Chinese Guidelines for the Management of Acne Vulgaris: 2019 Update#

Acne Group, Combination of Traditional and Western Medicine Dermatology; Acne Group, Chinese Society of Dermatology; Acne Group, Chinese Dermatologist Association; Acne group, Dermatology Committee, Chinese Non-government Medical Institutions Association

Abstract The first Chinese guidelines for the management of acne vulgaris was developed and published in 2008 and updated in 2015.With the acquisition of new evidence-based data and the development of new medicines and techniques,the guidelines should be updated regularly. Here, the Chinese guidelines for the treatment of acne vulgaris 2019 update was developed based on the feedback of dermatologists applying in previous version,advances in acne research,as well as the opinions of the experts.

Keywords: acne vulgaris, Chinese, guidelines, treatment

Introduction

Acne vulgaris(AV)is a chronic inflammatory skin disease of pilosebaceous unit, which is common especially in adolescence and mainly affects the face. The incidence of AV in Chinese population in a cross-sectional statistics is 8.1%,1and it has a prevalence of over 90% among adolescents and persists in adulthood.2AV can cause permanent scars in 3%-7% of patients and has a large impact on physical and mental health.3-4

There are numerous methods of treatment available for AV.However,some of them are not effective or evidencebased, and some even cause injury to patients. It is necessary to develop the acne treatment guidelines suitable for Chinese population.The first Chinese guidelines for the management of AV was published in 20085and updated in 2015.6With the acquisition of new evidence-based data and the development of new medicines and techniques,these guidelines should be updated regularly. Here, we update the Chinese guidelines for the treatment of AV based on the feedback of dermatologists applying in previous version, advances in acne research, and the opinions of the experts.

Pathogenesis of acne

Hormones-mediated sebum overproduction,follicle hyperkeratinization, colonization of pilosebaceous microbe,especiallyPropionibacterium acnes(P.acnes),and inflammation and immune responses contribute to the acne pathogenesis,although the exact pathogenesis of acne has not been fully elucidated until now.7Genetic factors play an important role in the development of acne, especially in severe cases.8-9Androgen is related to hyperplasia of sebaceous glands (SGs) and sebum overproduction, while other hormones such as insulin-like growth factor-1(IGF-1),insulin,and growth hormone(GH)also play important role in acne pathogenesis.10Overproduction of sebum is regarded as a prerequisite for acne,besides the altered lipid composition such as increased ratio of squalene,wax esters,free fatty acids, and unsaturated fatty acids, as well as decreased proportion of linoleic acid.11

Pilosebaceous microorganisms such asP. acnesparticipate in the development of acne,and are involved in both innate and adaptive immunity.12Abnormal keratinization of the pilosebaceous ducts and inflammatory and immunological responses are main pathological features of acne, and inflammatory response affects the whole disease process.13In the earlier stage, the pilosebaceous microorganisms and/or abnormal sebum produce interleukin-1α (IL-1α) and other related inflammatory factors through the activation of toll-like receptors(TLRs),which are major factors in the keratinization of pilosebaceous structures and the formation of microcomedones and comedones.11-13In the later stage of disease,accumulation of sebum leads to overproliferation ofP. acnes, which is lipophilic and anaerobic, and a further activation of acquired immunity response. The aggressive inflammatory response destroys the wall of follicle, which allows sebum, microorganisms, and hair to enter the dermis,causing a foreign body reaction.7Erythema, hyperpigmentation, and scar formation often occur after acne lesions subside, which are closely related to the severity of acne,individual differences,and/or previous improper treatment.14

Grading of acne vulgaris

Acne grading systems are essential for selecting the appropriate treatment and monitoring improvement during the treatment of acne, and there are over 25 acne grading/classifying systems in the world until now.15Here,the authors suggest three degrees with four levels in accordance with the nature of the skin lesions.Mild(level 1):comedones; moderate(level 2): involves inflammatory red papules; moderate (level 3): involves pustules; and severe (level 4): involves nodules and/or cysts.

