Guidelines of care for the management of acne vulgaris : American Academy of Dermatology

Recommendations for Grading and Classification of Acne

• Clinicians may find it helpful to use a consistent classification/grading scale (encompassing the numbers and types of acne lesions as well as disease severity, anatomic sites, and scarring) to facilitate therapeutic decisions and assess response to treatment.


• Currently, no universal acne grading/classifying system can be recommended.

Recommendations for Microbiologic and Endocrinologic Testing

• Routine microbiologic testing is unnecessary in the evaluation and management of patients with acne. Those who exhibit acne-like lesions suggestive of gram-negative folliculitis may benefit from microbiologic testing.


• Routine endocrinologic evaluation (e.g., for androgen excess) is not indicated for the majority of patients with acne. Laboratory evaluation is recommended for patients who have acne and additional signs of androgen excess.

Recommendations for Topical Therapies

• Benzoyl peroxide or combinations with erythromycin or clindamycin are effective acne treatments and are recommended as monotherapy for mild acne, or in conjunction with a topical retinoid, or systemic antibiotic therapy for moderate to severe acne.


• Benzoyl peroxide is effective in the prevention of bacterial resistance and is recommended for patients on topical or systemic antibiotic therapy.


• Topical antibiotics (e.g., erythromycin and clindamycin) are effective acne treatments, but are not recommended as monotherapy because of the risk of bacterial resistance.


• Topical retinoids are important in addressing the development and maintenance of acne and are recommended as monotherapy in primarily comedonal acne, or in combination with topical or oral antimicrobials in patients with mixed or primarily inflammatory acne lesions.


• Using multiple topical agents that affect different aspects of acne pathogenesis can be useful. Combination therapy should be used in the majority of patients with acne.


• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in the management of preadolescent acne in children.


• Azelaic acid is a useful adjunctive acne treatment and is recommended in the treatment of postinflammatory dyspigmentation.


• Topical dapsone 5% gel is recommended for inflammatory acne, particularly in adult females with acne.


• There is limited evidence to support recommendations for sulfur, nicotinamide, resorcinol, sodium sulfacetamide, aluminum chloride, and zinc in the treatment of acne.

Recommendations for Systemic Antibiotics

• Systemic antibiotics are recommended in the management of moderate and severe acne and forms of inflammatory acne that are resistant to topical treatments.


• Doxycycline and minocycline are more effective than tetracycline, but neither is superior to each other.


• Although erythromycin and azithromycin can be effective in treating acne, its use should be limited to those who cannot use the tetracyclines (i.e., pregnant women or children <8 years of age). Erythromycin use should be restricted because of its increased risk of bacterial resistance.


• Use of systemic antibiotics, other than the tetracyclines and macrolides, is discouraged because there are limited data for their use in acne. Trimethoprim-sulfamethoxazole and trimethoprim use should be restricted to patients who are unable to tolerate tetracyclines or in treatment-resistant patients.


• Systemic antibiotic use should be limited to the shortest possible duration. Re-evaluate at 3 to 4 months to minimize the development of bacterial resistance. Monotherapy with systemic antibiotics is not recommended.


• Concomitant topical therapy with benzoyl peroxide or a retinoid should be used with systemic antibiotics and for maintenance after completion of systemic antibiotic therapy.

Recommendations for Hormonal Agents

• Estrogen-containing combined oral contraceptives are effective and recommended in the treatment of acne in females.


• Spironolactone is useful in the treatment of acne in select females.


• Oral corticosteroid therapy can be of temporary benefit in patients who have severe inflammatory acne while starting standard acne treatment.


• In patients who have well-documented adrenal hyperandrogenism, low-dose oral corticosteroids are recommended in treatment of acne.

See Table VIII in the original guideline document for the World Health Organization recommendations for combined oral contraceptive usage eligibility.

Recommendations for Isotretinoin

• Oral isotretinoin is recommended for the treatment of severe nodular acne.


• Oral isotretinoin is appropriate for the treatment of moderate acne that is treatment-resistant or for the management of acne that is producing physical scarring or psychosocial distress.


• Low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medication-related side effects. Intermittent dosing of isotretinoin is not recommended.


• Routine monitoring of liver function tests, serum cholesterol, and triglycerides at baseline and again until response to treatment is established is recommended. Routine monitoring of complete blood count is not recommended.


