Professionals with extensive experience in the management of acne were identified in their respective countries as individuals who work in academic settings, deliver lectures at conferences, and possess in-depth knowledge in providing care for patients with acne. The expert panel comprised eight dermatologists from Latin America, representing countries such as Argentina, Brazil, Chile, Colombia, Peru, Ecuador, Mexico, and Panama.

The process was led by the chairman, who was also part of the panel and responsible for the design of the Delphi survey.

The Delphi modified methodology8 consisted of reviewing the literature to update the most relevant topics in the clinical management of acne and potential gaps, as well as to identify the specificities of acne in the Latin American population. Searches were performed using PubMed Central, Cochrane, and Lilacs databases from January 2000 to December 2022, including English and Spanish articles. These data were presented by the expert panel during a face-to-face meeting to guide the discussion. This was followed by two e-surveys and a live virtual meeting between the first and second e-surveys (Fig. 1). The results of the e-surveys were presented by the chairman.

Figure 1.

Delphi process modified for Acne Consensus.

(0.23MB).

The e-surveys were designed to assess the level of agreement with each statement. Two different ways of approaching the questions were used in the first e-survey. Sixteen questions measured the answer according to an answer range: “strongly disagree”, “disagree”, “agree”, “strongly agree”, or “unable to answer”. A consensus was reached when ≥75% of panelists voted “agree” or “strongly agree”. For eleven questions, the answer was measured as “yes” or “no” and a written explanation for the answer was selected. A consensus was reached when ≥ 75% of panelists voted for one of the answers. The explanations were analyzed by the chairman and relevant issues were presented for discussion during the first interim webinar.

Two topics in the e-survey didn't reach the minimum 75% agreement level. These topics were discussed during the interim web meeting, a new literature review was carried out and a new vote was taken.

The e-surveys were programmed and managed by Sprim Brazil to ensure blinding.

In the first round, sixteen out of seventeen questions reached a consensus with ≥75% of votes “agree” or “strongly agree” (Table 1). The result of the voting on the consensus statement is given in parentheses (e.g., 7/8 voted “agree” or “strongly agree”) after each topic discussed.

Ten out of eleven questions, measured by a “yes” or “no” answer, achieved consensus with ≥75% “yes” answers (Table 2).

During the second e-survey, two topics that did not reach consensus in the first e-survey were reassessed. In the second e-survey, consensus was achieved on these 2 topics with 100% “agree” answers and ≥75% “yes” answers in a “yes/no” question (Tables 3 and 4).

Acne is a condition that has a significant negative impact on quality of life.9 In addition, long-term sequelae, such as the presence of scarring after acne has resolved, cause significant emotional, social, and functional concerns. Familiarity with the psychological aspects of acne is important for holistic patient management. Psychological factors can exacerbate acne and decrease patient compliance.3

Often, the patient's perception of the disorder may differ from the dermatologist's assessment, and the intensity of the disorder is not always directly related to the degree of psychological impact. There are several psychometric tools to assess this impact, among them Acne-QoL and Dermatology Life Quality Index (DLQI). Some of them have been translated and published in Portuguese and Spanish. However, in day-to-day practice, these tools are impractical and take a long time to apply and analyze (8/8 -100% of agrement). There is a lack of a quick and practical tool to assess and monitor the psychological impact on acne patients.

Social networks have become a means of sharing information about health-related issues.10 Currently, all of our patients are increasingly exposed to controversial content on various social media platforms, which is emerging as a public health problem that may, in the long run, prevent us from providing fully effective care and delay effective treatment.

To improve this situation, the authorss suggest developing educational campaigns to help users reject false or misleading information while promoting the dissemination of rigorous, evidence-based dermatology knowledge.

Dermatologists should be encouraged to increase their presence on various social media platforms, always considering privacy and ethical principles of their position as physicians, and to build a more solid base of correct orientations within these channels11 (8/8).

Generation Z individuals were born between 1995–2010, so they are the first generation to be born with full access to the Internet (“digital natives”). Several studies have looked at how to approach education with this generation and how to use social media as an educational tool. A 2020 study of nursing students12 found that participants used social media for an average of 1.37 hours for clinical learning and about twice as long for personal purposes. Therefore, using social networking to connect, engage, and educate this generation of patients is a useful and necessary tool.12–15

Therefore, this expert panel believes that a specific language associated with the use of digital resources (WhatsApp® messages/direct messages on Instagram®) is important to connect with Generation Z, favoring the follow-up of physical and psychological symptoms and the treatment of these patients (8/8).

