guidelines for acne vulgaris
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penanganan acne vulgarisTRANSCRIPT
Guidelines for acne vulgaris treatment
Management of Acne: A Report from a Global Alliance to Improve Outcomes in Acne
Key consensus recommendations:
Acne pathophysiology should influence treatment, which should target as many factors as possible.
Retinoids
Most patients with acne benefit from a retinoid – with a topical agent as part of conventional therapy, or oral isotretinoin for treatment-resistant cases.Topical retinoids have multiple anti-acne actions, and should be primary treatment for most forms of acne vulgaris.
Use early for best results. Should be applied to the entire affected area. Combine with antimicrobial therapy when inflammatory lesions are present. Essential part of maintenance therapy.
Antimicrobials plus topical retinoid therapy
Antimicrobial therapy plus topical retinoid therapy is significantly better than antimicrobials alone. Combination therapy allows targeting of different pathophysiologic factors. Topical retinoid therapy is likely to enhance penetration of antimicrobial agents. Add topical retinoids early—at the onset of therapy—for greatest and fastest results. Maintain success by continuing with topical retinoid.
Combination therapy
Should be used when inflammatory lesions are present. Speeds clearing and provides greater resolution of both inflammatory lesions and comedones Topical retinoid should be started at the initiation of antimicrobial therapy Antibiotic should be discontinued when inflammatory lesions resolve adequately. If this is not possible, then switch to a combination agent with benzoyl peroxide plus an antibiotic. Continue use of topical retinoid to maintain remission of new acne lesions when antibiotic therapy is
discontinued.
Antimicrobial therapy
Antimicrobial therapy primary affects inflammatory lesions. Oral and topical antibiotics should not usually be used as monotherapy. Antibiotics are generally well tolerated, but are associated with rare instances of severe adverse events
(minocycline). Antibiotics should be combined with topical retinoids to enhance efficacy against comedones and
inflammatory acne lesions. Benzoyl peroxide alone significantly improves inflammatory acne. Topical benzoyl peroxide or azaleic acid treatment may be added to antibiotics to reduce the potential of
developing P acnesresistance.
Hormonal therapy
Excellent choice for women who need oral contraception for gynaecologic reasons. Use early in female patients with moderate to severe acne or with seborrhea/acne/hirsutism/alopecia
(SAHA) symptoms. Useful as a component of combination therapy in women with or without endocrine abnormalities. Sometimes used in women with late-onset acne.
Oral retinoids
Oral isotretinoin is the mainstay of therapy for severe acne. Targets all pathophysiologic factors in acne. May achieve dramatic results even in severe disease. Now used more frequently in moderate, nonresponsive acne. Side-effects are common, but usually manageable. Education is vital (side-effects, teratogenicity, adverse psychiatric events, monitoring). Variable rate of recurrence; retreatment may be necessary. (Ref: Cunliffe WJ and Gollnick H, H. Management of acne. A report from a global alliance to improve
outcomes in acne. Am Acad Dermatol 2003; 49 (1): S1-S37)
Use of isotretinoinAdvice on the safe introduction and continued use of isotretinoin in acne in the UK 2010.ref: Goodfield, MJD, Cox, NH, Bowser A et al. BJD 2010; 162: 1172-1179
Clinical Knowledge SummaryAcne vulgaris management
NICE referral advicehttp:/www.nice.org.uk/nice-eb/pdf/NICE_GP_Referral_cues_4.pdf[Alison Layton includes these – but I can’t find on the NICE website – I can only find the following:NICE. Referral Advice.
US guidelinesAmerican Academy of Dermatologists: Guidelines of care for acne vulgaris management.Ref: Strauss JS, Krowchuk DP, Leyden JJ et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007; 56: 651-663
What are the clinical characteristics of acne?
A spectrum of lesions may be present, including non-inflammatory open and closed comedones (blackheads and whiteheads, respectively) and inflammatory papules, pustules, nodules, and cysts. Lesions may be present on the face, neck, chest, or back—areas with the greatest density of pilosebaceous units.12 Comedone formation is intrinsic to the diagnosis of acne vulgaris—when not clinically apparent, consider alternative diagnoses. Diseases that mimic acne include rosacea, folliculitis, angiofibromas, perioral dermatitis, and keratosis pilaris.5 13 14 The patient’s age may also help to distinguish these disorders from acne. Keratosis pilaris and perioral dermatitis, for example, tend to present in childhood, whereas rosacea tends to affect older adults. In cases of diagnostic uncertainty, referral to specialist care is warranted.
