Systematic review of clinical practice guidelines for acne vulgaris published between January 2017 and July 2021

Problem

Acne is a common inflammatory skin condition, which can be associated with an increased risk of mental health conditions including depression. Effective treatment is essential to prevent physical sequelae. Treatment regimens frequently involve topical or oral antibiotics, but rising levels of antibiotic resistance necessitates regular review of prescribed therapies.The aims of this project are: o to update the systematic review of acne clinical practice guidelines published in 2017 o to critically appraise reporting of acne guidelines using AGREE II (Appraisal of Guidelines for Research and Evaluation Reporting) checklist o to examine guidance on acne treatments, particularly recommendations around oral antibiotic use

Approach

We systematically searched for acne guidelines from 01 January 2017 to 31 July 2021 using: MEDLINE, Embase, Google Scholar, LILACS. We supplemented this by searching a guideline-specific depository and checking for updates to guidelines included in the 2017 review. There were no language restrictions, and guidelines not in English were translated prior to assessment and data extraction. We excluded guidelines that focussed on a single intervention, conference abstracts, editorials, letters or regional adaptations of guidelines. A critical appraisal of guideline quality was completed using the AGREE II checklist. We extracted recommendations from all guidelines that met inclusion criteria regardless of quality score. Data on recommendations of pre-specified treatments of interest were also extracted and analysed.

Findings

Ten guidelines fulfilled eligibility criteria, including the first NICE guideline on acne. AGREE II scores were substantially improved since the 2017 review of acne guidelines, suggesting increased rigour in guideline development and reporting. Recommendations within guidelines for first-line treatments (topical treatments) were hampered by lack of consistency in outcome reporting between trials. Comparisons of recommendations between guidelines were also challenged by differing definitions of mild, moderate or severe acne.The indications for commencing oral antibiotics varied between guidelines (e.g. ‘truncal acne’, ‘mild/moderate acne resistant to treatment’ or ‘severe papulopustular acne’), and recommendations for maximum duration of treatment varied from 3 to 6 months. All of the guidelines advocated second generation tetracyclines as first line oral antibiotic at a similar dose and recommended co-prescribing non-antibiotic topical treatment alongside oral antibiotics.All guidelines advocated second generation tetracyclines as first line oral antibiotic at a similar dose, except two that were unclear on this point. Several guidelines recommended that non-specialists with appropriate experience could initiate oral isotretinoin.

Consequences

The results from this systematic review can be used to guide clinicians and raise awareness of differing recommendations on the treatment of acne. All guidelines agree on the importance of co-prescribing a non-antibiotic topical agent with an oral antibiotic, as well as limiting the duration of treatment with oral antibiotics. This review also highlights variations in access to non-antibiotic treatments.