extensive moderate papulopustular acne, additional systemic antibiotics to the topical medications are a further option.27,29-38 If not successful, oral isotretinoin may be considered while continuing topical therapy and skincare.27,29-38
Nodulocystic acne
Efficacy was shown with isotretinoin and subsequent active comparators in severe nodular acne.32 Given the potential for adverse events and teratogenicity, prescribing oral isotretinoin should be limited to physicians trained and experienced in its use, monitoring, and appropriate pregnancy-prevention measures.32,59 Racial/ethnic disparities in access to isotretinoin have been reported.65-67 Given the higher risk of long-term sequelae (including PIH and keloidal/hypertrophic scars) in SOC patients with acne, the threshold for isotretinoin use should be low in those who respond inadequately to other therapies or patients who present with nodulocystic acne.68 Skin care is a crucial adjunct to medical treatment as oral isotretinoin-related dryness is a typical result of treatment.69
If oral isotretinoin is not suitable, systemic antibiotics in combination with topical BPO, with or without a topical retinoid, may be considered.32 The addition of BPO is recommended to limit the emergence of antibiotic-resistant bacteria.32 Hormonal therapy with an oral contraceptive or spironolactone may be a further option for women.27,29-38
Relapse
Topical retinoids or topical antimicrobials may be used for maintenance treatment.27,29-38,55 Other examples of products suitable for maintenance are alpha hydroxy acid (AHA)-, beta-hydroxy acid (BHA)-, and glycolic acid (GA)-containing creams, gels, serum, and lotions, ceramide-containing foaming cleansers, and, soap-free cleansers.16,40,43
In nonprescription products, low concentrations of GA (4%- 10%) are used.40,43 These nonprescription products can be especially helpful in acne maintenance care. However, caution is advised given the risk for irritation and consequently PIH in SOC patients.40,43
In a study of acne in people of Asian descent, a moisturizer containing licochalcone a, decane diol, l-carnitine, and salicylic acid was reported to be beneficial for the prevention of acne relapse.70
Although guidelines recommend acne maintenance treatment,29-38 Tan and colleagues found the guidance on escalating or de-escalating acne maintenance treatment insufficient.27 The personalized acne care pathway provides detailed clinical consideration, discussion, and pivot points that support healthcare providers in making decisions on maintenance approaches.27
Acne-related PIH
PIH is often the presenting complaint among SOC patients with acne, causing significant distress.9,11-16,42,71,72 Treatment of acne-induced PIH includes sun protection, topical therapies, chemical peels, microneedling (once acne is resolved), lasers, and other energy-based devices.11-16,42,71-74 Superficial chemical peels such as salicylic acid (20%-30%), glycolic acid (20%-30%), and Jessner peels have been widely used to treat acne-related PIH in SOC patients.71-73 The risk of pigmentary alterations as a complication of chemical peels and other cosmetic procedures must be balanced with the potential benefit. Careful selection of peeling agents, judicious technique, and associated skin care (including sun protection) help to reduce the risk of complications from peels and other cosmetic procedures for PIH. Skin-lightening products (eg, hydroquinone and nonhydroquinone cosmeceuticals) can also be used to directly treat PIH.74
Acne-related scarring
A Japanese study demonstrated that acne-related scars severely impact patients' QoL.75 The treatment depends on the scar's size, type, depth, and the clinician's preference.71,75 For hypertrophic scars and keloids, intralesional injections of triamcinolone acetonide 10-40 mg/mL every 4 to 6 weeks can be utilized until resolved.71 In patients with SOC, surgical approaches to atrophic acne scarring include elliptical excision, punch excision, punch elevation, punch autografting, subcutaneous incision, microneedling, and fillers. Ablative laser skin resurfacing and dermabrasion should be used with caution due to the risk of dyspigmentation.71,75 Treatment using lasers involves fractional photothermolysis, which has emerged as a treatment option for acne scars in SOC patients.76 This procedure produces microscopic columns of thermal injury in the epidermis and dermis, sparing the surrounding tissue and minimizing downtime and adverse events.76 Because fractional photothermolysis does not target melanin and produces limited epidermal injury, it can be safely and effectively used in SOC patients with acne-related scarring.76
Superficial and deep carbon dioxide (CO2) fractional laser has been used in a small study to successfully treat acne-related scarring in SOC patients.77 Another single-center prospective study assessed the clinical efficacy and safety of the 1450- nm diode laser for the treatment of acne scarring in patients