Several groups have proposed standardized measures for classifying acne, although none has been universally accepted.10 13 15 Classification is important because it helps to inform treatment strategies.3 11 Acne is categorized broadly into mild, moderate, and severe forms. Mild acne is typically limited to the face and is characterized by the presence of non-inflammatory closed and open comedones with few inflammatory lesions. Moderate acne is characterized by an increased number of inflammatory papules and pustules on the face and often mild truncal disease. Finally, acne is considered to be severe when nodules and cysts are present. In these cases, facial lesions are often accompanied by widespread truncal disease.
What causes acne?
Acne is an inflammatory disease of the pilosebaceous duct that results from four primary pathophysiologic processes:
Abnormal keratinocyte proliferation and desquamation that leads to ductal obstruction
Androgen driven increase in sebum production Proliferation of Propionibacterium acnes Inflammation.2 9 13 16 17
Increased androgen production causes abnormal epithelial desquamation and follicular obstruction, which lead to the primary precursor lesion in acne—the microcomedone. Microcomedones are pathological structures not visible to the naked eye that evolve into visible lesions.18 An increase in circulating androgens also promotes sebum production, causing these obstructed follicles to fill with lipid rich material and form visible open and closed comedones.12 19 Sebum serves as a substrate for bacterial growth, leading to proliferation of P acnes. Finally, P acnes releases chemical mediators that promote inflammation, which is propagated
by traumatic rupture of comedones into the surrounding dermis.2 17 This inflammation manifests through the development of inflammatory papules, pustules, nodules, and cysts.
The successful management of acne requires an understanding of these four facets of the pathophysiology of acne. Clinicians should select mechanistically driven treatment regimens that target each patient’s predominant lesion types.
Can acne be prevented?
Myths about the causes of acne abound. The central discoloration in blackheads is not dirt, but oxidized melanin.20 A comprehensive systematic review found little evidence for an association between acne and poor facial hygiene and provided minimal support for frequent face washing.21 Aggressive cleansing may cause irritation, thereby exacerbating active lesions or limiting the patient’s tolerance of therapy.21 22 Basic care with twice daily washing and use of a moisturizer that does not contribute to comedone formation (noncomedogenic) is an accepted standard.9 Although misconceptions about dietary triggers have been largely dispelled, recent reports—including a systematic review of dietary influences on acne and a randomized investigator masked controlled trial of glycemic load and acne severity—suggest that acne is associated with high dairy diets and those with a high glycemic load.23 24 25 26 27 Finally, a cross sectional analysis found a significant dose dependent association between smoking and acne severity.20 28
How is acne treated?
Careful assessment of the morphology and severity of acne is an important first step in management, because lesion morphology largely dictates the optimal treatment approach. Treatment should be designed to target precursor lesions (microcomedones) and active inflammatory lesions. Milder cases are best managed with topical regimens, whereas systemic drugs are indicated in more severe cases. The box summarises the mechanisms of action of the most commonly used agents. The table⇓ provides a treatment framework based on disease severity.
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General treatment algorithm according to acne severity
Effects of the different agents used to treat acne
Topical retinoids: Comedolytic and sometimes anti-inflammatory
Antibiotics: Antimicrobial and anti-inflammatory Benzoyl peroxide: Antimicrobial plus weakly anti-inflammatory and
comedolytic Hormonal agents: Sebosuppressive Oral retinoids: Comedolytic, sebosuppressive, antimicrobial, and anti-
inflammatory
Topical agents
Retinoids
Retinoids are vitamin A derivatives that normalize keratinocyte desquamation and adhesion, leading to comedolysis and preventing formation of new microcomedones. Some retinoids also display anti-inflammatory properties.11 15 29 30 31 32 Perhaps the most notable recent development in the treatment of acne is the increased use of topical retinoids.29 Many randomized trials show the efficacy of these drugs relative to vehicle, and they are recommended for all cases of acne, except when oral retinoids are used.9 11 Studies show improvements within weeks, with maximal benefit after three to four months.13 15 18 Mild non-inflammatory comedonal acne may be treated with retinoid monotherapy. When inflammatory lesions are present, retinoids should be combined with antimicrobial therapy or benzoyl peroxide.9 16 Because retinoids prevent the development of microcomedones, they can also be used for maintenance therapy.9
