Acne is a chronic inflammatory condition that causes both psychological and physical scarring. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. Acne is associated with significant physical and psychological morbidity, such as permanent scarring, poor self-image, depression, and anxiety. In fact, data indicates that the negative effects of acne on a patient’s quality of life are similar to that of asthma, epilepsy, or arthritis. [Zaenglein 2018] Negative impacts of acne can be greater in adults than in adolescents because acne is not normally seen as a condition that affects adults.
The good news is that clinicians in primary care can make a major difference for people with acne by taking a proactive approach and offering guideline-recommended treatments, many of which are available over-the-counter (OTC). [Jefferany 2010]
Enhancing Communication About Acne in Primary Care
Despite the profound impact of acne, patients report that their healthcare professionals (HCPs) often have “unempathetic” responses when they voice their concerns. [Golnick 2008] One reason is that many clinicians consider acne as a minor condition that will go away after adolescence, and so they do not feel an urgency to offer treatment. However, primary care clinicians are on the front line and have the ability to positively impact the care of their patients with acne by providing proactive management and counselling.
Primary care clinicians have the ideal opportunity to ask their adolescent and adult patients about acne during the annual wellness visit. Based on feedback from patients with acne, clinicians should be aware that the patient’s perception of their acne severity and the personal impact may not necessarily correlate with the clinical assessment. Therefore, clinicians should be empathetic and ask specific questions to determine the patient’s perception of their acne.
The short, four-question Acne-Q4 questionnaire can be used to evaluate the impact of acne on patients. Questions are focused on being dissatisfied with appearance, feeling upset, concerns about meeting new people, and fears about scarring. The questionnaire can also be used to evaluate the impact of treatment. [Saitta 2012]
Acne vulgaris is characterized by noninflammatory, open or closed comedones and by inflammatory papules, pustules, and nodules. It typically affects the face, upper chest, and back.
Acne severity is classified based on the number and type of lesions and is used to inform guideline-based treatment decisions (Table 1): [Van Onselen 2017]
Table 1: Classification of Acne Severity [Zaenglein 2016]
It is important to be aware that the formation of acne scars can occur even in patients with mild acne; however, early and effective treatment can help reduce the risk of scar formation. [Zaenglein 2018; UK Guidelines; Kownacki 2016]
Management of Acne
The 2016 American Academy of Dermatology (AAD) acne management guidelines provide primary care providers with simple directions (Table 2). [Zaenglein 2016] Mild to moderate acne can usually be effectively managed with topical OTC treatments, while patients with severe acne should be referred to a dermatologist.
Table 2: Treatment algorithm for the management of acne vulgaris [Zaenglein 2016]
Note: underlined text indicates that the drug may be prescribed as a fixed combination product or as separate component.
The most appropriate treatment is based on the grade and severity of the acne [Zaenglein 2018] and should be directed toward the known pathogenic factors, including:
increased sebum production
hyperkeratinization of the follicular infundibulum
presence of Cutibacterium acnes (formerly Propionibacterium acnes)
Topical retinoids (e.g.., adapalene, tretinoin, and tazarotene) are the foundation of maintenance treatment for acne of any severity. They are anti-inflammatory and comedolytic, and they treat precursor microcomedone lesions. They also treat secondary lesions, including scarring and pigmentation through actions in the dermis. [Leyden 2017] Standard tretinoin formulations cannot be applied at the same time as benzoyl peroxide. And while they are unstable when exposed to light, microsphere and polyolprepolymer formulations do not have these restrictions. [Zaenglein 2018] Adapalene 0.1% gel has similar efficacy as tretinoin 0.025% gel with a better safety profile, and this concentration is available OTC. [Khemani 2016] A long-term safety study of a higher concentration of adapalene (0.3%) gel applied once daily for 52 weeks showed that signs and symptoms of local cutaneous irritation (e.g., erythema, dryness, scaling, and stinging/burning) are usually mild or moderate. Mean tolerability scores in the study were below 1 (mild) at all time points for the parameters assessed. [Weiss 2008],
BP is the topical antimicrobial of choice for acne, and it is often combined with retinoids due to synergistic effects. It releases free oxygen radicals that reduce the concentration of C. acnes without causing antimicrobial resistance. [Zaenglein 2018] The bactericidal properties of BP and the complementary comedolytic and anti-inflammatory effects of topical retinoids make these agents the preferred choice. [Zaenglein 2018] The synergistic efficacy of BP with adapalene is evidenced by pooled data from 3 double-blind controlled studies, in which patients were randomized to receive adapalene-BPO, adapalene, BPO, or vehicle once daily for 12 weeks. The combination was significantly more effective than individual components in decreasing lesion counts as early as week 1 and throughout 12 weeks. [Tan 2011] Many formulations of BP are available OTC, including washes and leave-on creams and gels. Conveniently, BP 2.5% gel is also available in prescription formulations in a fixed-dose combination with adapalene 0.1% and 0.3% gel. [Zaenglein 2018]
The topical antibiotics clindamycin and erythromycin also decrease the concentration of C. acnes, but their use can lead to bacterial resistance. They should be used in combination with tretinoin or BPO in patients with moderate to severe acne. [Zaenglein 2018] They should only be used for 3 to 4 months to limit the development of antimicrobial resistance.
