Updated AAD Guidelines for Acne Vulgaris: A Summary of Key Points

In this episode of Topical Conversations, join John Barbieri, MD, MBA, FAAD as he summarizes some key points from the American Academy of Dermatology’s updated guidelines for the management of acne vulgaris. These evidence-based recommendations were last updated in 2016. 

Topical treatments 

Several new treatments have emerged since the prior guidelines were released, including the antiandrogen clascoterone, the first topical treatment that addresses the fundamental hormonal causes of acne. Clascoterone, which is safe for both men and women and approved for patients 12 years and older, received a conditional recommendation for use in the new guidelines. Clascoterone demonstrates a high certainty of benefits over risks; however, a conditional recommendation was issued due to the current high cost of treatment that may impact equitable access. 

Oral antibiotics 

Sarecycline 

Sarecycline, a narrow-spectrum tetracycline, received a conditional recommendation in the updated guidelines. Sarecycline, while effective at treating acne, can have a negative impact on the gut microbiome. As an oral antibiotic, it comes with the limitations and challenges of using antibiotics in the treatment of acne; however, it poses some theoretical advantages to other antibiotics currently in use for acne treatment. The high cost of sarecycline treatment was also a factor in issuing a conditional recommendation for this treatment. 

Doxycycline and minocycline 

Notably, doxycycline received a strong recommendation in the updated guidelines while minocycline received a conditional recommendation. The conditional recommendation is supported by the potential for side effects that are unique to minocycline, including severe cutaneous adverse reactions and vestibular dysfunction. Considering this, the guidelines recommend doxycycline over minocycline for the typical patient with acne. 

This represents a departure from current practice, where both drugs tend to be used equally. 

Trimethoprim-sulfamethoxazole 

The guidelines also discuss limiting the use of antibiotics like trimethoprim-sulfamethoxazole, as these can be associated with serious cutaneous adverse reactions and acute respiratory failure. Isotretinoin The guidelines also discuss the use of isotretinoin, one of the most effective treatments currently available for acne. The updated guidelines discuss recommendations for lab monitoring and notable adverse effects like inflammatory bowel disease and neuropsychiatric symptoms. 

Spironolactone 

The guidelines also detail recommended lab monitoring for spironolactone. For healthy patients who do not have other risk factors for hyperkalemia, the guidelines advise that routine potassium monitoring is likely a low-value practice. This determination may help clinicians feel more comfortable with patients who would prefer to pursue less lab monitoring while undergoing treatment for acne vulgaris. 

Key points 

• Clascoterone and sarecycline received conditional recommendations for use in the updated guidelines, with high cost of treatment and potential impact on equitable access contributing to the recommendation 
• Doxycycline received a strong recommendation 
• Minocycline received a conditional recommendation supported by potential for adverse effects unique to minocycline 
• Doxycycline is recommended over minocycline for the typical patient, representing a departure from current practice 
• The guidelines recommend limiting the use of trimethoprim-sulfamethoxazole 
• The guidelines advise that routine potassium monitoring for most patients on spironolactone is likely a low-value practice