Acne: Inside the New Guidelines

New recommendations by the American Academy of Dermatology were released in February, just two months ago, regarding the conventional treatment of acne. These are an update from the previously released guideline published in 2006. The guidelines discuss recently approved topical therapies, the importance of using a few approaches simultaneously, and they discuss a controversial report linking benzoyl peroxide to the carcinogen benzene.

In short, these guidelines make a "strong" recommendation for topical retinoids based on "moderate" evidence based on four randomized controlled trials which found individuals with #acne who used the medications were more likely to have improvement. The four current retinoids are adapalene, tretinoin, tazarotene, and trifarotene.

Adapalene is understood as the more tolerable option, while tazarotene is the more effective option. These work to prevent and treat scarring which is significant, and they work against comedonal lesions and inflammatory lesions. Newer concentrations are the tretinoin 0.05% lotion, tazarotene 0.045% lotion, and trifarotene 0.005% cream. The trifarotene concentration is helpful for moderate acne on the chest, back, or shoulders and interestingly, also noted that whey protein appears to exacerbate symptoms and just yesterday I was writing about evidence finding whey protein either before or after a work out can double weight loss from fat over muscle. This should be a question asked of athletes, especially adolescents. Potentially they may find greater benefit from a vegetarian option.

Acne vulgaris is one of the most common skin conditions diagnosed and treated by dermatologists in the United States, and even among primary care providers. My approach is to correct the health of the gut, guide the client in skin care, address environmental factors including stress, and consider botanical medicine, as well as utilize pharmaceuticals as appropriate. These recently released guidelines from the American Academy of Dermatology were specific to, and limited to, pharmaceuticals approved by the FDA which is consistent to the approach of conventional medicine.

It's important to understand that these guidelines are just that - guides created by experts on a panel, fourteen in this scenario. Certainly there was back-and-forth debate about what should and should not be recommended, and even with this publication, there will be debate among practitioners in how they will utilize these recommendations. We all see the evidence a little bit differently. Guidelines are not written in stone, nor are they perfect or even the professional expectation. They are a handy guide for new practitioners especially, but also busy ones with limited time to explore extensive research reviews.

Basic Understanding of Acne

First however, let's get familiar with the basic pathophysiology of acne because understanding the why, helps us find the best treatment and resolution. Acne can occur from increased sebum production, from follicular hyperkeratinization or clogged pores, from bacteria on the skin, or from inflammation after an acne lesions ruptures. Beyond this, the cause for acne gets a bit more multifactorial and complex.

One of the more common triggers for acne include stimulation of the sebaceous gland growth and secretory function, as a result of androgens, which leads to seborrhea and seborrhea is a great medium for C. acnes growth because this bacteria feeds on sebum. A lipid rich environment allows C. acnes to thrive. Medications such as lithium, steroids, and anticonvulsants are also causes of acne. Excess photodamage, oil-based cosmetics, and even endocrine disorders such as PCOS, amenorrhea, dysmenorrhea, or even PMS are common causes. Genetic factors play a role, as do repetitive traumas to the area from soap or deodorants. Psychological stress and lack of sleep are also implicated as an underlying cause of acne. Insulin resistance causes an increase in facial sebum, so of course that means more acne (Vora et al., 2008), and finally, milk consumption and high glycemic diets are also associated (Abeamo et al., 2005).

Acne is largely a chronic inflammatory disorder affecting the pilosebaceous unit and it is mostly commonly triggered by P. acnes. There are two ways to further classify acne, either inflammatory or non-inflammatory. Inflammatory lesions are typically red, swollen, and painful. This type of acne is well treated with routine skincare; however, it usually needs a prescription or a dermatology consult as well. Non-inflammatory lesions are much more common and can usually be treated with skincare, chemical peels, and microneedling.

When evaluating a client, clinicians will grade the acne, which helps guide treatment. Mild acne, or grade 1, is mostly open and closed comedones, with a few papules and pustules. Moderate acne is also called pustular acne, and this is mostly limited to the face. It becomes more severe when there are numerous papules and pustules, along with occasionally inflamed nodules, and they extend down the back and chest. The final grade, grade 4, is the severe, nodulocystic acne. It presents with numerous large, painful and inflamed pustules and nodules.

Treatment requires two-to-three months, consistently, before we can really evaluate the effectiveness of treatment. Many are tempted to quit prematurely, because these regimens demand diligence, but in time, they will prove worth their sacrifice in time and convenience. A week will not suffice so hold strong. Long-term treatment is often necessary because most skincare products are considered suppressive and not curative. This is why functional medicine practitioners go deeper, into the gut to provide holistic care.

Taking Multiple Approaches, Especially with Antibiotics

The new recommendations state that it is good practice, when managing acne with topical medications, to offer more than one option for treatment simultaneously. They state that topical antibiotics are effective treatments on their own, including erythromycin, clindamycin, and minocycline, but antibiotics have significant setbacks, including antibiotic resistance and of course, they can create significant gut dysbiosis which may be part of the underlying issue causing acne in the first place. This is why we try to avoid prescribing systemic antibiotics for acne, although with moderate to severe, especially initially, they may be offered, as might hormonal agents or steroids. If scarring is present, isotretinoin may be offered.