Several topical retinoid products exist, including tretinoin, isotretinoin (not available in the United States), adapalene, and tazarotene (not licensed for treatment of acne in the United Kingdom).18 These products are available in cream, gel, liquid, and microsphere formulations, each at multiple concentrations. Formulations vary by country.9 18 Use of retinoids is limited by transient skin irritation, which may be prevented by selecting lower concentration or cream based formulations.18 29 31 A meta-analysis of five randomized controlled trials suggests that adapalene is the best tolerated retinoid, whereas several moderately sized randomized studies found tazarotene to be most efficacious at the expense of irritation.13 18 29 31 32 33 34 35 36 37 38 In addition, anecdotal evidence suggests that some patients experience an initial “flare” in acne lesions, which subsides with continued use.2 18 31 Lastly, pregnant and breastfeeding women should avoid topical retinoids.18 Women of child bearing age should be counselled about the need for contraception.17
Topical antibiotics
The primary topical antibiotics used for acne are clindamycin and erythromycin.30 These agents have bacteriostatic and anti-inflammatory
properties.11 30 32 Topical antibiotics are used for mild to moderate acne when inflammatory lesions are present.16
Antibiotic resistance is a growing concern and has prompted efforts to limit the duration of antibiotic courses and to emphasize combined regimens.2 Patterns of P acnes resistance correspond to trends in antibiotic use.2 39Treatment outcomes worsen when resistance is present—systematic reviews show decreasing antibiotic efficacy over time, particularly for erythromycin and clindamycin.2 32 40 41 P acnes resistance is not the only concern—Staphylococcus and Streptococcus resistance may also develop.39 42 In practice, this means avoiding antibiotic monotherapy and maintenance therapy.19 20 Instead, topical antibiotics should always be used with retinoids, and possibly benzoyl peroxide. Several double blind randomized controlled trials have found that the addition of retinoid or benzoyl peroxide therapy to topical antibiotics improves treatment outcomes.9 10 17 39 43 44 Retinoids do not decrease resistance but promote antibiotic efficacy by improving penetration and providing synergistic comedolytic and anti-inflammatory effects.18 45 Benzoyl peroxide has bactericidal properties, thereby minimizing bacterial resistance.39 45 Topical antibiotic courses should be limited to 12 weeks’ duration when possible.9 16 46 Finally, combined topical and oral antibiotics should be avoided.15 47
Benzoyl peroxide
Benzoyl peroxide is a non-antibiotic antimicrobial agent that has bactericidal effects by generating reactive oxygen species within the follicle.15 32 48 49 It also has weak comedolytic and anti-inflammatory properties.32Owing to its bactericidal properties, benzoyl peroxide produces rapid improvement in inflammatory lesions and prevents the development of antibiotic resistance.15 32 39 45 48 49 50 51 52 Although data on the comparative efficacy and tolerability of benzoyl peroxide and topical retinoid monotherapy are conflicting, most guidelines recommend a mechanistically driven approach, with the addition of benzoyl peroxide mainly when inflammatory lesions are present.9 10 17 Some studies, including a small double blind randomized trial, show that inflammatory lesions improve more rapidly with benzoyl peroxide than with topical retinoids.53
Benzoyl peroxide is available in numerous formulations, in concentrations ranging from 2.5% to 10%,29 none of which show clear superiority in systematic reviews, although irritation increased with higher concentrations.27 32 48 52 Irritation typically resolves with continued use. In addition, patients should be warned that benzoyl peroxide may bleach clothing, bedding, and hair.13 32 Finally, because all retinoids except adapalene are unstable with benzoyl peroxide, these agents should be applied separately.18 31 32
A patient’s story
I first developed acne in high school. My family encouraged me to wash my face often with several over-the-counter products, which mostly exacerbated my symptoms. I was so embarrassed about my skin that I started to avoid spending time with friends. When my mother noticed this change, she agreed to take me to a dermatologist, who suggested topical antibiotics and benzoyl peroxide. These treatments caused substantial irritation, so I stopped using them promptly. I was sure that my acne was incurable, so I learned to live with it.
When I reached adulthood, I began taking oral contraceptive pills, not knowing that they could affect the acne. Within a month of starting treatment, my acne improved dramatically. After six months, my lesions had nearly disappeared. I was thrilled to be disease free for the first time in nearly a decade but felt sad that this therapy had not been offered to me years earlier. I suspect this would have substantially improved my teenage confidence and self esteem.
Combination products
The benefits of combined regimens include complementary mechanisms of action, reduced risk of antibiotic resistance, and improved treatment outcomes.2 9 10 13 15 17 18 30 47 48 An increasing number of antibiotic-retinoid and antibiotic-benzoyl peroxide combinations are now available. Retinoid-benzoyl peroxide combinations are limited by retinoid instability in the presence of benzoyl peroxide.
The biggest drawback to combined products is cost. Individual generic components are typically less expensive and can be applied simultaneously with equivalent effects.32 46 Nevertheless, a small investigator blinded randomized controlled trial found that combined products improve patient adherence by simplifying daily regimens.54 For many clinicians and patients, this improved ease of application and corresponding increase in adherence justifies the cost of combined therapies.