Topical therapies

Topical therapy is the first-line choice for mild to moderate acne and important adjuvant treatment for moderate to severe acne that is being treated systemically.16

Topical retinoids

Mechanism of action:Topical retinoids can normalize keratinization,dissolve comedones and microcomedones,have anti-inflammatory effects, and further prevent and improve formation of pigmentation and scarring of acne.17-19In addition, topical retinoids can improve skin permeability and thus increase the efficacy of topical antibacterial and anti-inflammatory agents.

Indication and choice of agents:Topical retinoids can be used as a single first-line choice for mild acne and combinational choice for moderate acne, as well as the first-line choice in acne maintenance. Normally the first-generation retinoids (all-trans retinoic acid and isotretinoin) and the third-generation retinoids (adapalene and tazarotene) are recommended. Topical adapalene is recommended as a first-line option because of its better tolerance to the skin than other topical retinoids.20-21

Usage and notice:Topical retinoids are recommended to apply on both acne lesions and predilection sites of acne before bedtime. Mild skin irritation characterized by erythema, desquamation, tightness, burning, and hypersensitivity often occur. However, in most of cases, skin can set up tolerance gradually. Treatment should be discontinued immediately if severe reactions appear. In addition, photodegradation phenomenon of retinoic agents (mainly first-generation retinoids), increased sensitivity of skin, and transient exacerbation of skin lesions during the 2-4 weeks should be taken care of after the application of topical retinoids.Therefore,with regard to usages, the following are recommended: lower initiating concentration(if available)and small tested area,reduced times of application,and keeping skin dry,which will help to increase compliance and avoid more serious irritations.Furthermore,skin barrier repair agents and sun protection are recommended.18,22

Topical antimicrobial agents

Benzoyl peroxide

Benzoyl peroxide (BPO) has the ability to killP. acnes,dissolve comedones mildly,as well has anti-inflammatory effectviareleases of free oxygen radicals and benzoic acid,and as of now no bacterial resistance to BPO has been reported. BPO is recommended as the first-line topical agent for inflammatory lesions.BPO can be used alone or in combination with topical retinoids or other antibiotics,and the available formulations include wash,cream,or gel with concentrations from 2.5% to 10%. Mild irritation may occur during the treatment course, and it is thus recommended to start with a lower concentration and to test the treatment on a small trial area. BPO has an oxidative bleaching effect on clothing and hair;therefore,direct contact should be avoided.In addition,the oxygenfree radicals released by BPO can inactivate all-trans retinoic acid, and these two agents should be administered at different times when they are used in combination.23-26

Other topical antibiotics

Antibiotics are applied in acne as the first-line choice treatment because of both its actions againstP.acnesand its anti-inflammatory effects. Commonly used topical antibiotics23,26in acne treatment include erythromycin,lincomycin,and its derivatives clindamycin,chloramphenicol, clindamycin, and fusidic acid.27-28As topical antibiotics have less skin irritation, they are theoretically applicable to superficial inflammatory acne lesions such as papules and pustules. However, since topical antibiotics can induceP. acnesresistance, they are not advised for long-term therapy.The combination of topical antibiotics/BPO and topical retinoids is encouraged.29

Other topical agents

Topical agents with various concentrations and formulations of azelaic acid,dapsone,30selenium disulfide,sulfur,and salicylic acid are also available in acne treatment,which can inhibitP. acneand have anti-inflammatory or mild exfoliative effects. Furthermore, skin barrier repair agents and sun protection are recommended.

Systemic medication

Systemic antibiotics

Systemic antibacterial agents with anti-inflammatory effects are commonly used in the treatment of moderate to severe acne. However, it is very important to regulate the use of antibiotics according to the acne severity, not only to ensure the efficacy,but also to minimize antibiotic resistance or abuse.31-33

Indications:(1) The first-line choice for patients with moderate to severe acne, and an alternative treatment for moderate acne when only topical treatment is ineffective.(2)Early stage of patients with severe inflammatory acne;(3) Oral isotretinoin fails. (4) Fulminant acne and early treatment of acne conglobata.

