What’s new in the management of acne vulgaris?
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, May 1, 2024
In this month’s Clinical Applications column, DermWorld Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with John Barbieri, MD, MBA, FAAD, co-chair of the Academy’s Acne Guidelines Workgroup, about his JAAD paper on ‘Guidelines of care for the management of acne vulgaris.’
DermWorld: First of all, I’d like to thank you and all the AAD members and staff who contributed to the recently published guidelines for the management of acne vulgaris. When were the last guidelines published and was this a scheduled update or did something specific prompt it?
DermWorld: Can you briefly describe the process of creating guidelines? How do you decide to make a recommendation?
Dr. Barbieri: After establishing the guideline workgroup and its scope, a topic list with clinical questions is developed. This topic list is used to generate Population, Intervention, Comparison and Outcomes (PICO) criteria for a systematic review of the available literature. After this systematic review is completed, the evidence is quantitatively synthesized and reviewed using the GRADE evidence profile and potential recommendation statements are drafted by members of the guideline workgroup, informed by the GRADE evidence to decision framework. These recommendations are then presented to the full workgroup and voted for inclusion in the guidelines.
Of note, in an effort to align the guideline process with international standards, the Academy is in the process of transitioning from using Strength of Recommendation Taxonomy (SORT) to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. These 2024 acne guidelines were one of the first to use this GRADE approach. While GRADE has important strengths including rigor, reproducibility, and broad acceptance in the international community, it also has some challenges as it can be rigid, making it difficult to include nuanced recommendations and to use expert opinion for areas with less certain evidence.
See the guideline
Access the newly revised acne vulgaris guideline.
DermWorld: What’s the difference between an evidence-based guideline and a good practice statement?
Dr. Barbieri: When available, we rely on clinical trial outcomes for evidence-based recommendations. However, there are instances where, despite the evidence not being of the highest quality or directly applicable, there is a need for clinical guidance. In such cases, there are a set of rules established by GRADE that allow for “good practice statements.” The 2024 guidelines include good practice statements about using multimodal topical therapy, antibiotic stewardship, use of intralesional steroids, and use of isotretinoin.
DermWorld: The group addressed a series of clinical questions. Were any of these questions new from the previous guidelines?
Dr. Barbieri: The clinical questions are largely similar between the guidelines. Both consider acne grading, microbiologic and endocrine testing, topical and systemic medications, physical modalities, complementary and alternative medicine, and diet. The 2024 guidelines explore a broader list of treatments given new developments in the management of acne since the 2016 guidelines.
DermWorld: Obviously, you made many recommendations (for which we hope everyone reads the entire guidelines!). Were there any major changes in recommendations from the previous guidelines? Any you felt that are particularly important?
Dr. Barbieri: The new guidelines provide important recommendations for novel acne treatments such as clascoterone and sarecycline. 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.
We also discuss growing evidence to suggest that frequent laboratory monitoring for young, healthy patients on isotretinoin or spironolactone is not a high-value practice. The updated guidelines provide specific recommendations about laboratory monitoring that can help clinicians and patients who are interested in less-frequent monitoring feel more comfortable with these approaches.
DermWorld: Oral antibiotics. Is it still OK to use them to treat acne?
Dr. Barbieri: Oral antibiotics remain an important treatment option for patients with acne. However, dermatologists prescribe more oral antibiotics than any other major medical specialty with much of this use for acne, so it is important for us to be thoughtful about antibiotic prescribing. We now have several new topical treatments such as clascoterone and growing evidence to support the role of non-antibiotic systemic treatments such as spironolactone and isotretinoin, which I hope can reduce our reliance on oral antibiotics. In addition, we should be sure to use concomitant benzoyl peroxide with topical and oral antibiotics to prevent the development of antibiotic resistance. The updated guidelines also discuss that doxycycline and sarecycline are likely preferred initial options over minocycline, which has a higher risk of severe drug eruptions and neurologic side effects like vestibular dysfunction. Use of trimethoprim-sulfamethoxazole should be limited due to risk of severe adverse reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis and acute respiratory failure.
DermWorld: Do you anticipate that the recommendations and practices offered will change the way dermatologists treat acne?
Dr. Barbieri: The updated guidelines provide practical recommendations for both dermatologists and other clinicians caring for those with acne. We review the role for new treatments such as clascoterone, which I think is an exciting option that can complement other topical treatments for acne given its novel mechanism of action as a topical antiandrogen. We also review updated evidence for oral antibiotics, hormonal therapy, and isotretinoin. I think there are continued opportunities to utilize hormonal therapies such as combined oral contraceptives and spironolactone to reduce our reliance on oral antibiotics and improve outcomes for female patients with acne. We also have opportunities to optimize our lab monitoring for spironolactone and isotretinoin to ensure we are providing high-value care.
John Barbieri, MD, MBA, FAAD, is the director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital, and instructor in dermatology at Harvard Medical School. He served as co-chair of the Academy’s Acne Guidelines Workgroup. The paper appeared in JAAD. Dr. Barbieri has no relevant financial or commercial conflicts of interest.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