The Academy's recommendation is to offer oral retinoid isotretinoin in conjunction with topical medications, and a fixed combination because this improves adherence. The guidelines also recommend use of benzoyl peroxide, which has "moderate" support in the evidence for preventing the development of antibiotic resistance. Benzoyl peroxide penetrates the skin and releases oxygen, which creates an inhospitable environment for the anaerobic bacteria, effectively reducing their numbers. Lower strengths are less irritating, and over-the-counter formulations are already available. Keep in mind, these can bleach your clothes and towels, so be careful with use. My recommendation is practice is to utilize ZO Acne Control, applying a thick layer after cleansing in the morning and at bedtime.

Admittedly, many of us in practice use topical retinoids in the initial management of acne and for maintenance (unless pregnant or breastfeeding), and in my experience, it has been great used all by itself with mild acne. In my own practice, I typically recommend a product called Skinbetter Clearing Serum. It is non-irritating and requires only one pump as the last step in one's skin care regimen prior to bed.

For moderate-to-severe acne, the Academy offers a newly approved triple combination therapy for acne, combining 1.2% clindamycin, 3.1% benzoyl peroxide, and 0.15% adapalene (Cabtreo) and is FDA-approved for treating acne in those 12 years and older. These fixed dose combination products are cheaper than prescribing their individual components separately.

Dapsone gel 7.5% (Aczone) is also an option for acne. It's a topical so you don't need to do G6PD testing, and it's well-tolerated. Lesions are typically reduced by about half, more so in females than males.

Clascoterone 1% cream (Winlevi), approved in 2020, is appropriate for males and females, aged 12 and up and it's the only topical anti-androgen that can be used in males. There is a high level of evidence here too with moderate to severe acne, but it is expensive. GoodRx lists it at about $590 to $671 for a 60-gram tube. This one works better over the long term too, so hard to justify for most.

Two additional topicals are salicylic acid, based on one randomized controlled trial, and azelaic acid (Azelex, Finacea), based on three randomized controlled trials (Reynolds et al., 2024). These are both conditional recommendations because the evidence is limited, but azelaic acid in particular, may be helpful with individuals who have more sensitive or darker skin from scarring because it can lighten dyspigmentation. Glycolic acid (AHA) has long been used in acne treatment as well, but not mentioned by the Academy in their most recent recommendations. Each of these chemicals though, are used as part of a chemical exfoliant, as a critical step in treating acne in a basic skincare regimen. In my own practice, I will include this for mild to moderate acne utilizing ZO Complexion Renewal Pads offering glycolic acid (AHA) and salicylic acid (BHA), one pad in the morning and another in the evening. They should wipe their entire face until dry.

Topical therapies, with exception of topical retinoids, are preferred during pregnancy. Tazarotene is contraindicated during pregnancy, and salicylic acid should only be used in limited areas of exposure. There is no data for dapsone or clascoterone during pregnancy or lactation, and minocycline is not recommended.

Recommendations regarding topical glycolic acid, sulfur, sodium sulfacetamine, and resorcinol for acne treatment were not offered as the Academy claims there was insufficient evidence, and there is no real evidence available to help understand how topical BP, retinoids, antibiotics, and their combinations work in combination. In clinical practice though, sulfur is considered a great add-on product for clients with acne. We do know that it has antibacterial properties and it helps to shed dead skin. It also helps dry up excess sebum. Maybe the science isn't here yet, but that may only mean this is yet to be understood. I often recommend ZO Complexion Clearing Mask as part of routine skincare in my own practice. Another ingredient, hypochlorous acid, was also skipped over in the new guidelines, but it has shown to be a powerful yet gentle ingredient known particularly for its antimicrobial and anti-inflammatory benefits. There is a really wonderful spray I recommend to clients they can utilize all day, especially those who are inclined to pick at their skin, Hydrinity Hyacyn Active Spray. It's powerful, yet gentle, known for its antimicrobial and anti-inflammatory benefits.

A final note is that a recent report released by Valisure, an independent laboratory, reported finding high levels of the cancer-causing chemical benzene in several acne treatments, including brands such as Clearasil and other quite popular, and highly recommended products. Some were as much as 800 times greater than what the FDA allows for benzene when heated, so if you choose not to discontinue this medication, at least utilize it at room temperature.

Complementary & Alternative Therapies

The expert panel felt there was insufficient evidence on these modalities to make a recommendation, although ironically made comment about pharmaceuticals with just one randomized control trial on this issue. This is the bane of botanical medicine though. Topical tea tree oil, topical green tea, topical witch hazel, oral pantothenic acid, oral and topical zinc, oral and topical niacinamide and diet therapies are discussed in another post.

References

Reynolds, R. V., Yeung, H., Cheng, C. E., Zaenglein, A. L., Han, J. M., & Barbieri, J. S. (2024). Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology.

Vora, S., Ovhal, A., Jerajani, H., Nair, N. & Chakrabortty, A. (2008). Correlation of facial sebum to serum insulin-like growth factor-1 in patients with acne. British Journal of Dermatology, 159(4), 990-991.