There are many classification and grading systems for acne, but no agreed upon standard.

Some grading systems

are complex and more suited for use in clinical trials. When treating patients, a simple classification that guides
treatment without getting overly complicated makes the most sense. Quality-of-life issues, including potential
scarring, should also be taken into account.
The uropean vidence-!ased "uidelines for the Treatment of #cne use the relatively straightforward classification
system of comedonal acne$ mild to moderate papulopustular acne$ severe papulopustular acne and moderate
nodular acne$ and severe nodular acne and conglobate acne.
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# simple classification system based on predominate lesion morphology was also adopted by the authors of the
vidence-!ased (ecommendations for the )iagnosis and Treatment of *ediatric #cne+ comedonal acne with closed
and open comedones$ inflammatory acne, characteri,ed by erythematous pustules, papules, nodules, or cystlike
nodular lesions$ or mixed, in which both types of lesions are present.
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#cne severity is then designated as mild,
moderate, or severe according to the number and type of lesions and the amount of skin involved.
#ntibiotics work for . reasons+ /irst, because antibiotics decrease P acnes levels, and second, because some
antibiotics, namely the tetracycline family, are anti-inflammatory in and of themselves. The tetracycline family
includes tetracycline, minocycline, and doxycycline, although the newer-generation tetracycline derivatives
0minocycline, doxycycline1 are now the most commonly used antibiotics for the treatment of acne in the 2nited
States. The tetracycline family has antigranuloma-forming activity through the inhibition of protein kinase 3. The
tetracyclines are antichemotactic for white blood cells and probably have other actions we have not yet discovered$
the tetracyclines are a remarkable group of drugs. So there are . mechanisms for tetracyclines and 4 mechanism
for the rest of the antibiotics$ namely, killing P acnes.
There are . issues. 5ne is antibiotic resistance in P acnes, making P acnes less susceptible to antibiotics, both oral
and topical, that used to work. The other issue can be posed in the form of a 6uestion+ )oes acne therapy with
antibiotics raise up resistant populations of pathogens on the bodies of people being treated for acne7 8et9s talk
about the first issue first.
:t is clear that P acnes that is resistant to erythromycin and clindamycin is much less responsive to treatment in
acne, and patients with these resistant organisms do not do as well as patients who have sensitive organisms. The
incidence of resistance to erythromycin and clindamycin has risen steadily since these drugs were introduced about
;< years ago. :t is now at the point that oral and topical erythromycin and clindamycin are useless as monotherapy
in acne and contribute very little to any acne therapy, even when used in combination therapy. There are patients
who seem to have acne that is resistant because their bugs are resistant to those . drugs. With doxycycline and
minocycline, you can show that the minimal inhibitory concentration in P acnes has crept upward over the years but
does not reach the level of true resistance.
The bigger issue of whether long-term acne therapy is raising up resistant populations on patients is tougher to
answer. We know that ;< or &< years of using oral tetracyclines has not resulted in an increase in Staphylococcus or
Streptococcus infections in those patients. =owever, at the same time, we note that these patients carry bugs that
could learn to be resistant to doxycycline with enough exposure. Staphylococcus aureus would be a particular
tragedy because even the resistant Staphylococcus infections, such as methicillin-resistant S aureus0>(S#1, at
least in most geographic areas, tend to be susceptible to doxycycline. :f we overuse doxycycline and educate the
>(S# to resist doxycycline, we will have lost a very safe and effective drug to treat >(S# infections.
Whenever you treat a human with an antibiotic, the presumption is that there is a good reason for it. /or example,
take a teenager with scarring acne, which is a guaranteed risk vs a theoretical risk of generating resistance
somewhere on the patient9s body. : will choose to treat the patient9s acne first and worry second about resistance.