Medicines selection:The choice of oral antibiotics is based on that if the drugs have high sensitivity toP.acnes,if have non-specific anti-inflammatory effects, if form higher concentration in the pilosebaceous unit, and less adverse effects. Tetracyclines such as doxycycline and minocycline are recommended to be the first-line treatment. When tetracyclines are intolerable or contraindicated, macrolide antibiotics such as erythromycin,roxithromycin, and azithromycin are recommended.Sulfamethoxazole-trimethoprim (complex sulfamethoxazole) can also be chosen. Other antibacterial medicines such as β-lactams,cephalosporins,and quinolones should be avoided in acne treatment.As tetracycline has poor oral absorption and a high rate of resistance toP. acnes,doxycycline or minocycline are preferred.Minocycline has a higher concentration in tissue and a lower incidence of drug resistance. When treating cases of recurrence, the antibiotics that were effective in the previous treatment should be selected again, while random replacements should be avoided.

Dosage and duration of treatment:Recommended doses of doxycycline, minocycline, and erythromycin are 100-200mg/d (usually 100mg/d), 50-100mg/d, and 1.0g/d,respectively. Eight-week is recommended maximal duration.

Note34: (1) Using antibiotics alone should be avoided.(2) Treatment should be discontinued or switched if oral antibiotics fail after two to three weeks. (3) Ensure adequate duration of treatment and avoid intermittent use.It is also not recommended to increase the dose or extend the duration without rational reasons. Furthermore,systemic antibiotics cannot be used in maintenance therapy and prevention of acne. (4) Combinational therapy of oral antibiotic with topical retinoids or BPO is recommended, which can improve the efficacy and reduce antibiotic resistance. (5) Combinational therapy with phototherapy or other methods will help to reduce the use of antibiotics. (6) Adverse effects, including gastrointestinal reactions, drug eruptions, liver damage, photosensitivity, pigmentation, and dysbacteriosis, should be taken care of especially for tetracyclines.In a small number of patients, oral minocycline may cause vestibular problems (causing symptoms such as dizziness and/or vertigo),rare lupus-like syndrome,and benign intracranial hypertension (presenting as headache); in such cases,minocycline should be discontinued immediately. Tetracyclines should not be combined with oral retinoids to avoid aggravating benign intracranial pressure. Tetracyclines should not be used by pregnant women, lactating women, and children under the age of 8 years; However macrolide antibiotics should be considered for such populations.

Oral retinoids

Oral retinoids significantly inhibit secretion of SGs,regulate abnormal keratinization of pilosebaceous follicles, improve the anaerobic environment, and reduceP.acnesreproduction,have anti-inflammatory effects,and prevent scar formation. Oral retinoids are the only medicine that targets all four key factors in acne pathogenesis.35

Indications:(1) First-line treatment for severe nodulocystic acne.(2)Alternative therapy if other treatments are ineffective for moderate to severe acne. (3) Patients with acne scarring or a tendency toward scar formation need to use oral retinoids as early as possible. (4) Patients with frequent acne recurrence for which other treatments are ineffective. (5) Acne with sebum overproduction. (6)Patients with mild to moderate acne desire rapid improvement. (7) Acne variants such as acne fulminans and acne conglobata;oral retinoids can be used after oral antibacterial drugs and glucocorticoids,which are administered to control the inflammatory response.

Drug selection:Current systemic retinoids include oral isotretinoin and viaminati.36Isotretinoin is an oral retinoid that is routinely used as the first-line choice for acne worldwide. The usual initiating dose for isotretinoin is 0.25-0.5mg/(kg·d),37with the dose then gradually increased in accordance with the patient’s tolerance and the response to the medicine. The dosage for severe nodulocystic acne can be gradually increased to 0.5-1mg/(kg·d).Viaminati belongs to the first generation of retinoic acid developed and produced in China.36The dosage for viaminati is 50mg three times per day. Both isotretinoin and viaminati need to be taken with a fatty meal to increase the bioavailability of oral absorption. The duration of treatment depends on the treatment effect and the total dosage,but isusuallynolessthan16weeks.Thetreatmentis generally effective after three to four weeks.After the acne lesions are controlled,the dosage should be reduced and the treatment course is recommended as two to three months or longer.

