Guidelines for Acne Treatment: 2016 Treatment Updates Direct Pharmacist Counseling
More than a decade ago, acne was described as a mischievous disease, with lesions that come and go seemingly at will, causing profound anxiety and depression. Many patients today still feel the same way as they struggle to find the treatment that will finally stop their outbreaks.
Pharmacists need to keep up-to-date with guidelines for acne management because patients often have many questions about the multitude of acne products. Whether these patients use prescription medications or buy over-the-counter products, they depend on your expertise to help guide their choices.
American Academy of Dermatology Acne Treatment Guidelines
The American Academy of Dermatology (AAD) makes it a point to say that their updated guidelines are not meant to set a standard of care. Their goal is to make the best recommendations based on the current evidence, but ultimately, each treatment decision should be tailored for the individual and based on the physician’s experience. Here’s what the most recent guidelines suggest for adult acne treatment:
Oral antibiotics – For moderate-to-severe inflammatory acne, systemic antibiotics remain the first-line treatment. The length of antibiotic therapy should be limited to three months for most patients, but prolonged therapy may be considered in those who aren’t candidates for oral isotretinoin, topical agents or combined oral contraceptives.1
- Avoid monotherapy – Systemic antibiotics should always be combined with topical retinoids and/or benzoyl peroxide.
- Use tetracyclines or macrolides – Tetracycline, doxycycline and minocycline are first-line agents, followed by azithromycin and erythromycin. The use of other systemic antibiotics, including cephalosporin and penicillin, is discouraged due to limited evidence supporting their efficacy.
Maintenance with topical agents – After antibiotic treatment is discontinued, topical therapies are usually effective, even in patients with moderate-to-severe inflammatory acne. The maintenance regimen primarily relies on topical retinoids and antimicrobials, but with one caveat:
- Lack of evidence for two topicals – Data does not support the efficacy of topical sulfur or sodium sulfacetamide.
- Strongly recommended – Peer-reviewed literature leads to strong recommendations for topical retinoids, benzoyl peroxide, topical antibiotics, azelaic acid, dapson and salicylic acid. These agents may be used as monotherapy or in various combinations. First-line therapy incorporates combinations of benzoyl peroxide, topical antibiotics and retinoids.
Oral Isotretinoin – This agent continues to be recommended for nodulocystic acne and for patients with moderate-to-severe inflammatory acne that’s recalcitrant to treatment with other pharmaceuticals. Patients must be carefully screened and receive ongoing assessment for inflammatory bowel disease and depression. The AAD recommends testing for liver function, serum cholesterol and triglycerides at baseline and when response to treatment is established. Women of child-bearing age should be counseled about contraceptive methods. All patients must agree to adhere to the iPLEDGE risk management program.
Hormone therapy – Estrogen-containing combined oral contraceptives effectively treat inflammatory acne in women. Patients must be screened for risk factors, such as a family or personal history of blood clotting disorders, hypertension and stroke.
Physical modalities – A phase 2 study that was active in July 2016—five months after the AAD guidelines were published—reported that the number of inflammatory acne lesions was significantly reduced in patients who received photodynamic therapy combined with investigational topical methyl aminolevulinate.2 Emerging trials aside, the guidelines do not recommend laser treatments or chemical peels for routine acne treatment because studies show they yield mild results that aren’t long lasting.
Recommendations on Dietary Modifications
Over the years, fatty foods, fried foods, chocolate, soft drinks and dairy products have been rumored to cause acne. Sometimes it wasn’t even a rumor—the advice carried authority because it came from parents, teachers and health professionals. Questions about diet still persist, so pharmacists should be ready to offer answers. For the most part, research has failed to prove an association between acne and most types of foods and beverages, but there’s at least one intriguing exception—the role of high glycemic foods:
- High vs low glycemic foods – In two studies, acne improved when patients followed a low-glycemic diet. The most recent study, published in 2012 in Acta-Dermato Venereologica, reported that subjects randomized to a low-glycemic diet experienced a statistically significant improvement in acne severity, which was verified by tests showing a decrease in inflammatory cells and smaller sebaceous glands compared to their size before the diet change.3
- Dairy products – Limited evidence suggests that dairy products may trigger acne, although the association is stronger for skim milk and no link exists with yogurt or cheese.
- Other types of foods – Some studies suggest that probiotics, fish oil and antioxidants such as oral zinc are connected to acne, but the existing evidence isn’t strong.
The AAD does not recommend any dietary changes because more research is needed to establish causality. However, patients still need some straight advice, so clue them in to the potential connection with sugar. Warn them to limit high-glycemic products, such as those containing processed flour or white rice, and anything with added sugar – candy, baked goods and sweetened or caloric beverages.
Even if definitive proof is elusive, people do notice a link between acne and foods like whey protein powder, milk and chocolate. Food sensitivities may also trigger a flare-up.4 It doesn’t hurt for patients to temporarily eliminate one food at a time to see if their acne improves. On the flip side, they also need to be reminded that healthy skin thrives on a well-rounded diet that includes essential fatty acids, protein and micronutrients, especially vitamins A, C, D and E.5
Reach Out to Patients Buying OTC Products to Ensure Safety
The first retinoid OTC product for acne – adapalene gel – was approved by the FDA in July 2016.6 While it’s great that patients have another OTC option, the release of this agent highlights the vital role of pharmacist counseling. OTC products tend to carry an aura of safety simply because they’re available without a prescription. However, adapalene is a Pregnancy Category C agent, so women should be warned.
All acne products, especially adapalene, can cause potentially severe skin irritation and some make patients more sensitive to sunlight – information that they’ll miss if they don’t read the label carefully. Train everyone at the checkout to ask patients to talk with the pharmacists before they buy OTC acne treatments. Your diligent outreach ensures safe and effective use of powerful OTC pharmaceuticals.
Pharmaceutica North America provides an emollient, irritant-free delivery base for topical agents, as well as prescription drug products and bulk active pharmaceutical ingredients. Contact us today to talk about how we can help you support your patients’ health care with high-quality pharmaceuticals.
- “Guidelines of Care for the Management of Acne Vulgaris,” February 2016, https://www.aad.org/File%20Library/Main%20navigation/Practice%20tools/Quality%20care%20and%20guidelines/Acne-Guideline-2016.pdf ↩
- “Combination Therapy Shows Promising Phase 2 Results,” July 2016, http://dermatologytimes.modernmedicine.com/dermatology-times/news/combination-therapy-shows-promising-phase-2-results ↩
- “Clinical and Histological Effect of a Low Glycaemic Load Diet in Treatment of Acne Vulgaris in Korean Patients: A Randomized, Controlled Trial,” May 2012, http://www.ncbi.nlm.nih.gov/pubmed/22678562 ↩
- “Diet, Skin Disease Data Growing,” May 2016, http://dermatologytimes.modernmedicine.com/dermatology-times/news/diet-skin-disease-data-growing ↩
- “Micronutrients and Skin Health,” September 2011, http://lpi.oregonstate.edu/mic/micronutrients-health/skin-health ↩
- “In Rx-to-OTC Switch, FDA Approves First OTC Retinoid,” September 2016, http://www.pharmacytoday.org/article/S1042-0991(16)30799-X/fulltext ↩