This is not being cavalier about the issue of resistance, it is being more concerned about the patient who is in front
of me.
5ral antibiotic use should be minimi,ed to reduce the possibility of resistant strains of P acnes. :f you can get a
patient better without antibiotics, great. :f you have to use antibiotics, do it boldly and get it over with as 6uickly as
you can.5ral antibiotics are generally used in patients with moderate to severe inflammatory acne. 5ne consensus
panel has recommended limiting the duration of oral antibiotic therapy to 4. to 4? weeks.
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There are several ways to limit the duration of oral antibiotic treatment. 5ne would be to not fiddle around with a low
dose but to give a higher dose in combination with a second drug that will work to make the acne more treatable in
time. That second drug would be a topical retinoid+ ta,arotene, tretinoin, or adapalene. Topical retinoids have a
direct effect on the formation of comedones and also have anti-inflammatory effects. These drugs are used in the
treatment of both comedonal and inflammatory acne and are generally recommended in the initial management of
most patients with acne. #ll these retinoid drugs will help get patients off oral antibiotics more 6uickly if you use one
of them from day 4. *atients who have done well after . or ; months of oral antibiotic therapy, which will be the
maAority of patients, can be taken off the antibiotic and maintained Aust on the topical regimen. That is a great way to
get people off oral antibiotics relatively 6uickly.
:ncluding ben,oyl peroxide in acne regimens is another tactic to avoid bacterial resistance. !en,oyl peroxide is a
bactericidal agent that is directly toxic to microorganisms. >aking sure that ben,oyl peroxide is part of any topical
antibiotic regimen will discourage the development of resistance in P acnes and, presumably, any bacteria it comes
in contact with. :f you are going to use topical clindamycin, make sure ben,oyl peroxide is on board too, whether it is
in a combination ben,oyl peroxide-clindamycin product or a ben,oyl peroxide wash. rythromycin-ben,oyl peroxide
combination products are also available.
# fixed combination of adapalene and ben,oyl peroxide is available in a gel formulation. :n a &-week, open-label
study, this fixed-combination product inhibited both antibiotic-resistant and antibiotic-susceptible P acnes.
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#nother way to avoid bacterial resistance is to prescribe isotretinoin for severe, resistant acne. :n the 2nited
Cingdom, for example, the standard of care is ; months of therapy with an oral antibiotic and a topical retinoid. :f the
patient is not clear after ; months, you go right to isotretinoin. :n the 2nited Cingdom, they worry more about
bacterial resistance than they do about birth defects. :n the 2nited States, we take a different approach and worry
more about the teratogenicity of isotretinoin than we worry about antibiotic resistance. :t is something to ponder
when making treatment decisions.D
#nother option is hormonal treatment. :t only works in women because men get femini,ed when you inhibit their
androgens, but in women, there are great approaches. Spironolactone entered the world -< years ago as a diuretic,
but it is also an oral antiandrogen that has been used off-label in the 2nited States for the treatment of acne in
women for approximately ;< years. 5ral spironolactone is an efficacious way to treat fairly severe acne without
going anywhere near an antibiotic. **
:n the uropean 2nion, cyproterone acetateEethinylestradiol is approved for the treatment of moderate to severe
acne related to androgen sensitivity 0with or without seborrhea1 in women of reproductive age for whom topical or
systemic antibiotic acne treatment has failed. This drug is not available in the 2nited States, and recent concerns
about the risks for venous thromboembolism have spurred labeling changes in the uropean 2nion.
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The problem of antibiotic resistance has informed current guidelines for the treatment of acne vulgaris 0Tables 4 to
&1.
Table 1. Pediatric Treatment Recommendations for Mild Acne
Initial Treatment !*
OR
Topical retinoid
OR Topical 3ombination TherapyD
!* F #ntibiotic
OR
(etinoid F !*
OR
(etinoid F #ntibiotic F !*
If Inadequate Response*

