Clinical, Cosmetic and Investigational Dermatology Dovepress open access to scientific and medical research Open Access Full Text Article EVIDENCE 2 PRactice Management strategies for acne vulgaris Kristen M Whitney1 Clinical question: What are the most effective treatment(s) for mild, moderate, severe, and Chérie M Ditre2 hormonally driven acne? Results: Mild acne responds favorably to topical treatments such as benzoyl peroxide, salicylic 1Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA; acid, and a low-dose retinoid. Moderate acne responds well to combination therapy comprising- 2Skin Enhancement Center and topical benzoyl peroxide, antibiotics, and/or retinoids, as well as oral antibiotics in refractory Cosmetic Dermatology, Department cases and oral contraceptive pills for female acne patients. Severe nodulocystic acne vulgaris of Dermatology, University of Pennsylvania School of Medicine, responds best to oral isotretinoin therapy. In female patients with moderate to severe acne, facial Philadelphia, PA, USA hair, loss of scalp hair and irregular periods, polycystic ovarian syndrome should be considered Date of preparation: 30th November 2010 and appropriate treatment with hormonal modulation given. Adjunctive procedures can also be Conflicts of interest: None declared considered for all acne patients. Implementation: Pitfalls to avoid when treating acne: treatment of acne in women of child- bearing age; familiarization of all acne treatments in order to individualize management for patients; indications for specialist referral. Keywords: acne vulgaris, benzoyl peroxide, retinoids, antibiotics, light and laser therapy, photodynamic therapy, photopneumatic therapy, chemical peels Acne vulgaris Definition: Acne vulgaris is a common multifactorial inflammatory condition of the pilo sebaceous follicle. Classification: Based on the severity: mild, moderate, or severe, and the types of lesions present: comedones, papules, pustules, and nodules as well as the presence or absence of scarring. Pathogenesis: Four factors: follicular epidermal hyper proliferation, surplus of sebum production, inflammation, and the concentration and activity of Propionibacterium acnes.1 Incidence: Mean age for the start of acne in girls is 11 years and boys 12 years, as concluded by several studies from multiple countries,2 with a peak at 15 to 18 years.3 Acne prevalence in the adolescent community is estimated at 70% to 87%.2 In one Correspondence: Chérie Ditre Penn Medicine at Radnor, 250 King of large community based study in the United Kingdom, physiologic facial acne was seen Prussia Road, Radnor, PA 19087, USA in 54% of the adult population (ages 25 to 58 years), with clinical acne estimated at Tel +1 610–902–2419 Email ché[email protected] 3% in adult men and 12% in adult women.4 submit your manuscript | www.dovepress.com Clinical, Cosmetic and Investigational Dermatology 2011:4 41–53 41 Dovepress © 2011 Whitney and Ditre publisher and licensee Dove Medical Press Ltd. This is an Open Access article DOI: 10.2147/CCID.S10817 which permits unrestricted noncommercial use, provided the original work is properly cited. Whitney and Ditre Dovepress Assessment: Note areas involved (face, neck, chest, and/ Economics: US$100 million per year is spent on over-the- or back), type and number of acne lesions, presence/absence counter treatments for acne, while the price of acne likely and tendency for scarring, possible hormonal influence exceeds US$1 billion per year in the United States.6 relating to acne flare, and the psychological role acne may be playing in the patient’s life.5 In females with moderate to Treatment: Goal of therapy is to target the four steps severe acne, a history of facial hair, loss of scalp hair, and contributing to the pathogenicity of acne, while selecting irregular periods should be noted. In males, use of anabolic a treatment based on the patient’s skin type and acne steroids should be ascertained. severity. Outcomes: Patients seek improvement of acne lesions, Consumer summary: Acne is a common skin complaint with the hope of full clearing. Relapse is common. A patient which can affect both genders at all ages. Treatment is specific course of therapy is needed, and may require trials based on the severity and appearance of acne, and consists of different medications and procedures until an optimal of various topical and oral medications, as well as medical regimen is found. procedures. The evidence What treatments are most effective that benzoyl peroxide is effective as a first-line treatment for mild to moderate acne? for mild to moderate acne as measured by the reduction in Search sources: PubMed, Cochrane Library, Medline, clinical total lesion counts. If acne does not significantly