Treatment algorithms are much different than traditional guidelines in that they are precise and detailed plans for a regimen over time, where guidelines review evidence over a study period in a well-defined population. Algorithms are practical as they provide dermatologists information that can be used every day to deliver evidence-based care consistently and in a standardized fashion.

Many algorithms for acne are published within or alongside the context of guidelines. However, there are two main limitations that must be considered: 1) they are based on severity and/or lesion type, and are not reflective of specific patient features and 2) patients’ perspectives not reflected.

In 2016, 17 acne experts reviewed existing highly cited evidence-based guidelines and developed three acne-specific algorithms based on the following types of acne:¹

• Comedonal
• Papulopustular
• Nodular/conglobate.

This approach was very useful for dermatologists as it provided a sense of how to address a complicated patient as well as provided checklists and a global evaluation scale.¹

There are 5 principal reasons why treatment responses may fail. These include:

• Non-drug-related reasons
• Drug-related reasons
• Poor adherence
• Adverse events
• Disease progression.

The development of checklists to determine the causes for a lack of treatment response are a useful tool to optimize acne management (Table)¹.

The Global Alliance to Improve Outcomes in Acne recently published a therapeutic algorithm that provided practical management information over time for treating mild, moderate, severe, and very severe acne.² This algorithm also provides reasons for lack of response as well as considerations for treatment amendment.

The importance of skin care regimens is a strong consideration and is discussed in the acne algorithm by Bagastin et al. as these regimens are commonly overlooked by dermatologists and patients alike.³

Items Not Included in Algorithms

Patients themselves are not frequently represented in algorithms. Often times they may have questions related to cosmeceuticals or over-the-counter preparations and how they may fit into a regimen.

There are a number of suggestions that have shown efficacy in the management of patients with acne.

• Many of the algorithms agree that a topical retinoid is a first-line approach for comedonal acne and subsequent maintenance.
• Topical product combinations/fixed dose topical combinations are central to acne management as they provide:
  • An effective first-line therapy for mild-to-moderate papulopustular disease
  • An increased efficacy, improved rate of lesion resolution, and minimized potential for antibiotic resistance
  • A further benefit of increased convenience and potential to improve adherence

• Therapy comprising various combinations of topical retinoids, benzoyl peroxide, antibiotics (topical or oral), and hormonal therapy for women is now considered the primary best standard of care.
• The use of topical and systemic antibiotics should be optimized by using appropriate combinations to reduce the development of antibiotic resistance. This includes use for a predefined duration
• Patient education is of vital importance to ensure:
  • Patients are aware of how to use the treatment
  • Apply medication to affected areas
  • Aware of adverse events
  • This is also a time to discuss skin care regimes and review the multifactorial/chronic nature of acne.
• For best results, patients should be seen within 6 to 8 weeks to assess response/lack of response and adjust treatment as necessary.

With funding from a National Institutes of Health grant, the Acne Core Outcomes Research Network sought to develop a universal set of core outcome measures for use in clinical trials:⁴

• Satisfaction with appearance
• Satisfaction with treatment received
• Signs and symptom of acne
• Extent of scars and dark marks
• Long-term control of acne
• Health-related quality-of-life.

Patient’s should be included in the deciding factors for their treatment. This allows patients to be more involved, increase knowledge, reduce passivity, and improve patient/practitioner communication. There are a number of patient decision tool aids available on the internet, some with videos, checklists, and other programs. It is important to encourage patients to play a more active role in their acne treatment decision-making.