Note38: Isotretinoin commonly has adverse effects,which most relieve after drug discontinuation. Serious adverse effects are rare.The most prevalent adverse effect is mucocutaneous dryness, and so the skin barrier repair agents are recommended. Lip dryness is most common in mucocutaneous reactions, but this is also an indicator of the effective drug dosage. Less common reactions include musculoskeletal pain, elevated blood lipids,abnormal liver enzymes, and dry eyes. These usually occur during the first two months of treatment. Isotretinoin should be used with caution in patients with obesity,dyslipidemia,and liver disease.If necessary,liver function and blood lipid concentration should be assessed regularly.Long-term isotretinoin use before puberty may cause premature closure of the epiphysis,bone hyperplasia,and osteoporosis; thus, isotretinoin is not recommended for children under 12 years of age. Isotretinoin has a strong teratogenic effect, and female patients who may become pregnant should follow a strict contraceptive regimen for one month before treatment, during treatment, and for three months after treatment. The association between isotretinoin and depression or suicidal tendencies is unclear, and isotretinoin should be used with caution in patients with substantial depressive symptoms or depression.39Some patients experience short-term exacerbation of acne lesions after two to four weeks, which is usually transient, and those with severe reactions need to reduce or even discontinue isotretinoin. Viaminati has similar but a lesser degree adverse effects as isotretinoin.

Hormone therapy

Antiandrogen therapy

Mechanism:Androgen is the most important endogenous factor in the pathogenesis of acne. Antiandrogen agents reduce or antagonize active androgen by inhibiting the production of androgen precursors or acting on androgen metabolism enzymes and androgen receptors in the skin.Antiandrogen therapy reduces the secretion of sebum and improves acne. Common antiandrogen agents include estrogen, progesterone, spironolactone, and insulin sensitizers.10

Indications:(1) Female acne patients with clinical manifestations indicating high androgen levels, such as lesions distributed in the lower third of the face,irregular menstruation, obesity, excess body hair, marked seborrhea,and androgenetic alopecia.(2)Postpubertal females with acne.(3)Female patients with premenstrual acne.(4)Females who don’t respond well to systemic antibiotics or retinoids,or experience rapid relapse after discontinuation of these agents.10

Estrogen and progesterone:Estrogen and some kinds of progesterone have antiandrogen effects, the combination formula of the two short-acting contraceptives is usually used to treat acne. Common combinations include 2mg cyproterone acetate and 0.035mg ethinyl estradiol, 3mg drospirenone and 0.03mg ethinyl estradiol, and 3mg drospirenone and 0.02mg ethinyl estradiol.The onset time of oral contraceptives is two to three months, and the treatment course should be longer than six months.Adverse effects include a small amount of irregular uterine bleeding, breast pain, nausea, weight gain, venous and arterial thrombosis,and chloasma.Taking the medication on the first day of menstruation reduces the risk of uterine bleeding. Drugs containing drospirenone can reduce the risk of weight gain.Sunscreen should be applied during the treatment course to reduce the occurrence of chloasma.Contraindications include a family history of thrombosis,liver disease, and smoking. Relative contraindications include lactation, hypertension, migraine, malignant tumors, diabetes mellitus, coagulopathy, and a high risk of breast cancer.40-41

Spironolactone:The recommended dose of spironolactone is 60-200mg/d, and the treatment course is three to six months. Adverse effects include hyperkalemia, irregular menstruation (incidence correlated with dose), gastrointestinal reactions(including nausea,vomiting,anorexia,and diarrhea), lethargy, fatigue, dizziness, and/or headache.42Spironolactone has teratogenic effects and should not be used during pregnancy.

