Guidelines for the Management of Acne

Recommendations From a French Multidisciplinary Group

L. Le Cleach; B. Lebrun-Vignes; A. Bachelot; F. Beer; P. Berger; S. Brugére; M. Chastaing; G. Do-Pham; T. Ferry; J. Gand-Gavanou; B. Guigues; O. Join-Lambert; P. Henry; R. Khallouf; E. Lavie; A. Maruani; O. Romain; B. Sassolas; V.T. Tran; B. Guillot


The British Journal of Dermatology. 2017;177(4):908-913. 

In This Article

Guideline Development

Methodology and Participants

The 'Clinical Practice Guidelines' method established by the French National Authority for Health (Haute Autorité de Santé, HAS) was followed.[5] The Working Group (WG) comprised 19 people: dermatologists (7); drug-safety specialist (1); endocrinologist (1); infectious diseases specialist (1); microbiologist (1); psychiatrist (1); paediatrician (1); gynaecologists (2); general practitioners (2); and HAS methodologists (2). In accordance with HAS policy,[6] WG members and technical review authors had no conflicts of interest (COIs). COI declarations were examined by the HAS Ethics and Independent Expertise Committee COI.[7]

Literature Search to Technical Review to Guidelines Procedure

An HAS health librarian conducted a literature search (see Supplementary Information Material S1 for sources and equations) for references from 2007 to September 2014 on the following topics: acne grading systems, influencing factors, interventions to improve adherence, efficacy and safety of topical and systemic treatments, bacterial resistance to antibiotics, physical therapies. Six physicians with skills in methodology (Master's degree or PhD) extracted data from each report, entered them into an extraction table, analysed methodology and risk of bias using Appraisal of Guidelines for REsearch & Evaluation (AGREE)[8] for guidelines, Assessing Methodological quality for SysTemAtic Reviews (AMSTAR)[9] for systematic reviews and the Risk-of-Bias tool for randomized controlled trials (Cochrane collaboration).[10] Based on these analyses, they drafted the technical review that served as the basis for the WG's meetings and discussions to devise guidelines and recommendations. The ensuing initial version of the guideline served as the basis for all future work. It and the technical report were submitted to four acne experts, who were then interviewed for their opinions. Thereafter, the WG revised, if necessary, the first version of the guideline and recommendations. These documents were then submitted online (via the HAS website) to a peer review group of 51 physicians from different specialties, representing those in the WG, who gave a formal opinion on the content and form of the initial version of the guideline, in particular its applicability, acceptability and readability. Each guideline recommendation was rated on a Likert scale from 1 (totally disagree) to 9 (fully agree) for form and substance. Recommendations that achieved a < 90% mean score > 5 had to be reexamined by the WG. Recommendation grades are described in Table 1 and guideline rating according to AGREE in Table 2.

Process for Updating These Guidelines

The literature search conducted on 28 July 2016 (sources and equations in Supplementary Material SM1) identified 63 new references since the last search (September 2014). After selection, 34 were included for analysis in the update, which is ongoing. The technical report will be revised with new evidence and resubmitted to the WG. Should the WG deem that a modification of the current guidelines would be useful, an updating process will be launched.

Evidence Base

Among the 652 references identified by the literature search (79 guidelines, 53 systematic reviews, 232 randomized controlled trials (RCTs), 161 isotretinoin adverse effects, 47 epidemiology, 40 treatment adherence and 40 antibiotic resistance), 128 were included after selection. Among the numerous tools used to grade acne severity, none satisfied the mandatory essential clinical components.[11] Because the Global Acne Severity scale has been validated through an adequate process and provides a clear description of each grade supported by clinical photography, the WG chose to build its recommendations and base its algorithm on it.[12]

Recommendations according to acne severity are reported in the form of an algorithm (see Figure 1). The WG considered poor treatment adherence to be a major concern (Table 3).

Figure 1.

French guidelines for acne management: treatment algorithm for acne in adults and adolescents. For definitions of grades and Consensual Working Group opinion (CWGO), see Table 1. aNo trial has demonstrated the superiority of one benzoyl peroxide concentration over the others; no specific concentration is recommended. Patients must be informed of the risk of this product bleaching clothes. bConsidering the low level of evidence of comparative efficacies between different topical retinoid molecules and doses, no recommendation was given for a specific molecule or its dose. cIn the absence of a trial comparing the efficacies of and tolerances to the fixed-concentration adapalene 0·1%–benzoyl peroxide 2·5% vs. application of each molecule separately, and demonstration of better adherence, the fixed combination is not considered preferable. dOral isotretinoin is prescribed at 0·5 mg kg−1 day−1. Concerning isotretinoin-related adverse events, notably its teratogenicity, recommendations for its prescription must be strictly followed. eFor forms with numerous and severe comedones, oral isotretinoin should be started at a lower dose (0·2–0·3 mg kg−1 day−1) to lower the risk of an acne flare (CWGO).