, according to the consensus of an international panel of dermatologists, led by Diane M. Thiboutot, MD, professor of dermatology, Penn State University, Hershey.
Dr. Thiboutot is the chair of the Global Alliance to Improve Outcomes in Acne, an international group of dermatologists interested in acne research and education; they have been meeting regularly since 2001 and continuously evaluate the literature on acne.
Dr. Diane Thiboutot
A Delphi panel and questionnaire method was used to reach consensus. A panel of 36 dermatologists from 27 countries who were members of the alliance answered a set of questionnaires on selected topics. An online questionnaire on various topics was developed, and panel members were asked to rate agreement with each statement on a 5-point Likert scale. If they selected disagree, strongly disagree, or unable to answer, they were asked to provide a written explanation of what they disagreed with. Ultimately, consensus was reached if 75% of more of the panel members agreed on a statement.
Assessing acne severity
The term “severe acne” currently is perceived to refer to nodular/conglobate acne, which is generally treated with oral isotretinoin. But development of added first-line treatment options means there may be a need for a system of classifying moderately severe, severe, and very severe acne. The 2016 European S3 Acne Guideline uses a 4-point classification system that might help: 1) comedonal acne, 2) mild-moderate papulopustular acne; 3) severe papulopustular acne, moderate nodular acne; and 4) severe nodular acne, conglobate acne. In a similar fashion, the U.S. Food and Drug Administration’s Investigator’s Global Assessment scale considers quality of lesions and quantity, including a grade of severe acne that is separate from nodular/conglobate acne.
“We propose that the designation “very severe” be reserved for cystic and conglobate acne,” Dr. Thiboutot and her associates wrote.
Strategic approach to acne therapy
First-line therapy for most patients with inflammatory acne, comedonal acne, or both, should be a topical retinoid plus topical benzoyl peroxide (BPO), the panelists agreed.
Topical or systemic antibiotics should not be used as monotherapy because of the rapid development of resistance. All strains of Propionibacterium acnes are sensitive to BPhO.
Topical retinoids (with or without BPO) or azelaic acid are the treatment of choice for maintenance, not topical antibiotics, they said.
Oral isotretinoin is indicated as first-line therapy for very severe (cystic and conglobate) acne. A small percentage of patients, perhaps 15%, experience acne flare on oral isotretinoin. This often can be managed by using low-dose therapy, say 0.5 mg/kg, although some panelists said that in some cases inflammatory flare occurs regardless of dose.
Oral tretinoin therapy should continue until full clearance of acne. More studies are needed to define the total cumulative dose that maintains remission, the alliance members said.
Determining the risk-benefit for using systemic antibiotics needs to balance individual need against public interest in preserving antibiotic effectiveness, the authors said. Antibiotics should be avoided when there are effective alternatives.
Oral antibiotics are indicated if inflammatory acne isn’t responding well to topical treatments, and acne involves the trunk or multiple bodily areas. Evaluate response to therapy at 6-8 weeks, and don’t treat for more than 3-4 months. After stopping antibiotics, use a topical retinoid and BPO or azelaic acid, they said.
The article, published in the Journal of the American Academy of Dermatology, provides an acne management algorithm that summarizes a treatment approach on the basis of these consensus recommendations.
Special populations
The panelists largely agreed that azelaic acid cream 20% or gel 15% can be useful to treat acne in pregnant women and patients with acne and postinflammatory hyperpigmention, although some said it can cause irritation and aggravate already inflamed skin.
In patients with inflammatory acne, devices such as laser, intense pulsed light, and photodynamic therapy should not be considered first-line treatment, they concluded.
The article also includes clinical pearls for treating acne and postinflammatory hyperpigmentation, questions to ask when taking an acne scar history, an atrophic acne scar risk-assessment tool, clinical pearls for preventing atrophic acne scars, interventions for treating facial atrophic acne scars, clinical pearls for preventing and managing hypertrophic or keloidal scars, and clinical pearls regarding acne in women.
The study is supported by an unrestricted educational grant from Galderma International SAS, Paris. All authors have served as advisory board members for Galderma and received honoraria. Dr. Thiboutot has received fees and research funding for serving as a consultant and investigator for Allergan, Mimetica, Novan, and Sebacia and as a consultant for Dermira, Galderma, Photosonix, and Xenon. Many of the other alliance members have financial associations with biopharmaceutical companies.
SOURCE: Thiboutot DM et al. J Am Acad Dermatol. 2018 Feb. doi: 10.1016/j.jaad.2017.09.078.