New Acne Guidelines Recommend Topical Combinations, Judicious Use of Antibiotics

Antibiotics, benzoyl peroxide, topical retinoids, and oral isotretinoin received strong recommendations for acne treatment from a panel of experts who drafted an update to the American Academy of Dermatology (AAD) clinical guidelines.

The panel made 18 treatment recommendations (categorized as strong or conditional) and five good practice statements. Five strong recommendations were made for oral doxycycline, topical antibiotics (including fixed-dose combinations), topical retinoids, and topical benzoyl peroxide. Additionally, the panel strongly recommended isotretinoin for severe acne.

The recommendations, published in the Journal of the American Academy of Dermatology (JAAD), begin with a good practice statement: “When managing acne with topical medications, we recommend multimodal therapy combining multiple mechanisms of action.”

Other good practice statements advised clinicians to use fixed-dose topical antibiotics plus other topical agents, intralesional corticosteroid injections as adjuvant therapy for larger papules or nodules, and isotretinoin for severe, treatment-resistant acne, as well as to limit use of systemic antibiotics whenever possible.

“The new guidelines provide important recommendations for novel acne treatments such as clascoterone (Winlevi) and sarecycline (Seysara),” guideline panel co-chair John Barbieri, MD, of Brigham and Women’s Hospital in Boston, told MedPage Today via email. “Clascoterone is the first FDA-approved treatment that can address hormonal causes of acne in both men and women. Sarecycline is a narrow-spectrum tetracycline that might have some advantages over other tetracyclines such as doxycycline and minocycline.”

“It will be important that payers provide coverage to ensure that patients have access to these valuable new treatments,” he added. “We also discuss other new treatments such as minocycline foam and lotion formulations of tretinoin and tazarotene.”

The guidelines reflect the AAD’s transition from Strength of Recommendation Taxonomy (SORT) to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, which aligns more closely with international standards. A strong recommendation means the benefits clearly outweigh the risks and burdens and apply to most patients. A strong recommendation against means the risks and burdens clearly outweigh the benefits.

Conditional recommendations mean that the benefits are closely balanced with risks and burdens, whereas a conditional recommendation against means the risks and burdens are closely balanced with the benefits. Conditional recommendations for or against imply that the most appropriate action might differ, depending on patient or other stakeholder values.

The guideline panel conditionally recommended the topical agents clascoterone (though supported by high-level evidence), salicylic acid, and azelaic acid, as well as the systemic antibiotics minocycline and sarecycline. The panel also conditionally recommended doxycycline over azithromycin.

“While minocycline and doxycycline are currently prescribed in roughly equal proportions for the management of acne, there is a lack of evidence that minocycline is more effective, and there are important safety concerns such as vestibular dysfunction, autoimmune hepatitis, drug-induced lupus, and drug reaction with eosinophilia and systemic symptoms (DRESS),” Barbieri noted. “As a result, while the guidelines have a strong recommendation for the use of doxycycline, they have a conditional recommendation for the use of minocycline. We should consider whether reducing use of minocycline might be beneficial to our overall care of patients with acne.”

With respect to hormonal treatments, the panel conditionally recommended oral contraceptives and spironolactone. Potassium monitoring for spironolactone is not necessary in healthy patients but might be considered for patients with risk factors for hyperkalemia.

For patients with severe acne, conditional recommendations were made for daily isotretinoin dosing over intermittent dosing and for use of standard isotretinoin or lidose-isotretinoin. The experts conditionally recommended against adding pneumatic broadband light to adapalene gel.

The panel advised clinicians to limit use of trimethoprim-sulfamethoxazole because of a risk of severe adverse reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis and acute respiratory failure.

The complete guidelines are available to the public on the JAAD website.

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