Acne guidelines clarify role of antibiotics with topical therapy

Translating Evidence Into Practice: Acne Guidelines (F048)

The highlights of AAD Guidelines of Care for the Management of Acne Vulgaris, including the use of antibiotics, isotretinoin, hormonal therapy, and physical modalities, as well as the role of diet in acne, will be reviewed during an education session Saturday morning.

“The audience and others in practice ask: Will this restrict what they are able to do? That is not the intent of guidelines. The intent of the guidelines is to review the literature to see what data are available based on current evidence and then provide recommendations in line with that evidence that would be directly applicable to various clinical scenarios,” said the session director, Bethanee J. Schlosser, MD, PhD. She was also a member of the workgroup that wrote the guidelines, published last year (J Am Acad Dermatol 2016; 74(5):945-973).

One of the clinical guideline’s strongest statements is on antibiotic therapy, which should not be used alone, whether it is a topical or systemic antibiotic, said Dr. Schlosser, an associate professor in the department of dermatology at Northwestern University Feinberg School of Medicine.

“If patients do need antibiotics,” she said, “they should always be used in conjunction with a topical therapy, such as benzoyl peroxide, to decrease antibiotic resistance. A retinoid should also be used to enable patients to more quickly decrease or get off antibiotic therapy.

“The guidelines suggest that after initiating an oral antibiotic, patients should be evaluated at three months.”

The guidelines clarify the use of isotretinoin and its dosing strategies, which will be reviewed in the session. They also address concerns about potential links between isotretinoin and inflammatory bowel disease, depression, and mood disorders while advocating for the monitoring of individual patients for depression and mood disorders, Dr. Schlosser said.

Data regarding hormonal therapy for acne is plentiful, with no one oral contraceptive pill standing apart from others. The discussion of hormonal therapy will also address appropriate patient selection and the use of spironolactone as an off-label treatment for acne.

The role of diet in acne still is not clear, with no obvious dietary triggers in most patients, Dr. Schlosser said. However, the presentation will look at data that reviews a high glycemic index and skim milk in dairy products as possible triggers for acne.

The final presentation will explore physical modalities, such as chemical peels, lasers, and light therapy, but the guidelines note too much variability in procedures and outcomes to advocate their use, she said.

“The guidelines do recommend that you can consider those physical modalities of treatment as adjuvant in patients with acne or those who are not eligible for other therapies, but they should not replace standard-of-care therapy,” Dr. Schlosser said.

Most importantly, the new guideline recommendations differ from the previous guidelines by advocating for a greater emphasis on using topical retinoids both during and following oral antibiotics as maintenance therapy, she said.

“The guidelines are most helpful in terms of identifying what gaps there are in terms of the evidence in existence. They are not supposed to handcuff anyone, but are supposed to provide guidance,” Dr. Scholsser said.

To learn more about the acne guidelines, visit www.aad.org/dw/monthly/2015/august/overusing-acne-antibiotics.

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