WASHINGTON – Monotherapy is not recommended in treating moderate-severe acne, and antibiotics should always be coupled with topical therapy, according to the latest guidelines from the American Academy of Dermatology.

And although it may be hard – even nearly impossible – to discontinue antibiotics completely, patients should be reevaluated every 3-4 months to determine whether reducing the dosage may be possible while maintaining effectiveness, the document says.

AAD published the guideline on Feb 17. At the academy’s annual meeting, a panel met to discuss its practical application.

Topical therapy

Benzoyl peroxide is a first-line agent that not only effectively fights Propionibacterium acnes, but also discourages the development of antibiotic resistance. Topical antibiotics also decrease P. acnes populations and exert a mild anti-inflammatory effect; however, monotherapy with a topical antibiotic is strongly discouraged. These should be used in combination with another agent such as a retinoid, benzoyl peroxide, adapalene, azelaic acid, or dapsone. This approach decreases the chance of antibiotic resistance, attacks the acne on several fronts, and provides for a maintenance transition.

Systemic antibiotics

Tetracycline-class antibiotics are still the best option for moderate-severe acne. A Cochrane review found that minocycline and doxycycline are equally effective (Cochrane Skin Group Nov 2011. doi: 10.1002/14651858.CD002086.pub2).

The incidence of adverse events associated with each is low, although minocycline may be marginally more troublesome. Low doses seem to be as effective as traditional doses, but pulsed therapy is inadequate. To prevent antibiotic resistance, limit both dose and length of therapy as much as possible. This can best be accomplished by adding a topical agent – either benzoyl peroxide or a retinoid – to the regimen.

“This is critical,” Dr. Jonette E. Keri of the University of Miami said at the meeting. “When antibiotics are eventually discontinued, the retinoid will fulfill the need for maintenance therapy.”

Hormonal agents

Four combination oral contraceptives are Food and Drug Administration–approved for acne treatment. Each of them decreases androgens by interrupting the pathway of testosterone production. There are no data suggesting that one is better than the other; patient preferences and their individual clinical picture should drive choice. Because of the cardiovascular risks associated with these combination OCs, they should not be prescribed for anyone with a personal or family history of clotting disorders or thromboembolic events. Smoking should also be a contraindication.

Oral contraceptives can be tried alone or as part of a comprehensive treatment regimen, including one containing antibiotics. Rifampin and griseofulvin are the only antibiotics known to decrease the contraceptive effect of the medications.

The tincture of time is an important part of this therapy, said Dr. Diane M. Thiboutot, professor of dermatology at Pennsylvania State University, Hershey. “You can’t rush it. It may take three cycles to see any real improvement in acne, and patients should be aware of this.”

Isotretinoin

Oral isotretinoin is a highly effective treatment for severe, recalcitrant acne. It decreases sebum production, acne lesion count, and scarring. Despite concerns about depression and suicidality, isotretinoin treatment can actually improve mood in most patients, said Dr. Megha M. Tollefson of the Mayo Clinic, Rochester, Minn.

“A very well-done Swedish study published in 2010 in BMJ found a slightly increased risk of suicide in the first 6 months after treatment started, but that risk was already rising before treatment started, so it could [be unrelated] to the drug,” she said. “And, in those who got isotretinoin, the [suicide] rate after that was actually decreased, compared to the general population.”

Female patients need education on isotretinoin’s teratogenic potential. After discussions, they should sign the SMART or iPLEDGE agreements about using effective birth control while taking the drug. Unfortunately, Dr. Tollefson said, “We continue to see hundreds of isotretinoin-exposed pregnancies each year.”

A recent study found that up to 30% of women did not comply with the birth control measures they agreed to while taking the drug (J Am Acad Dermatol. 2011 Oct. doi: 10.1016/j.jaad.2013.08.034).

The link between isotretinoin and inflammatory bowel disease is not well founded, Dr. Tollefson said. Studies have been contradictory, and most evidence is based on case report and association studies. There is, however, some evidence suggesting an innate connection between acne and inflammatory bowel disease, she noted.

Diet

Emerging evidence suggests that high glycemic diets may be associated with acne, but these studies are small. However, those randomized to a low glycemic index diet showed decreased sebum production and inflammation.

A small case-control study in 2012 suggested a link between milk and acne. AAD makes no recommendation based on this. Milk remains an important source of calcium and vitamin D for Americans, especially children, the panel said.

Dr. Tollefson had no financial disclosures. Dr. Keri said she has been a consultant for Hoffmann-LaRoche.

msullivan@frontlinemedcom.com

Guidelines: Combine topical, oral therapy for most effective acne treatment