Other topical treatments
Azelaic acid
Azelaic acid is an alternative to retinoids that has comedolytic, antimicrobial, and anti-inflammatory properties.9 13 17 This agent has not been approved for acne by the US Food and Drug Administration, although it has been approved in many European countries, so receives greater emphasis in the European literature.10 55 A small double blind randomized trial demonstrated efficacy of azelaic acid relative to placebo.56 Studies comparing azelaic acid with other topical agents are limited. Azelaic acid is well tolerated but poses a risk of hypopigmentation in darker skinned patients.17
Salicylic acid
Salicylic acid is an over-the-counter agent with desquamating and comedolytic properties that is less potent than retinoids.48 Few studies of salicylic acid exist, although available studies show that it is less effective but better tolerated than other agents.17 29 48 Salicylic acid may be used when patients cannot tolerate standard agents.
Systemic agents
Systemic agents should be considered for patients with moderate to severe acne. These therapies are useful in patients with truncal disease in whom application of topical agents would be difficult.
Hormonal therapies
Hormonal therapies are a useful adjunct to treatment in women with moderate to severe acne, especially those who desire oral contraception or in whom traditional therapy has failed.27 Anecdotal evidence suggests that women with lesions confined to the lower face and jaw are most likely to benefit.15 57 Hormonal agents are available in two primary forms: combined oral contraceptives, which suppress ovarian androgen production, and androgen receptor blockers, such as cyproterone acetate, spironolactone, and flutamide. In the UK, a combined oral contraceptive containing cyproterone acetate and ethinylestradiol is licensed for the treatment of acne.13 57 58 These agents decrease androgen mediated effects on the sebaceous follicle.57 Although hyperandrogenic states such as polycystic ovarian syndrome are associated with acne, most women with acne have normal androgen levels but still benefit from antiandrogen therapy.57 Full benefit is seen after three to six months of treatment.15
A recent Cochrane review confirmed the efficacy of combined oral contraceptives in treating inflammatory and non-inflammatory acne but found few differences in efficacy between the different types, including cyproterone acetate, which is often recommended.59 60 It is therefore not clear whether formulations containing cyproterone acetate should be favored, especially because this agent may increase the risk of venous thromboembolism.27 57 59 Progesterin only contraceptives may worsen acne.9
Oral antibiotics
Systemic antibiotics are indicated for moderate to severe inflammatory acne.9 Like topical antibiotics, oral antibiotics have antimicrobial and anti-inflammatory effects.13 39 50 Doxycycline, minocycline, lymecycline, tetracycline, and erythromycin are most commonly used. Few comparative studies exist, although a systematic review of systemic therapy with tetracyclines found no antibiotic to be
more effective than another.17 41 46Although minocycline was previously favored by clinicians, a recent Cochrane review found no clear evidence of superiority.61 62 Given the lack of comparative data, antibiotic selection may be driven by side effect profiles and patterns of P acnes resistance. Tetracyclines must be avoided in pregnant women and children given the associated risk of tooth discoloration. Women of childbearing age should be advised to use contraception when taking these agents. Doxycyline causes photosensitivity. In rare cases minocycline leads to skin hyperpigmentation and drug induced systemic lupus erythematosus. Limecycline has gained popularity in Europe but is not available in the US.63 Increasing P acnes resistance has decreased reliance on erythromycin and tetracycline.11 42 49 50
As with topical antibiotics, oral antibiotics should be combined with other agents to minimize the development of bacterial resistance and improve treatment efficacy. Always use oral antibiotics in conjunction with a topical retinoid or benzoyl peroxide16 50—several small to moderate sized randomized controlled trials have shown that this increases efficacy.64 65 66 Assess treatment response at six to eight weeks, at which point a decision to continue or change antibiotics may be made.50 When possible, limit antibiotic courses to 12 weeks’ duration.2 16 46
Isotretinoin
Isotretinoin is remarkably efficacious in the treatment of severe acne, as well as treatment resistant moderate disease, and is now the first line treatment in such cases.10 13 Isotretinoin is thought to target all four components involved in the development of acne by normalizing follicular desquamation, decreasing sebum secretion, inhibiting the growth of P acnes, and exerting anti-inflammatory effects.13 31 49 Given these broad effects and the potential for adjunctive therapy to compound adverse effects, isotretinoin is prescribed as monotherapy.