Insulin sensitizers:Insulin sensitizers such as metformin improve insulin resistance, reduce insulin-like growth factor-1, and induce androgen production. Insulin sensitizers are suitable for treating acne in patients with polycystic ovarian syndrome,obesity,insulin resistance,or hyperinsulinemia.43

Glucocorticoids

Physiological doses of glucocorticoids inhibit the secretion of adrenal androgen precursors. Furthermore, small to medium doses of glucocorticoids have anti-inflammatory effects and are suitable for early treatment of severe inflammatory acne. Patients with marked inflammation,acne fulminans, and acne conglobata are recommended to administrate prednisone 20-30mg/d(or the equivalent dosage of dexamethasone) for no more than four weeks,combined with oral isotretinoin subsequently. Patients with severe premenstrual aggravation of acne are prescribed prednisone 5-10mg/d (or the equivalent dosage of dexamethasone) every night for 7-10 days before the start of the next menstrual cycle;the treatment course should be stopped when the patient experiences menstrual cramps, and the total course should be no longer than six months. Long-term high-dose glucocorticoids should be avoided due to its associated adverse effects.23,44

Physical and chemical modalities

Physical and chemical treatments for acne or its sequelae include photodynamic, red or blue light, photon therapy,and chemical exfoliation.

Photodynamic and red or blue light therapy

Topical 5-aminolevulinic acid is enriched in the pilosebaceous unit and metabolized to produce the photoactive protoporphyrin IX. The photochemical reaction occurs after irradiation with red light (630nm) or blue light(415nm), which can inhibit sebum secretion, killP.acnes, regulate the immune system, improve the keratinization of pilosebaceous follicles, and prevent or reduce the formation of acne scars. Photodynamic therapy is used as an alternative treatment for patients with moderate or severe acne in whom systemic drug administration has failed or been intolerable.45-46The blue light alone killsP. acnesand has anti-inflammatory effects, while the red light alone has a tissue repairing effect that can be used as an alternative treatment for moderate acne.47

Laser and intense pulsed light therapy

A variety of near-infrared wavelength lasers (eg, 1,320,1,450, and 1,550nm) help to inhibit sebaceous gland secretion and have anti-inflammatory effects. Strong pulsed light and pulsed dye laser therapy helps reduce erythema after inflammatory acne. Non-exfoliating fractional lasers(1,440,1,540,and 1,550nm)and exfoliative fractional lasers (2,940 and 10,600nm) have beneficial effects on acne scars.During clinical application,multiple treatments of relatively low energy and low dot density are recommended on small areas.48

Radiofrequency therapy

Fractional radio frequency and fractional micro-needle radio frequency may improve acne scars and reduce the risk of pigmentation in Asian patients.49

Chemical peel treatment

Superficial chemical peels include fruit acid,salicylic acid,and complex acid. Chemical peels reduce the adhesion of keratinocytes, accelerate the exfoliation and renewal of epidermal cells, stimulate dermal collagen synthesis and tissue repair, have mild anti-inflammatory effects, reduce acne lesions,and improve skin texture.Chemical peels are used as an adjuvant treatment for mild to moderate acne and post-acne pigmentation.50

Treatment for special populations

Preadolescent children

Acne that occurs before adolescence is divided into neonatal acne(＜6 months),infantile acne(6-12 months),childhood acne(1-7 years),and preadolescent acne(8-12 years). Neonatal acne is affected by maternal hormones and can resolve with the disappearance of these hormones.Infants and children with acne need to be carefully screened for endocrine diseases.The USA Food and Drug Administration has approved the use of 2.5% BPO plus 1% adapalene gel for children ≥9 years, and the use of 0.05% retinoic acid gel for children ≥10 years.Other topical retinoids agents can be used in patients≥12 years of age. Systemic antibiotics appropriate for preadolescents with acne include macrolides such as erythromycin or azithromycin. Children under 12 years of age should not systemically use tetracycline antibiotics and retinoids.23,51

Acne females during pregnancy or lactation

It is generally safe to take drugs three months before pregnancy. The treatment of acne during pregnancy or lactation should be based on topical drugs. Strict contraception should be followed from one month before oral retinoid treatment until three months after the treatment is discontinued.52

Acne females during pregnancy

Mild acne:Topical retinoids should be avoided(pregnancy grade C-X), while BPO can be used in small areas(pregnancy grade C) and topical azelaic acid and clindamycin are safe(pregnancy grade B).Moderate acne:Topical retinoids can be combined with short-term oral antibiotics if necessary (avoid the first three months of pregnancy), but the use of tetracyclines is prohibited(pregnancy grade D).Severe acne:In addition to the above mentioned topical or systemic treatments, short-term prednisone treatment may be considered.52