Oral contraceptives containing an estrogen and a progestin are as effective as oral antibiotics to control inflammatory acne in adolescent and adult women. [Zaenglein 2018]
Spironolactone has potent antiandrogen activity by decreasing testosterone production and by inhibiting the binding of testosterone and dihydrotestosterone to androgen receptors in the skin. It is recommended in the 2016 AAD guidelines as a treatment option for acne in select females. Zaenglein 2016]
Oral isotretinoin is a last resort for patients with severe acne. It is a teratogenic agent and must be prescribed only by providers, usually dermatologists, who are enrolled in the FDA-mandated risk management program iPLEDGE. (Further details regarding this program can be found at www.ipledgeprogram.com). [Zaenglein 2018]
Despite evidence-based recommendations for topical retinoids as the foundation of treatment for all types of acne, they are underused in clinical practice by both primary care and dermatology clinicians, especially in the preadolescent population. [Leyden 2017] Data from a recent survey of patients with acne of all severities indicates that only about 1/3 actually purchased OTC formulations of BPO, but most did get their recommended prescription products. [Huyler 2017; Zaenglein 2018] Primary care clinicians can take an active role in ensuring that their patients with mild to moderate acne have access to the most effective and well-tolerated treatments for acne, including the foundational treatment of a retinoid in combination with BP. [Zaenglein 2018]
Reducing Skin Irritation and Optimizing Adherence to Acne Treatment
Nonadherence to acne treatment is common and is often due to inappropriate selection and/or application of medications, as well as unrealistic expectations about the time course of treatment response. Clinicians should use a shared decision-making approach when selecting a personalized treatment plan with consideration of individual factors, such as skin sensitivity, lifestyle, patient preferences, and experience with previous treatments to optimize adherence.
Since skin irritation from topical treatments with retinoids and BP is a common cause of non-adherence, it is important to select agents with a good tolerability profile. For example, adapalene is significantly less irritating than tretinoin or tazarotene. [Burchett 2017] And using lower concentrations of BP is often as effective as higher concentrations and decreases irritation.
BP does have a bleaching effect on colored garments and sheets, however, so patients should be instructed to take necessary precautions or be recommended a BP-based wash.
Following a good basic skin care routine is also important to achieve optimal results. Clinicians should instruct patients to follow a skin routine that limits washing to twice daily using gentle, non-comedogenic cleansers. A fragrance-free moisturizer applied over topical medication can also minimize dryness and irritation. All the retinoids are mildly photosensitizing, so patients should always use sunscreen to avoid sunburn. [Zaenglein 2018]
It is critically important for clinicians to set clear expectations about the time course of treatment response. Patients often expect immediate results and become discouraged, causing them to stop treatment. They should understand that it may take up to 8 to 12 weeks before they notice an improvement in their acne, and there may even be a transient worsening shortly after treatment is started. Noncomedogenic makeup may be used to cover blemishes until the medications take effect. [Zaenglein 2018]
Scheduling close follow-ups and continued communication with the patient through the HIPPA-compliant patient portal are possible strategies that clinicians can use to motivate their patients to adhere to their treatment. For example, clinicians can encourage patients to document their treatment progress by taking pictures at regular intervals.
Primary care clinicians who proactively identify and evaluate acne severity and provide evidence-based treatments for their adolescent and adult patients address an important unmet need. By developing an individualized treatment plan and providing appropriate education, they can maximize patient adherence and optimize outcomes of their patients with acne.
Burchett S. Is treatment of acne as simple as encouraging primary care physicians to prescribe more retinoids? JAAD. 2017;76:37.
Gollnick HP, Finlay AY, Shear N; Global Alliance to Improve Outcomes in Acne. Can we define acne as a chronic disease? If so, how and when? Am J Clin Dermatol. 2008;9(5):279-84.
Hauk L. Acne Vulgaris: Treatment Guidelines from the AAD. Am Fam Physician. 2017 Jun 1;95(11):740-741.
Jafferany M1, Vander Stoep A, Dumitrescu A, Hornung RL. The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol. 2010 Jul;49(7):784-9.
Khemani UN, Khopkar US, Nayak CS. A comparison study of the clinical efficacy and safety of topical adapalene gel (0.1%) and tretinoin cream (0.025%) in the treatment of acne vulgaris. IJBCP. 2016. DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20161465.
Saitta P, Grekin SK. A Four-question Approach to Determining the Impact of Acne Treatment on Quality of Life. J Clin Aesthet Dermatol. 2012 Mar; 5(3): 51–57.
Stein Gold L, Weiss J, Rueda MJ, Liu H, Tanghetti E. Moderate and severe inflammatory acne vulgaris effectively treated with single-agent therapy by a new fixed-dose combination adapalene 0.3 %/ benzoyl peroxide 2.5 % gel: a randomized, double-blind, parallel-group, controlled study. Am J Clin Dermatol. 2016;17: 293-303.
Tan J, Gollnick HP, Loesche C, Ma YM, Gold LS. Synergistic efficacy of adapalene 0.1%-benzoyl peroxide 2.5% in the treatment of 3855 acne vulgaris patients. J Dermatolog Treat. 2011 Aug;22(4):197-205.
Van Onselen J. Managing acne in primary care. Br J Fam Med. 2017. Available at: https://www.bjfm.co.uk/managing-acne-in-primary-care. Accessed Sept. 10, 2017.
Weiss JS, Thiboutot DM, Hwa J, Liu Y, Graeber M. Long-term safety and efficacy study of adapalene 0.3% gel. J Drugs Dermatol. 2008 Jun;7(6 Suppl):s24-8.
Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33.
Zaenglein AL. Acne vulgaris. N Engl J Med. 2018; 379:1343-52.