Acne treatment in the field: how guidelines and other sources can be included in daily practice

Authors


Correspondence: B. Rzany. E-mail: rzany@kudamm183.de

Abstract

Background

Acne is a complex disease ranging from mild to very severe. Quality of life can be considerably affected although the impact on the quality of life does not necessarily correlate with the severity of the disease.

Aim

To show how good external evidence can be used in individual treatment decisions.

Methods

Description of four typical case secenarios usining the recommendation of the recent evidence based guidelines and other sources.

Results

The four quite typical patients presented here (i) a young boy with comedonal acne; (ii) a young black girl with papulopustular acne; (iii) an older boy with conglobate acne; and (iv) a young women with postadolescent papulopustular acne give a range of the possible challenges a dermatologist may face.

Conclusion

How can the best treatment be selected for our patients? By keeping a clear mind, using the available best evidence and taking of course into account individual factors.

Introduction

Acne patients can be divided by age in adolescents and adult patients. Patients in both categories might differ considerably. Adolescents usually accept mild and moderate acne more easily compared with older patients as basically everybody in the younger age group has some degree of comedones, papules and pustules.[1, 2] Older, postpuberty patients, might be totally different. In these patients even mild and moderate acne might have serious impact on the quality of life.[3]

Acne patients can be also divided according to the subtype of acne: comedonal acne, papulopustular acne and conglobate acne or with respect to their severity: mild, moderate and severe acne. The medical treatment can be divided into topical and systemic treatments or the combination of both. Except for hormone therapy (you do not want to treat male acne patients with antiandrogens!), the whole therapeutic armamentarium can be used in male and female patients. Of course systemic retinoids should be used with great caution and precautions in female patients. Besides that various technical systems as laser and intense pulse light are used in acute acne. The evidence base for these interventions, however, is much less than for the medical interventions. Adjunctive treatment can be divided into cosmetics and cosmeceuticals. Light peels also fall into this category. As said for lasers and intense pulse light (IPL), the evidence for these interventions is not as good although some good clinical data do exist.

The decision which treatment to use is very individual. It depends on the present knowledge, habits and available decision supporting instruments such as guidelines and systematic reviews. For acne there are a couple of guidelines[4, 5] available as well as systemic reviews.

Methods

The present article will focus on specific questions and try to answer them based on the current European acne guideline (Table 1)[4, 5] as well as the chapter of the current book on evidence-based dermatology.[6] A non-systematic search was added for further background information. Four clinical relevant case scenarios were chosen. Therapeutic recommendations for these scenarios are based on the above sources.

Table 1. Overview of the recommendation of the present European acne guidelines.[4, 5] Recommendations are based on available evidence and expert consensus. Available evidence and expert voting lead to classification of strength of recommendation
 Comedonal acneMild-to-moderate papulopustular acneSevere papulopustular/moderate nodular acneSevere nodular/conglobate acned
  1. a

    Limitations can apply that may necessitate the use of a treatment with a lower strength of recommendation as a first line therapy (e.g. financial resources/reimbursement limitations, legal restrictions, availability, drug licensing).

  2. b

    In case of more widespread disease/moderate severity, initiation of a systemic treatment can be recommended.

  3. c

    Adapalene to be preferred over tretinoin/isotretinoin.

  4. d

    Systemic treatment with corticosteroids can be considered.

  5. e

    Doxycycline and lymecycline.

  6. f

    Low strength of recommendation.

  7. g

    Indirect evidence from a study also including chorhexidine, recommendation additionally based on expert opinion.

  8. h

    Indirect evidence from nodular and conglobate acne and expert opinion.

  9. i

    Indirect evidence from severe papulopustular acne.

  10. j

    Only studies found on systemic AB + adapalene, Isotretinoin and tretinoin can be considered for combination treatment based on expert opinion.

  11. f.c., fixed combination.

High strength of recommendationAdapalene + BPO (f.c.) or BPO + clindamycin (f.c.)IsotretinoinaIsotretinoina
Medium strength of recommendationTopical retinoidcAzelaic acid or BPO or topical retinoidc or systemic antibioticb + adapalenejSystemic antibioticse + adapalenej or systemic antibioticse + azelaic acidh or systemic antibiotics + adapalene + BPO (f.c.)Systemic antibioticse + azelaic acid
Low strength of recommendationAzelaic acid or BPOBlue light or oral zinc or topical erythromycin + isotretinoin (f.c.) or topical erythromycin + tretinoin (f.c.) or systemic antibioticb,e + BPOg or systemic antibioticb,e + azelaic acidj or systemic antibioticsb,e + adapalene + BPO (f.c.)iSystemic antibioticse + BPOgSystemic antibioticse + BPOg or systemic antibioticse + adapalenei,j or systemic antibioticse + adapalene + BPO (f.c.)i
Alternatives for femalesHormonal antiandrogens + topical treatment or hormonal antiandrogens + systemic antibioticsfHormonal antiandrogens + systemic antibioticsf

Case scenario 1: 15-year-old boy with comedonal acne

This is a quite common scenario (Fig. 1). The question here is, how extensive is the comedonal acne and is the patient concerned about the comedones (e.g. how much is the quality of life of this young patient impaired). If the patient is not too concerned – he probably will not be too enthusiastic about treatment scenarios which involve daily therapeutic activities e.g. like applying a topical treatment. If he wants a treatment the first choice according to the European guidelines are topical retinoids. Adjunctive treatments with cosmetics and cosmeceuticals might be helpful, however, only if there is some psychological strain.