#dd !* or retinoid, if not already prescribed

OR
3hange topical retinoid concentration, type, andEor formulation
OR
3hange topical combination therapy
!* G ben,oyl peroxide.
DTopical fixed-combination prescriptions are available.
H#ssess adherence.
/rom ichenfield 8/, et al.
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Table 2. Pediatric Treatment Recommendations for Moderate Acne
Initial Treatment Topical 3ombination TherapyD
(etinoid F !*
OR
(etinoid F 0!* F #ntibiotic1
OR
0(etinoid F #ntibiotic1 F !*
OR 5ral antibiotic
F
Topical retinoid F !*
OR
Topical retinoid F #ntibiotic F !*
If Inadequate
Response*

3hange topical retinoid concentration, type,
andEor formulation
AND/OR
AND/
OR
#dd or change oral antibiotic
3onsider hormonal therapy for
OR 3onsider oral
isotretinoin
I

3hange topical combination therapy female patients
I

!* G ben,oyl peroxide.
DTopical fixed-combination prescriptions are available.
H#ssess adherence.
I3onsider dermatology referral.
/rom ichenfield 8/, et al.
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Table 3. Pediatric Treatment Recommendations for Seere Acne
Initial Treatment
!
3ombination TherapyD
5ral antibiotic
F
Topical retinoid
F
!*
FE-
Topical antibiotic
If Inadequate Response
!
3onsider changing oral antibiotic
AND
3onsider oral isotretinoin
3onsider hormonal therapy for female patients
I

!* G ben,oyl peroxide.
DTopical fixed-combination prescriptions are available.
H#ssess adherence$ consider change of topical retinoid.
I3onsider dermatology referral.
/rom ichenfield 8/, et al.
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Table ". #uropean Acne Treatment $uidelines
%i&'(stren&t' Recommendations Medium(stren&t' Recommendations Alternaties for )emale Patients
*omedonal acne+ Jo high-strength
recommendation
Mild(to(moderate papulopustular
acne+ #dapalene F !* 0fc1 OR !* F
clindamycin 0fc1
Seere papulopustular,moderate
nodular acne+ :sotretinoin
Seere nodular,con&lobate acne+
:sotretinoin
*omedonal acne+ Topical retinoid
Mild(to(moderate papulopustular acne+ #,elaic
acid OR !* OR topical retinoid OR systemic
antibiotic F adapalene
Seere papulopustular,moderate nodular acne+
Systemic antibiotics F adapalene OR systemic
antibiotics F a,elaic acid OR systemic antibiotics F
adapalene F !* 0fc1
Seere nodular,con&lobate acne+ Systemic
antibiotics F a,elaic acid
Seere papulopustular,moderate nodular
acne+ =ormonal antiandrogens F topical
treatment 5( hormonal antiandrogens F
systemic antibiotics
Seere nodular,con&lobate acne+ =ormonal
antiandrogens F systemic antibiotics
!* G ben,oyl peroxide.
/rom Jast #, et al.
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Medscape+ -'at is t'e current role of topical antibiotics in t'e treatment of acne. &ien t'e problem of
antibiotic resistance and t'e efficac/ of ot'er topicals suc' as ben0o/l pero1ide and topical retinoids2
3r -ebster+ Topical erythromycin and clindamycin as monotherapy have little role in treating acne because of the
predominance of resistant strains of P acnes. *roducts that pair erythromycin or clindamycin with ben,oyl peroxide
remain effective.
Medscape+ 4ou 5ere part of t'e &roup t'at deeloped t'e #idence(6ased Recommendations for t'e
3ia&nosis and Treatment of Pediatric Acne. 5'ic' 5ere publis'ed in 2713.
89:
T'ese recommendations 5ere
deeloped t'rou&' t'e American Acne and Rosacea Societ/ and endorsed b/ t'e American Academ/ of
Pediatrics. -'/ are t'ese &uidelines important2
3r -ebster+ #cne is one of the most common skin conditions in children and adolescents, but until now there have
not been standard guidelines for the management of pediatric acne. 5ne of the messages of the guidelines is that
treatment should be appropriately aggressive. When a kid has acne, even at an age when you do not expect acne,
the child9s age is not a reason to not treat or to undertreat. Kounger kids deserve sufficiently vigorous treatment to
get them better, Aust like older kids. That message needs to be emphasi,ed, especially to pediatricians. #cne is not
nothing, and it is reasonable to treat it properly even in a younger child.
* :n the 2nited Cingdom, isotretinoin must be prescribed under the supervision of a dermatologist with an
understanding of the risks of retinoid treatment and the monitoring re6uirements for the use of isotretinoin. #
*regnancy *revention *rogramme is also in place.
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DD2S /ood and )rug #dministration labeling for spironolactone carries the following boxed warning+ LSpironolactone
has been shown to be a tumorigen in chronic toxicity studies in rats. Spironolactone should be used only in those
conditions described under :ndications and 2sage. 2nnecessary use of this drug should be avoided.L