From the Journals

Expert panel addresses gaps in acne guidelines



A distinguished international panel of acne experts has identified major gaps in current clinical practice guidelines for the management of acne.

“The challenge with acne guidelines is they mainly focus on facial acne and they’re informed by randomized controlled trials which are conducted over a relatively short period of time. Given that acne is a chronic disease, this actually produces a lack of clarity on multiple issues, including things like truncal acne, treatment escalation and de-escalation, maintenance therapy, patient perspective, and longitudinal management,” Alison Layton, MBChB, said in presenting the findings of the Personalizing Acne: Consensus of Experts (PACE) panel at the virtual annual congress of the European Academy of Dermatology and Venereology.

The PACE panel highlighted two key unmet needs in acne care as the dearth of guidance on how to implement patient-centered management in clinical practice, and the absence of high-quality evidence on how best to handle long-term maintenance therapy: When to initiate it, the best regimens, and when to escalate, switch, or de-escalate it, added Dr. Layton, a dermatologist at Hull York Medical School, Heslington, England, and associate medical director for research and development at Harrogate and District National Health Service Foundation Trust.

Most of the 13 dermatologists on the PACE panel were coauthors of the current U.S., European, or Canadian acne guidelines, so they are closely familiar with the guidelines’ strengths and shortcomings. For example, the American contingent includes Linda Stein Gold, MD, Detroit; Hilary E. Baldwin, MD, New Brunswick, NJ; Julie C. Harper, MD, Birmingham, Ala.; and Jonathan S. Weiss, MD, of Georgia, all members of the work group that created the current American Academy of Dermatology guidelines.

Strong points of the current guidelines are the high-quality, evidence-based recommendations on initial treatment of facial acne. However, a major weakness of existing guidelines is reflected in the fact that well over 40% of patients relapse after acne therapy, and these relapses can significantly impair quality of life and productivity, said Dr. Layton, one of several PACE panelists who coauthored the current European Dermatology Forum acne guidelines.

The PACE panel utilized a modified Delphi approach to reach consensus on their recommendations. Ten panelists rated current practice guidelines as “somewhat useful” for informing long-term management, two dermatologists deemed existing guidelines “not at all useful” in this regard, and one declined to answer the question.

“None of us felt the guidelines were very useful,” Dr. Layton noted.

It will take time, money, and research commitment to generate compelling data on best practices for long-term maintenance therapy for acne. Other areas in sore need of high-quality studies to improve the evidence-based care of acne include the appropriate length of antibiotic therapy for acne and how to effectively combine topical agents with oral antibiotics to support appropriate use of antimicrobials. In the meantime, the PACE group plans to issue interim practical consensus recommendations to beef up existing guidelines.

With regard to practical recommendations to improve patient-centered care, there was strong consensus among the panelists that acne management in certain patient subgroups requires special attention. These subgroups include patients with darker skin phototypes, heavy exercisers, transgender patients and patients with hormonal conditions, pregnant or breast-feeding women, patients with psychiatric issues, and children under age 10.

PACE panelists agreed that a physician-patient discussion about long-term treatment expectations is “paramount” to effective patient-centered management.

“To ensure a positive consultation experience, physicians should prioritize discussion of efficacy expectations, including timelines and treatment duration,” Dr. Layton continued.

Other key topics to address in promoting patient-centered management of acne include discussion of medication adverse effects and tolerability, application technique for topical treatments, the importance of adherence, and recommendations regarding a daily skin care routine, according to the PACE group.

Dr. Layton reported serving as a consultant to Galderma, which funded the PACE project, as well as half a dozen other pharmaceutical companies.

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