• All patients treated with isotretinoin must adhere to the iPLEDGE risk management program.


• Females of child-bearing potential taking isotretinoin should be counseled regarding various contraceptive methods including user-independent forms.


• Prescribing physicians also should monitor their patients for any indication of inflammatory bowel disease and depressive symptoms and educate their patients about the potential risks with isotretinoin.

Recommendations for Miscellaneous Therapies and Physical Modalities

• There is limited evidence to recommend the use and benefit of physical modalities for the routine treatment of acne, including pulsed dye laser, glycolic acid peels, and salicylic acid peels.


• Intralesional corticosteroid injections are effective in the treatment of individual acne nodules.

Recommendation for Complementary/Alternative Therapies

Herbal and alternative therapies have been used to treat acne. Although most of these products appear to be well tolerated, limited data exist regarding the safety and efficacy of these agents to recommend their use in acne.

Recommendations for the Role of Diet in Acne

• Given the current data, no specific dietary changes are recommended in the management of acne.


• Emerging data suggest that high glycemic index diets may be associated with acne.


• Limited evidence suggests that some dairy, particularly skim milk, may influence acne.

Strength of Recommendations for the Management and Treatment of Acne Vulgaris

Recommendation	Strength of Recommendation	Level of Evidence	References
Grading/classification system	B	II, III	Tan et al., 2007; Mallon et al., 1999; Gupta, Johnson, & Gupta, 1998; Lasek & Chren, 1998; Martin et al., 2001; Rapp et al., 2006; Dréno et al., 2007; Pochiet al., 1991; Doshi, Zaheer, & Stiller, 1997; Lucky et al., 1996; Cook, Centner, & Michaels, 1979; Burke & Cunliffe, 1984; Allen & Smith, 1982; Dréno et al., 2011; Hayashi, Akamatsu, & Kawashima, 2008; Hayashi et al., 2008; Tan et al., 2012; Tan et al., 2013; Beylot et al., 2010; Tan, Fung, & Bulger, 2006; Bergman et al., 2009; Min et al., 2013; Qureshi et al., 2006; Choi et al., 2012; Choi et al., 2011; Dobrev, 2010; Choi, Choi, & Youn, 2013; Kim et al., 2006; Xhauflaire-Uhoda & Piérard, 2007; Youn et al., 2013; Youn et al., 2009; Zane et al., 2008
Microbiologic testing	B	II, III	Cove, Cunliffe, & Holland, 1980; Mourelatos et al., 2007; Shaheen & Gonzalez, 2011; Fitz-Gibbon et al., 2013; Holland et al., 2010; Lomholt & Kilian, 2010; Miura et al., 2010; Tochio et al., 2009; Tomida et al., 2013
Endocrinologic testing	B	I, II	Lucky et al., 1997; Bunker et al., 1989; Lawrence et al., 1981; Timpatanapong & Rojanasakul, 1997; Lucky, 1983; Lucky et al., 1983; Abulnaja, 2009; Arora, Seth, & Dayal, 2010

Topical Therapies

Benzoyl peroxide	A	I, II	Fyrand & Jakobsen, 1986; Mills et al., 1986; Schutte, Cunliffe, & Forster, 1982
Topical antibiotics (e.g., clindamycin and erythromycin)	A	I, II	Mills et al., 2002; Bernstein & Shalita, 1980; Jones & Crumley, 1981; Shalita, Smith, & Bauer, 1984; Leyden et al., 1987; Kuhlman & Callen, 1986; Becker et al., 1981
Combination of topical antibiotics and benzoyl peroxide	A	I	Leyden et al., 2001; Lookingbill et al., 1997; Tschen et al., 2001
Topical retinoids (e.g., tretinoin, adapalene, and tazarotene)	A	I, II	Krishnan, 1976; Bradford & Montes, 1974; Shalita et al., 1999; Shalita et al., 1996; Cunliffe et al., 1997; Richter et al., 1998; Zouboulis et al., 2000; Christiansen et al., 1974; Dunlap et al., 1998; Kakita, 2000; Webster et al., 2001; Galvin et al., 1998
Combination of topical retinoids and benzoyl peroxide/topical antibiotic	A	I, II	Richter et al., 1998; Zouboulis et al., 2000
Azelaic acid	A	I	Cunliffe & Holland, 1989; Katsambas, Graupe, & Stratigos, 1989
Dapsone	A	I, II	Draelos et al., 2007; Lucky et al., 2007; Tanghetti, Harper, & Oefelein, 2012
Salicylic acid	B	II	Shalita, 1981

