoprim as a third-line antibiotic in the management of acne vulgaris. Available at Recommended treatments include topical therapy, antibiotics, isotretinoin, and oral contraceptives.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 acneTopical antibiotics (eg, erythromycin, clindamycin) are not recommended as monotherapy because of the risk of bacterial resistanceTopical retinoids as monotherapy in primarily comedonal acne, or in combination with topical or oral antimicrobials for mixed or primarily inflammatory acneTopical adapalene, tretinoin, and benzoyl peroxide can be safely used to treat acne in preadolescent childrenTopical dapsone 5% gel for inflammatory acne, particularly in adult femalesSystemic 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 tetracyclineTopical therapy with benzoyl peroxide or a retinoid should be used with systemic antibiotics and for maintenance after completion of systemic antibiotic therapyMonotherapy with systemic antibiotics is not recommendedSystemic antibiotic use should be limited to the shortest possible duration; to minimize the development of bacterial resistance, reevaluation at 3-4 monthsUse 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 resistanceIsotretinoin 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 symptomsCombined 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 eligibilityDespite the lack of published data, relying on available evidence, experience, and expert opinion, the guidelines support the use of spironolactone in select womenIn 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.

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