. 2021 Oct 18;5:101–111. doi: 10.1016/j.jdin.2021.09.006

Table III.

Treatment initiation/modification phase—gaps and detailed considerations, discussion points, and pivot points

Gaps
• There is a need for high-quality evidence for when to escalate, switch, or de-escalate both acne initiation and maintenance treatment^∗ (12/13) • Common reasons for nonadherence to initiation and maintenance treatment include treatment intolerance (eg, local irritation)^∗ (13/13), perceived lack of efficacy^∗ (11/13), and perceived difficulty of use/inconvenience^∗ (10/13)

Consider
• Acne type and severity • Acne location (facial and/or truncal acne) • Patient preference • Burden of disease^∗ (13/13) • Risk or presence of sequelae • Factors that may affect adherence to treatment (including prior adherence) • Degree of seborrhoea/oiliness • Skin sensitivity • Comorbidities

Discuss
• Goal setting ○ The goals of initiation treatment are to achieve clear or almost-clear skin (depending on patient acceptability) with no new acne lesions and to reduce the risk of sequelae^∗ (13/13) ○ Personalized treatment goals depending on the specific impact of acne in certain regions^∗ (13/13) ○ Any immediate short-term goals (eg, wedding) • Managing expectations ○ It is of paramount importance to discuss long-term treatment expectations with acne patients^∗ (13/13) • Treatment ○ All options should be discussed (including over-the-counter and holistic treatments) based on patient preferences • Antibiotic resistance ○ Prescribers should discuss antibiotic resistance with patients who are prescribed an antibiotic for acne^∗ (13/13) • Potential reasons for prior nonadherence to acne medications with patients and adjust their management accordingly^∗ (13/13)

Discuss

•
Goal setting
- ○
  The goals of initiation treatment are to achieve clear or almost-clear skin (depending on patient acceptability) with no new acne lesions and to reduce the risk of sequelae^∗ (13/13)
- ○
  Personalized treatment goals depending on the specific impact of acne in certain regions^∗ (13/13)
- ○
  Any immediate short-term goals (eg, wedding)
•
Managing expectations
- ○
  It is of paramount importance to discuss long-term treatment expectations with acne patients^∗ (13/13)
•
Treatment
- ○
  All options should be discussed (including over-the-counter and holistic treatments) based on patient preferences
•
Antibiotic resistance
- ○
  Prescribers should discuss antibiotic resistance with patients who are prescribed an antibiotic for acne^∗ (13/13)
•
Potential reasons for prior nonadherence to acne medications with patients and adjust their management accordingly^∗ (13/13)

Pivot points
• In an ideal situation, patients should be followed up within 3 months where possible during the initiation phase of treatment • Consider increasing the frequency of follow-up when there are safety or tolerability concerns, adherence issues, the patient is particularly anxious or distressed if there is a high risk of sequelae, severe acne, or a lack of efficacy (with current or previous treatments) • Consider decreasing the frequency of follow-up when the treatment is well tolerated, the patient is stable, there is lack of evidence of sequelae development, adherence is good, or for reasons where the patient cannot return for appointments easily (such as going away to college) • Consider the period over which a prescribed treatment is expected to have an effect Review, assess, modify • Switching treatment ○ Consider when there is a lack of response^∗ (13/13), the patient is unsatisfied or unhappy with the response^∗ (10/13), adverse effects or issues with tolerability occur^∗ (12/13), or the patient desires to switch treatment^∗ (11/13) • Escalating treatment ○ Consider when there is an inadequate response^∗ (13/13) or the patient is unhappy or unsatisfied with the response^∗ (12/13) • De-escalating treatment ○ Consider when there are adverse effects/issues with tolerability^∗ (10/13) or a patient desire to de-escalate treatment^∗ (10/13) • Stopping treatment ○ Consider when treatment goals that were set together with the patient have been met^∗ (11/13), satisfactory efficacy outcomes have been achieved^∗ (10/13), adverse effects or issues with tolerability occur^∗ (10/13), or the patient desires to stop treatment^∗ (11/13)

Pivot points

•
In an ideal situation, patients should be followed up within 3 months where possible during the initiation phase of treatment
•
Consider increasing the frequency of follow-up when there are safety or tolerability concerns, adherence issues, the patient is particularly anxious or distressed if there is a high risk of sequelae, severe acne, or a lack of efficacy (with current or previous treatments)
•
Consider decreasing the frequency of follow-up when the treatment is well tolerated, the patient is stable, there is lack of evidence of sequelae development, adherence is good, or for reasons where the patient cannot return for appointments easily (such as going away to college)
•
Consider the period over which a prescribed treatment is expected to have an effect

Review, assess, modify

•
Switching treatment
- ○
  Consider when there is a lack of response^∗ (13/13), the patient is unsatisfied or unhappy with the response^∗ (10/13), adverse effects or issues with tolerability occur^∗ (12/13), or the patient desires to switch treatment^∗ (11/13)
•
Escalating treatment
- ○
  Consider when there is an inadequate response^∗ (13/13) or the patient is unhappy or unsatisfied with the response^∗ (12/13)
•
De-escalating treatment
- ○
  Consider when there are adverse effects/issues with tolerability^∗ (10/13) or a patient desire to de-escalate treatment^∗ (10/13)
•
Stopping treatment
- ○
  Consider when treatment goals that were set together with the patient have been met^∗ (11/13), satisfactory efficacy outcomes have been achieved^∗ (10/13), adverse effects or issues with tolerability occur^∗ (10/13), or the patient desires to stop treatment^∗ (11/13)

^∗

Indicates topics that were voted on via the Delphi process (Comprehensive list of statements available as Supplementary Material via Mendeley at https://data.mendeley.com/datasets/fy6mnvt7t7/1).