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

Table IV.

Maintenance treatment/modification phase—gaps and detailed considerations, discussion points, and pivot points

Gaps
• There is a need for guidance on the most appropriate time to initiate maintenance therapy^∗ (12/13) • Clinical practice guidelines do not provide sufficient guidance on the choice of acne maintenance treatment^∗ (12/13) • Clinical practice guidelines do not provide sufficient guidance on when to escalate, switch, or de-escalate acne maintenance treatment^∗ (13/13) • 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)

Gaps

•
There is a need for guidance on the most appropriate time to initiate maintenance therapy^∗ (12/13)
•
Clinical practice guidelines do not provide sufficient guidance on the choice of acne maintenance treatment^∗ (12/13)
•
Clinical practice guidelines do not provide sufficient guidance on when to escalate, switch, or de-escalate acne maintenance treatment^∗ (13/13)
•
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
• Clinical indicators to start maintenance treatment ○ Goals of the initiation phase of treatment achieved ○ Patient satisfaction with treatment response, treatment regimen, and appearance • Duration of treatment with antibiotics • Age/sex of patient (and associated risk of active acne returning) • Patient preference • Completion of the isotretinoin treatment course • Ongoing cost of treatment

Consider

•
Clinical indicators to start maintenance treatment
- ○
  Goals of the initiation phase of treatment achieved
- ○
  Patient satisfaction with treatment response, treatment regimen, and appearance
•
Duration of treatment with antibiotics
•
Age/sex of patient (and associated risk of active acne returning)
•
Patient preference
•
Completion of the isotretinoin treatment course
•
Ongoing cost of treatment

Discuss
• Goal setting ○ The goals of the maintenance phase are to maintain clear/almost-clear skin achieved during the initiation phase, to prevent acne from returning to a level that is unacceptable to the patient, and to reduce the risk of acne sequelae^∗ (13/13)

Pivot points
• In an ideal situation, patients should be followed up at least twice a year during the maintenance phase of treatment • Consider increasing the frequency of follow-up when there are safety or tolerability concerns or adherence issues, when the patient is particularly anxious or needs encouragement, if sequelae develop, or when there is a lack of efficacy or return of active acne to a level unacceptable to the patient • Consider decreasing the frequency of follow-up when the patient is stable, when the agreed treatment goals have been met, or for reasons where the patient cannot return easily for appointments (such as going away to college) Review, assess, modify • Switching treatment ○ Consider when there is a lack of response^∗ (10/13), the patient is unsatisfied or unhappy with the response^∗ (10/13), there are adverse effects/issues with tolerability^∗ (12/13), or there is poor acceptability of treatment (eg, oiliness, odor, and bleaching/staining)^∗ (10/13) • Switching from maintenance back to initiation treatment ○ Consider when there is a lack of response (eg, acne returning to premaintenance state)^∗ (13/13) or the patient is unsatisfied or unhappy with the response^∗ (11/13)

Pivot points

•
In an ideal situation, patients should be followed up at least twice a year during the maintenance phase of treatment
•
Consider increasing the frequency of follow-up when there are safety or tolerability concerns or adherence issues, when the patient is particularly anxious or needs encouragement, if sequelae develop, or when there is a lack of efficacy or return of active acne to a level unacceptable to the patient
•
Consider decreasing the frequency of follow-up when the patient is stable, when the agreed treatment goals have been met, or for reasons where the patient cannot return easily for appointments (such as going away to college)

Review, assess, modify

•
Switching treatment
- ○
  Consider when there is a lack of response^∗ (10/13), the patient is unsatisfied or unhappy with the response^∗ (10/13), there are adverse effects/issues with tolerability^∗ (12/13), or there is poor acceptability of treatment (eg, oiliness, odor, and bleaching/staining)^∗ (10/13)
•
Switching from maintenance back to initiation treatment
- ○
  Consider when there is a lack of response (eg, acne returning to premaintenance state)^∗ (13/13) or the patient is unsatisfied or unhappy with the response^∗ (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).