Acne females during lactation

Topical BPO and azelaic acid can be used. Systemic macrolide antibiotics can be used for a short time.Clindamycin can be used during lactation,but may cause adverse gastrointestinal effects in infants. The AAP and WHO guidelines state that tetracycline antibiotics may be used less than three weeks.52

Traditional Chinese Medicine (TCM) therapy for acne

Internal treatment

In accordance with the disease duration,skin lesions,and other manifestations,TCM therapy is based on syndrome differentiation in accordance with the addition or subtraction theory.53-55

Pulmonary wind-heat syndrome:Skin lesions mainly comprise red or skin-colored papules, comedones, or itching,with yellow urine,constipation,dry mouth,red or thin yellow tongue, and a superficial and rapid pulse.Pulmonary wind-heat syndrome is equivalent to levels 1 and 2 in the acne classification. The treatment aims to dispel wind and diffuse the lungs,clear heat,and dissipate binds. The prescription is for the detergent lung with loquat and Xie Bai powder in accordance with the addition or subtraction theory of TCM, and the Chinese patented medicine Zhizi Jinhua pills.

Spleen and stomach damp-heat syndrome:Skin lesions are mainly red papules and pustules,with pain,and sebum overproduction on the face, chest, and back; other symptoms may include bad breath, a bitter taste in the mouth, poor appetite, diarrhea or sticky stools, yellow urine, a red or yellow greasy tongue, and a slippery or stringy pulse.Spleen and stomach damp-heat syndrome is equivalent to levels 2 and 3 in the acne classification.The treatment aims to clear heat,drain damp,relax the bowels,and detoxify.The prescription is Yinchenhao decoction or Qilianpingwei powder. The prescriptions recommended for constipation include the Chinese patented medicines Lianqiaobaidu pills,Fangfengtongsheng pills,and Runzao Zhiyang capsules. Those recommended for diarrhea include the Chinese patented medicines Xianglian pills and Shenqi Baishu powder.

Syndrome of phlegm and blood stasis:The skin lesions are mainly nodules and cysts, with color of dull redness.Pustules may be present,and the disease duration is long.Patients may have a poor appetite,loose stools,the tongue is dull or bruised, and a sinking pulse. Phlegm and blood stasis syndrome is equivalent to level 4 in the acne classification. The treatment aims to promote blood circulation and dissipate phlegm and stasis. The prescription is Haizaoyuhu decoction or Taohong siwu decoction combined with Erchen decoction in accordance with the addition or subtraction theory. Chinese patented medicines used for phlegm and blood stasis syndrome include Tanshinone capsules, Dahuang zecong pills, Huayusanjie pills, and Dangguikushen pills.

Syndrome of disharmony of Chong and Conception channels:Skin lesions are present on the forehead,eyebrows,or cheeks;symptom severity is increased before menstruation and reduced after menstruation, accompanied by irregular menstruation, premenstrual stress and irritability, and breast pain. The tongue is light red and thin,while the pulse is stringy or hesitant.Disharmony of Chong and Conception channels is equivalent to acne in females with high androgen levels.The treatment is chosen in accordance with Chong Ren and aims to regulate the flow of qi and activate blood circulation.The prescription is Xiaoyao powder or Erxian decoction combined with Zhibaidihuang pills in accordance with the addition or subtraction theory. Chinese patented medicines used for disharmony of Chong and Conception channels include Xiaoyao pills, Zhibaidihuang pills, Zuogui pills, and Liuweidihuang pills.

Topical treatments and other therapies56-58

TCM wet compress:A decoction composed of purslane,violae herba,and golden cypress is used as a wet compress that is applied twice daily for 20 minutes each time. This compress is effective for inflammatory papules and pustules, and plays roles in clearing heat, detoxification,and reducing inflammation.