Patients typically complete a 16-24 week course of isotretinoin, taking 0.5-1 mg per kg per day to target a cumulative dose of 120-150 mg per kg.11 16 49 The dose is slowly increased as tolerated. Effects are not usually seen for the first one or two months.67 Meta-analyses show that at least half of patients are permanently cured after a single course, and only 20% of patients require repeat treatment.15 17 31 49 68 69 Relapse is most common in younger patients, in women with hormonally driven acne, and when goal cumulative dosing is not achieved.31 57 70 71
Use of oral isotretinoin is tightly regulated because of its well known teratogenic effects and is available through specialist care only in many countries.42 Female patients must demonstrate a negative pregnancy test and use contraception.49 Although charged with having detrimental psychological effects, there is no clear evidence that isotretinoin leads to depression or suicidality.72 73 74 Other adverse reactions include chapped skin, dry eyes,
epistaxis, myalgias, and alterations in serum lipid and transaminase concentrations, most of which resolve after treatment is stopped.11 13 31 49
What are the consequences of acne?
Although many people dismiss acne vulgaris as an inconsequential disease of adolescence, it has clear long lasting psychosocial and physical effects. Many studies have shown an association between acne and depression and anxiety, independent of disease severity.7 75 Psychological effects improve with treatment.76 Furthermore, acne may cause permanent scarring that is difficult to correct. Finally, because of its frequency and chronicity, the economic burden of acne is substantial, with associated expenditure in the US alone exceeding $2.5bn (£1.64bn; €1.93bn) annually.20 To reduce these effects, patients with acne should receive early, aggressive, mechanistically driven therapy.
Areas for future research
Large randomized controlled trials on the treatment of acne are needed Comparative effectiveness research should be prioritized, as cited by the
Institute of Medicine77 Study of the cutaneous microbiome, including disease associations
with Propionibacterium acnes strains, may improve our understanding of the pathogenesis of acne and open up new therapeutic approaches78
Additional educational resources
Resources for healthcare professionals
American Academy of Dermatology: Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, Siegfried EC, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007;56:651-63
European Dermatology Forum: Nast A, Dreno B, Bettoli V, Degitz K, Erdmann R, Finlay AY, et al. European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol2012;26(suppl 1):1-29
Global Alliance to Improve Oucomes in Acne: Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2003;49(1 suppl):S1-37
National Institute of Health and Care Excellence (www.cks.nhs.uk/acne_vulgaris)—Clinical knowledge summary on acne vulgaris
Resources for patients
American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/acne)—Basic patient information regarding acne treatment with particular emphasis on adult acne
British Association of Dermatologists (www.bad.org.uk/site/793/default.aspx)—General overview of acne treatment
National Institute of Health and Care Excellence (www.cks.nhs.uk/acne_vulgaris)—Clinical knowledge summary on acne vulgaris
UpToDate Patient Information (www.uptodate.com/contents/acne-beyond-the-basics)—Patient oriented guide to the pathophysiology and treatment of acne
Notes
Cite this as: BMJ 2013;346:f2634
Footnotes
Contributors: Both authors had full access to the content of this review and are guarantors. ALD searched the literature, compiled the references, and drafted the manuscript. RPD critically revised the manuscript for intellectual content.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; externally peer reviewed. Patient consent obtained.
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Acne Vulgaris, I:
Pathogenesis and Diagnosis
Steve S. Oberemok, MD; Alan R. Shalita, MD
VOLUME 70, AUGUST 2002
Continuing Medical Education
Diagnosis
Acne is generally limited to areas where sebaceous
glands are largest and most abundant—the face,
neck, chest, upper back, and upper arms. Individual
lesions are centered about sebaceous follicles.
Correct classification of lesion type (Table) is
essential for choosing the most effective therapy.
At the 1990 Consensus Conference on Acne
Classification,21 a global evaluation of lesions and
their complications (eg, drainage, hemorrhage,
pain) was proposed. Psychosocial impact, failure
to respond to previous therapies, and occupational disability are 3 additional factors used in
grading acne.
Noninflammatory acne lesions are either closed
or open comedones. Acne that manifests as noninflammatory lesions is not classified severe unless
the number, size, and extent of such lesions are so
overwhelming as to warrant the designation.
Inflammatory acne lesions are papules, pustules,
and nodules. These lesions are classified as papulopustular, nodular, or both. The severity grades
assigned (mild, moderate, severe) are based on
lesion count approximations (Table).
The term cystic acne should probably be abandoned, as there are no true cysts in acne (on rare
occasion, these cysts develop as a residual effect of
acne lesion healing). The term severe acne may be
applied if ongoing scarring or persistent lesiondrainage is involved or if sinus tracts are present. In
addition, the most destructive forms of acne—acne
conglobata, acne fulminans, follicular occlusion
triad—are classified as very severe.