Systemic Antibiotics

Tetracyclines (e.g., tetracycline, doxycycline, and minocycline)	A	I, II	Garner et al., 2012; Leyden et al., 2013; Lebrun-Vignes et al., 2012; Kermani et al., 2012
Macrolides (e.g., azithromycin and erythromycin)	A	I	Rafiei & Yaghoobi, 2006
Trimethoprim (with or without sulfamethoxazole)	B	II	Jen, 1980; Fenner, Wiss & Levin, 2008
Limiting treatment duration and concomitant/maintenance topical therapy	A	I, II	Gold et al., 2010; Leyden et al., 2006; Margolis et al., 2010

Hormonal Agents

Combined oral contraceptives	A	I	Lucky et al., 2008; Maloney et al., 2008; Maloney et al., 2009; Plewig et al., 2009
Spironolactone	B	II, III	Shaw, 2000; Sato et al., 2006
Flutamide	C	III	Wang, Wang, & Soong, 1999; Castelo-Branco et al., 2009
Oral corticosteroids	B	II	Nader et al., 1984

Isotretinoin

Conventional dosing	A	I, II	Amichai, Shemer, & Grunwald, 2006; Goldstein et al., 1982; Jones et al., 1983; Layton et al., 1993; Lehucher-Ceyrac & Weber-Buisset, 1993; Peck et al., 1982; Rubinow et al., 1987; Stainforth et al., 1993; Strauss et al., "A randomized trial," 2001; Strauss et al., 1984; Strauss & Stranieri, 1982; Goldsmith et al., 2004; Lehucher-Ceyrac et al., 1999; Strauss et al., "Safety," 2001; Webster, Leyden, & Gross, 2013; Alhusayen et al., 2013; Crockett et al., 2009; Crockett et al., 2010; Etminan et al., 2013; Reddy et al., 2006; Sundstrom et al., 2010; Bozdag et al., 2009; Chia et al., 2005; Cohen, Adams, & Patten, 2007; Jick, Kremers, & Vasilakis-Scaramozza, 2000; Nevoralová & Dvoráková, 2013; Rehn et al., 2009
Low-dose treatment for moderate acne	A	I, II	Agarwal, Besarwal, & Bhola, 2011; Akman et al, 2007; Borghi et al., 2011; Kaymak & Ilter, 2006; Lee et al., 2011
Monitoring	B	II	Leachman et al., 1999; Bershad et al., 1985; De Marchi et al., 2006; Zech et al., 1983
iPLEDGE and contraception	A	II	Shin et al., 2011; Collins et al., 2014

Miscellaneous Therapies and Physical Modalities

Chemical peels	B	II, III	Grover & Reddu, 2003; Dréno et al., 2011; Ilknur et al., 2010
Intralesional steroids	C	III	Levine & Rasmussen, 1983; Potter, 1971
Complementary and alternative therapies (e.g., tea tree oil, herbal, and biofeedback)	B	II	Bassett, Pannowitz, & Barnetson, 1990; Enshaieh et al., 2007; Fouladi, 2012; Hunt & Barnetson, 1992; Lalla et al., 2001; Paranjpe & Kulkarni, 1995; Hughes et al., 1983

Role of Diet in Acne

Effect of glycemic index	B	II	Smith et al., 2007; Kwon et al., 2012; Smith et al., 2008; Preneau et al., 2013; Ismail, Manaf, & Azizan, 2012
Dairy consumption	B	II	Adebamowo et al., 2006; Adebamowo et al., 2008; Di Landro et al., 2012

You can read the full Guideline by clicking on the link :

Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, Bowe WP, Graber EM, Harper JC, Kang S, Keri JE, Leyden JJ, Reynolds RV, Silverberg NB, Stein Gold LF, Tollefson MM, Weiss JS, Dolan NC, Sagan AA, Stern M, Boyer KM, Bhushan R. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33. [315 references]