TCM mask:Reversed powder (rhubarb and sulfur fine powder)is mixed with water or honey into a thin paste and applied to the skin lesions once a night and washed off with water after 30 minutes. The TCM mask is used to treat inflammatory papules, pustule, blisters, nodules, and cystic lesions, and plays roles in clearing blood stasis,clearing heat, and dissipating binds.

Auricular acupoint pressure:Vaccaria seeds are placed on the endocrine, subcortical, lung, heart, stomach, and other acupoints,and are gently pressed by the patient for about 1 minute every day; the seeds are replaced every 5 days.

Ear pricking and bloodletting:The endocrine and subcortical acupoints of the ear tips or the ear are used.After routine disinfection, a triangular needle is used to puncture the ear tip; six to eight drops of blood are then squeezed from the puncture site once or twice weekly.

Acupuncture:The main acupoints used for acne are Baihui, Chize, Quchi, Dazhui, Hegu, and Feiyu. The adjunctive acupoints are Sibai, Zanzhu, Xiaguan, Jiache,and points around the skin lesions. The Shi Ping Bu Ping Xie method is used. After deQi has been obtained, the needles are retained for 30 minutes once a day.

Fire needles:The acupoints commonly chosen for acne treatment are the Beiyu acupoints, such as Feiyu, Geyu,Piyu,and Weiyu. If there is heat,the Dazui acupoints are added; Dachangyu is used in those with constipation,while Ciliao is added for those with menstrual irregularity.The skin is routinely disinfected, and the fire needles are heated using an alcohol lamp. Once the needle tip is redhot,the acupoints are quickly punctured,and each point is punctured three times once every other day.Alternatively,the fire needle is used to puncture the cysts and nodules,and each lesion can be punctured several times successively for 7-10 days per week. The lesions must be kept away from water for 24hours after treatment.

Pricking and cupping:The most common acupoints used to treat acne are Feiyu, Dazhui, Yuyu, Weiyu,Dachangyu, Geyu, and Shenyu, with four to six Beiyu points chosen each time. The skin is pierced with a triangular needle, and cupping is performed at the puncture site and retained for 10-15 minutes; the treatment is performed once every three days for a total of 10 times.

Maintenance therapy

Maintenance therapy reduces and prevents acne recurrence and improves the quality of life.Topical retinoids are the first-line treatment choice for acne maintenance. If necessary, the combination use of topical BPO and adapalene can be considered.59Topical 0.1% adapalene combined with low concentrations of fruit acid three times a week is another choice for maintenance,60and some clinically proven anti-acne functional skin care products also aid in maintenance therapy.61Maintenance therapy is usually continued for 3-12 months.

Combinational and grading treatment of acne

It is difficult to comprehensively and effectively cover all aspects of acne pathogenesis using only one treatment,and so a combination of multiple treatments is recommended.Mild to moderate acne is recommended to be treated with a combination of topical drugs. One topical drug usually only acts on one or two of the four pathogenic factors of acne except for sebum secretion, while a combination of topical drugs may act on two to three factors. The available agents include topical retinoids,antibiotics,BPO,and other topical compound agents. Patients with moderate to severe acne may need a combination of systemic and topical drugs, and/or a combination of systemic drugs and physiochemical treatments.Combination therapies substantially increase drug efficacy, reduce adverse effects, and increase compliance of patients.

The classification of acne reflects the severity of acne and the nature of skin lesions.The treatment of acne should be based on its grading to enable the selection of the appropriate treatments in accordance with the principle of individualized treatment. The recommended treatment plans in accordance with the acne classification are shown in Table 1.16,61-62

Treatments of acne sequelae

Erythema can be treated with the application of strong pulsed light,63pulsed dye laser,64non-exfoliating fractional laser (1,440, 1,550, and 1,565nm),65and intense pulsed light therapy (1,064nm Nd:YAG laser).

