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 206. The guidelines discuss recently approved topical therapies, the importance of using a few approaches simultaneously, and they discussion 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 more correct the health of the gut, guide the client in skin care, address environmental factors including stress, and consider botanical medicine but these guidelines were specific to pharmaceuticals approved by the FDA.
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.
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.
Their 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. 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.
There is also 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 another option for acne. It's a topical so you don't need to do G6PD testing, and it's well-tolerated, and mean total lesions fell by 48.9%. Interestingly, females do better with this one than boys.
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. 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.
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 was not offered as 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.
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.