improve, evidence. tretinoin or adapalene are effective treatment options as both Search strategy: Keywords used in this search include medications showed a reduction in noninflammatory and “mild acne”, “moderate acne”, “benzoyl peroxide”, “topical inflammatory lesion counts. Topical antibiotics (clindamycin retinoids and acne”, “topical acne antibiotics”, and “oral and erythromycin) are an effective treatment for predominance acne antibiotics”. Articles used were limited to systematic of inflammatory lesions in mild to severe acne, and can be reviews, meta-analyses, and randomized controlled trials combined with a regimen that contains topical benzoyl perox- (RCTs). Search limits include a publication date 1995 to ide, tretinoin, and/or adapalene. Evidence was lacking as to the present and English language. The systematic review and success of oral antibiotics in treating acne, but is recommended meta-analyses were selected based on evaluations of several for moderate acne patients whose acne severity has not been current treatments for mild and moderate acne. RCTs were adequately reduced by the above topical treatments. Oral chosen based on investigator-blind or double-blind, random- erythromycin demonstrated a similar efficacy to oral tetra- ized studies with at least an 11-week treatment duration, as cycline in total lesion count reduction. Oral doxycycline also well as documentation of acne severity, and reduction of total, showed a similar effectiveness as other oral antibiotics. One inflammatory, and/or noninflammatory lesions. Two RCTs crossover RCT reported a statistically significant reduction listed below (Thiboutot et al9 and Ozolins et al21) were also (P = 0.001) in inflammatory lesions versus placebo after analyzed in the systematic review. 4 weeks with 100 mg daily of oral doxycycline. The meta-analyses8 reviewed 23 studies of topical Systematic reviews: 1 nonretinoid combination acne treatments in comparison to the Meta-analyses: 2 corresponding single therapies in 7309 patients: 5% benzoyl RCTs: 12 (Tables 1–3) peroxide + 2% salicyclic acid, 2.5% to 5% benzoyl per- The systematic review7 looked at the efficacies and oxide + 1% to 1.2% clindamycin, 5% benzoyl peroxide, and 1% potential benefits of various topical and oral treatments for to 1.2% clindamycin. Acne severity was not specifically stated all stages of acne, and included 67 systematic reviews, RCTs, in the analysis results; however lesion counts were included and or observational studies. All medications were compared to are most consistent in patients with moderate acne. In short, placebo, except for oral erythromycin which was compared combination treatments offer the most favorable results in the to oral doxycycline and oral tetracycline, as no placebo reduction of acne lesions compared to the corresponding single studies were found at the time of search. Results showed therapies. Results showed that 5% benzoyl peroxide + salicylic 42 submit your manuscript | www.dovepress.com Clinical, Cosmetic and Investigational Dermatology 2011:4 Dovepress Dove Clinical, Cosmetic and Investigational Dermatology 2011:4 Cosmetic andInvestigational Clinical, press Table 1 RCTs of benzoyl peroxide and topical retinoids used to treat acne after 12 weeks Reference No of patients Acne Treatment Reduction of P value Reduction of P value Total P value severity inflammatory noninflammatory reduction lesions, % lesions, % of lesions, % Thiboutot adapalene gel moderatea adapalene gel 62.5 (1) vs 52 (1) vs 56 (1) vs (2) et al9 0.3% = 258 0.3% (1) vs 58 (2) = 0.015 43 (2) = 0.061 48 = 0.02 adapalene gel adapalene gel 47 (2) vs 29 (2) vs 36 (2) vs (3) 0.1% = 261 0.1% (2) vs (3) , 0.001 (3) , 0.001 , 0.001 vehicle = 134 gel vehicle (3) Tan et al10 adapalene- moderatea adapalene 0.1% /BPO 66 (1) vs (2, 3, 4) 58 (1) vs (2, 3, 4) 59 (1) vs BPO = 983 2.5% (1) vs 52 , 0.001 48 , 0.05 47 (2, 3, 4) adapalene = 986 adapalene 0.1% (2) vs 57 45 46 , 0.05 BPO = 979 BPO 2.5% (3) vs 38 38 33 vehicle = 907 vehicle (4) Shalita et al11 adapalene = 149 moderatea adapalene gel 0.1% vs 48 0.06b 46 0.02b 49 , 0.01b tretinoin = 139 tretinoin gel 0.025% 38 33 37 Cunliffe et al12 adapalene = 450 mild- adapalene gel 0.1% vs 52 0.51b 58 0.38b 57 0.48b (meta-analysis tretinoin = 450 moderate tretinoin gel 0.025% 51 52 53 of 5 trials) Shalita et al13 tazarotene = 424 moderatea tazarotene 0.1% 43 , 0.001b 44 , 0.001b 43 , 0.001b vehicle = 423 cream vs vehicle 27 24 23 cream Shalita et al14 tazorotene = 86 mild- tazarotene 0.1% 62 NS 68 # 0.001b n/a adapalene = 87 moderatea cream vs 50 36 n/a adapalene 0.1% cream submit your manuscript manuscript submit your Thiboutot tazorotene = 86 moderatea tazorotene 0.1% gel vs 59 0.066b 55 0.307b 57 0.515b et al15 adapalene = 86 adapalene 0.3% gel 67