Nodulocystic acne
Efficacy was shown with isotretinoin and subsequent active comparators in severe nodular acne.32 Given the potential for adverse events and teratogenicity, prescribing oral isotretinoin should be limited to physicians trained and experienced in its use, monitoring, and appropriate pregnancy-prevention measures.32,59 Racial/ethnic disparities in access to isotretinoin have been reported.65-67 Given the higher risk of long-term sequelae (including PIH and keloidal/hypertrophic scars) in SOC patients with acne, the threshold for isotretinoin use should be low in those who respond inadequately to other therapies or patients who present with nodulocystic acne.68 Skin care is a crucial adjunct to medical treatment as oral isotretinoin-related dryness is a typical result of treatment.69
If oral isotretinoin is not suitable, systemic antibiotics in combination with topical BPO, with or without a topical retinoid, may be considered.32 The addition of BPO is recommended to limit the emergence of antibiotic-resistant bacteria.32 Hormonal therapy with an oral contraceptive or spironolactone may be a further option for women.27,29-38
Relapse
Topical retinoids or topical antimicrobials may be used for maintenance treatment.27,29-38,55 Other examples of products suitable for maintenance are alpha hydroxy acid (AHA)-, beta-hydroxy acid (BHA)-, and glycolic acid (GA)-containing creams, gels, serum, and lotions, ceramide-containing foaming cleansers, and, soap-free cleansers.16,40,43
In nonprescription products, low concentrations of GA (4%- 10%) are used.40,43 These nonprescription products can be especially helpful in acne maintenance care. However, caution is advised given the risk for irritation and consequently PIH in SOC patients.40,43
In a study of acne in people of Asian descent, a moisturizer containing licochalcone a, decane diol, l-carnitine, and salicylic acid was reported to be beneficial for the prevention of acne relapse.70
Although guidelines recommend acne maintenance treatment,29-38 Tan and colleagues found the guidance on escalating or de-escalating acne maintenance treatment insufficient.27 The personalized acne care pathway provides detailed clinical consideration, discussion, and pivot points that support healthcare providers in making decisions on maintenance approaches.27
Acne-related PIH
PIH is often the presenting complaint among SOC patients with acne, causing significant distress.9,11-16,42,71,72 Treatment of acne-induced PIH includes sun protection, topical therapies, chemical peels, microneedling (once acne is resolved), lasers, and other energy-based devices.11-16,42,71-74 Superficial chemical peels such as salicylic acid (20%-30%), glycolic acid (20%-30%), and Jessner peels have been widely used to treat acne-related PIH in SOC patients.71-73 The risk of pigmentary alterations as a complication of chemical peels and other cosmetic procedures must be balanced with the potential benefit. Careful selection of peeling agents, judicious technique, and associated skin care (including sun protection) help to reduce the risk of complications from peels and other cosmetic procedures for PIH. Skin-lightening products (eg, hydroquinone and nonhydroquinone cosmeceuticals) can also be used to directly treat PIH.74
Acne-related scarring
A Japanese study demonstrated that acne-related scars severely impact patients' QoL.75 The treatment depends on the scar's size, type, depth, and the clinician's preference.71,75 For hypertrophic scars and keloids, intralesional injections of triamcinolone acetonide 10-40 mg/mL every 4 to 6 weeks can be utilized until resolved.71 In patients with SOC, surgical approaches to atrophic acne scarring include elliptical excision, punch excision, punch elevation, punch autografting, subcutaneous incision, microneedling, and fillers. Ablative laser skin resurfacing and dermabrasion should be used with caution due to the risk of dyspigmentation.71,75 Treatment using lasers involves fractional photothermolysis, which has emerged as a treatment option for acne scars in SOC patients.76 This procedure produces microscopic columns of thermal injury in the epidermis and dermis, sparing the surrounding tissue and minimizing downtime and adverse events.76 Because fractional photothermolysis does not target melanin and produces limited epidermal injury, it can be safely and effectively used in SOC patients with acne-related scarring.76
Superficial and deep carbon dioxide (CO2) fractional laser has been used in a small study to successfully treat acne-related scarring in SOC patients.77 Another single-center prospective study assessed the clinical efficacy and safety of the 1450- nm diode laser for the treatment of acne scarring in patients