Pigmentation can be treatedviathe topical drug such as retinoic acid, arbutin, and L-vitamin C.66Other effective treatments include fruit acid, intense pulsed light therapy, and Q-switched 1,064nm Nd:YAG laser treatment.67

For atrophic scarring, the first-line choice is exfoliating fractional laser therapy such as carbon dioxide fractional laser treatment and the second choice is ion beam or holmium laser treatment. Other effective treatments include nonexfoliating fractional laser, microneedle, or radio frequency treatment. Some large concave scars require blunt needle separation, filling, or surgical resection. Hypertrophic scars and keloids are more difficult to treat than atrophic scars. Comprehensive treatments currently being used include local glucocorticoid injection and laser treatments (dye laser, carbon dioxide fractional laser). Keloid scarring caused by acne can be treatedviasurgical resection followed by local radiotherapy.67-68

Education and management of patients with acne

Acne is a common discosmetic dermatosis mainly on the face. Good treatment outcomes are achieved by following the standard treatments recommended in the Chinese acne treatment guidelines, health education, scientific skin care, and regular follow-up throughout the treatment course.

Health education:Acne may be prevented and improved by a diet that is low in sugar, fat, and dairy products(especially skimmed milk),69appropriate weight control,70regular work and rest, and avoiding excessive sun exposure. Acne can cause anxiety and depression,especially in patients with severe acne, and treatment needs to be coordinated with psychological counseling.

Scientific skin care71-72: Patients with acne often have seborrhea.The skin should be cleaned with an oil-control moisturizing cleanser to remove excess oil, dander, and microbes, while avoiding overcleaning, squeezing, and scratching. After cleaning, skin care products containing active ingredients should be selected in accordance with skin type. Patients with oily skin should use oil-control moisturizing products; patients with a mixed skin type T area may choose oil-control moisturizing products for the T area, and allergy alleviation moisturizing skin care products for the cheeks.When using topical retinoids,BP,and other drugs or physical/chemical exfoliation treatments,the skin barrier is likely to be damaged,and so it is advisable to choose allergy alleviation moisturizing skin care products.73Cosmetic acne could be minimized or avoid by carefully choosing appropriate types of foundation, sunscreen, and other cosmetic products.

Regular follow-up:Acne is a chronic disease that requires regular follow-up. Treatments and skin care plans should be adjusted in accordance with the treatment response to reduce the risks of acne sequelae.

The author list

Qiang Ju, Renji Hospital, School of Medicine, Shanghai JiaoTong University, Shanghai; Wei-Xin Fan, The First Affiliated Hospital of Nanjing Medical University, Nanjing,Jiangsu;Jun Gu,the First Hospital of Naval Medical University, Shanghai; Fei Hao, Southwest Hospital, TheThird Affiliated Hospital of Chongqing Medical University,Chongqing;Li He,The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan; Heng-Jin Li,Chinese PLA General Hospital, Beijing; Tie-Nan Li,Shenyang Seventh People’s Hospital, Shenyang, Liaoning;Tong Lin, Hospital for Skin Diseases (Institute of Dermatology),Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu; Wei Lai, The Third Affiliated Hospital of Sun Yat-sen University,Guangzhou, Guangdo; Zhan-Yan Pan, Renji Hospital,School of Medicine,Shanghai JiaoTong University,Shanghai; Bao-Xi Wang, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing; Hai Wen, Changzheng Hospital, Naval Medical University, Shanghai; Yan Wu, Peking University First Hospital,Beijing;Ai-E Xu,Hangzhou ThirdMunicipal People’s Hospital,Hangzhou,Zhejiang;Jian-Zhong Zhang,People’s Hospital of Peking University, Beijing; Wei Zhang, Shanghai Skin Diseases Hospital, Shanghai; Min Zheng,The Second Affiliated Hospital,Zhejiang University SchoolofMedicine,Hangzhou,Zhejiang;Lei-HongXiang?,Huashan Hospital,Fudan University,Shanghai;Zhi-Zhong Zheng?,Huashan Hospital,Fudan University,Shanghai.

Table 1 Recommended treatments for acne

?Corresponding authors: Prof. Zhi-Zhong Zheng and Prof. Lei-Hong Xiang, Huashan Hospital, Fudan University, Shanghai 200040, China. E-mail: 5560732@qq.com(Zheng ZZ) and flora_xiang@vip.163.com (Xiang LH).