Figure 1.

Forehead of a young acne patient with comedones and some papules (© dEBM).

Case scenario 2: 16-year-old black girl with mild to moderate papulopustular acne

This is a common scenario with the exception that this patient has dark skin. Based on the current European guideline in case of mild papulopustular acne topical treatments are first – with the fixed combinations of adapalene and benzylperoxide (BPO) or BPO and clindamycin leading the line of topicals. In case that the girl is using cosmetics, it is important that non-comedogenic cosmetics (cleansers and moisturizers) are used. Again for the adjunctive treatment, the available evidence is limited. Last but not least: Are the recommendations for acne treatment different in patients with skin type III–V? As we all know postinflammatory hyperpigmentation might be more pronounced or at least more visible in patients with darker skin. The European guidelines fail to address this specific skin type group. There is a couple of publications available focusing on skin of colour.[7] For the recommendations above there will not be a change. Specifically as topical retinoids are also used in the treatment of postinflammatory hyperpigmentation which is more common in darker skin.

Case scenario 3: 17-year-old boy with conglobate acne

The patient presents with severe conglobate acne of the face and the trunk (Fig. 2). The acne severity increased rapidly during the last 2 months. The father presents himself with oily skin and severe acne scaring after severe conglobate acne in his youth. Based on the European guideline, the treatment of choice is isotretinoin. The guidelines give clear instructions (IX.3) on the dosage, duration of therapy as well as necessary measures (e.g. laboratory controls). In the presented case assuming a bodyweight of 75 kg the initial dosage would be 0.5 mg/kg (e.g. somewhat less than 40 mg of isotretinoin). This oral treatment could be combined with topical azelaic acid (not guidelines based). In case of severe inflammation, a short course of oral steroids can be considered.

Figure 2.

Trunk of a patient with severe conglobate acne. Please note the keloid scaring that developed in course of the acne (© dEBM).

Concerning the recommendations for laboratory controls one needs to be aware that guidelines just reflect the present knowledge. For example newer safety concerns are not addressed. There is a recent discussion on the risk of rhabdomyolysis in patients taking isotretinoin that might be triggered by exercise.[8] Based on these case reports a control of creatine kinase is encouraged[9] especially in patients with high physical activity such as athletes. For safety issues as well as for innovative therapeutic approaches, a regular check of new literature in PubMed is recommended. In severe acne, for example, infliximab treatment might improve symptoms.[10]

What else can be performed? Lasers and IPL have been used in patients with severe inflammation. However, the evidence is limited.[4, 5] Adolescent boys are usually not too excited about the use of cosmetics and cosmeceuticals. However, specifically with facial involvement they might be open for mild peels and non-comedogenic cosmeceuticals to conceal erythema and pustules.

Case scenario 4: 27-year-old actress with papulopustular acne

This is the hardest patient to treat. There are a couple of reasons for that: (i) first she is beyond the age where acne is usually prevalent and generally accepted, making her stick out of the crowd; (ii) papulopustules might be difficult to conceal even with good camouflage when she is in front of the camera; and (iii) there is an increased risk of using comedogenic camouflage or overtreatment.[11] This is the best patient to combine medical and adjunctive treatments.[3] Based on the current European guideline in case of mild papulopustular acne topical treatments are first – with the fixed combinations of adapalene and BPO or BPO and clindamycin leading the line of topicals. These topicals should be applied in the evening. Even a course of oral zinc might be considered, too, although this treatment option is not really based on good evidence. For this patient adjunctive treatment such as light peels with fruity acid in combination with cosmetics (cleansers and moisturizers) might be helpful.[3, 6, 12] Again as with other non-medical interventions these options are based on limited evidence.

Summary

The discussed case scenarios show that the European evidence-based guidelines as well as the chapter in the Evidence Based Dermatology textbook on acne might be quite helpful in answering important treatment questions as which intervention to choose and which controls if any to initiate. As with every guidelines or book chapter, one needs to be aware that the information consented in the guidelines or put down in a book chapter is time dependent. Newer treatments or recent important safety information might not be included. Therefore, it is the obligation of the clinician to use additional sources of information.

In contrast to drug treatment for the adjunctive treatments as light therapy or the use of cosmeceuticals and cosmetics the European guidelines as well as the book chapter are less specific. One reason for this is that the evidence behind these adjunctive treatments is limited. There is room for future studies here, e.g. on a potential benefit of an adjunctive treatment on early stages in acne.

Acknowledgements

Berthold Rzany was head of the division of Evidence Based Medicine (dEBM) at the Department of Dermatology at the Charité-Universitätsmedizin Berlin from 2002 to 2011. He was involved in the existing European Acne guidelines as a methodologist. Alexander Nast is the current head of the dEBM. He is the first author of the current European and German acne guidelines.

Conflict of interest

B. Rzany is an advisor and speaker for Beiersdorf.

A. Nast has received honoraria from Bayer HealthCare for guide-lines implementation CME-certified teaching activities.

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