Transgender individuals do not identify as the biological sex assigned at birth, and some seek medical assistance for interventions aimed at phenotypically restoring their gender identity. To maintain levels at physiological levels, between 320‒1000 ng/dL, transgender men must use testosterone continuously.16

Today, there is still a lack of well-conducted studies to guide the treatment of acne in transgender male patients (8/8). There is also very little scientific literature that analyzes the problems induced by hormone therapies in transgender male patients in the short and long term. A retrospective study conducted by the Mayo Clinic (USA) from 1986 to 2018 analyzed 222 transgender people, 36% of whom were female-to-male, and 91.4% of whom were receiving hormone therapy. Acne was the most commonly diagnosed side effect, present in 78.7% with an average onset of 11.5 months of testosterone therapy.17

The psychosocial impact of acne may exacerbate gender dysphoria and the already high rates of psychiatric comorbidity in transgender patients.18

The number of reported cases of severe or resistant acne in these patients responding only to oral isotretinoin is increasing, although it has been suggested that dermatologic changes are unrelated to plasma levels of androgens.19–22

It is important to note that these patients can still become pregnant. Therefore, contraception should always be used. The interaction between chronic testosterone uses and isotretinoin has not been widely studied, so this study group suggests frequent laboratory follow-up in these cases, especially analyzing liver function, lipids, and pregnancy tests (7/8).23

Childhood acne refers to lesions that are suggestive of acne in patients between the ages of 1 and 7 years of age. It is a very rare presentation, and a complete and thorough clinical evaluation must always be performed. This group considers that any patient with inflammatory acne in this age group should be referred to endocrinology to actively rule out other pathologies (8/8).24

This group recommends that the use of a skincare routine may be an important strategy in general and specifically in the treatment of acne in terms of patient satisfaction and adherence. Appropriate dermocosmetic recommendations are necessary to reduce side effects and improve treatment efficacy. This includes advice on the correct sunscreen, cleanser and moisturizer, with or without anti-acne ingredients, and make-up (8/8).

Almost all patients on systemic treatment, especially those using isotretinoin or topical retinoids and benzoyl peroxide, experience varying degrees of side effects such as irritation, burning, dry skin, erythema, and scaling, leading to poor adherence and compromising treatment efficacy. The overall risk of poor adherence to acne treatment is approximately 50% to 60%.39

The authors recommend the use of mild cleansers (syndets) and associated non-comedogenic moisturizers to improve the tolerability of topical medications and increase the chances of treatment success.40

Moisturizers and products containing sunscreen with a Sun Protection Factor (SPF) of at least 30 are important components of the acne patient's management to complement the pharmacologic regimen.

Acne patients should be advised to avoid oil-based and comedogenic sunscreens whenever possible, as these products may aggravate their acne vulgaris.

Dermocosmetics with whitening action can be combined with acne treatment to accelerate the improvement of post-inflammatory hyperpigmentation along with the improvement of acne (8/8).

Tables 6 and 7 list key ingredients for the proper selection of moisturizers, gentle cleansers, and Dermocosmetics (DCs).

Acne is more common in women than in men, and 58% of adult women always or almost always use makeup to improve their appearance and self-confidence.40 Data from the literature show that quality of life can be improved with corrective makeup. It is important to note that these studies generally involved few patients and primarily used cosmetic foundations.41,42 Our panel of experts recommends non-comedogenic makeup for acne patients to reduce the impact of the presence of lesions at the beginning of treatment (8/8).

Isotretinoin is clearly indicated for severe or refractory acne (nodular, cystic, or active scarring), but is also indicated for moderate (papulopustular) acne that does not respond to conventional therapy.43,44

The relapse rate of patients taking isotretinoin for acne is about 30%, but it has been described as high as 50% up to five years after discontinuation of the drug, especially in severe truncal acne, younger age of drug initiation, and in patients with macrocomedos, according to various studies.45–47

Our group recommends that, when oral isotretinoin is required, treatment should be based on clinical evaluation and no longer just on the cumulative dose alone. If necessary, the treatment should be continued, even after 150 mg/kg (8/8). Additionally, the authors agreed that after the use of oral isotretinoin, a one-year maintenance topical treatment should be recommended for all patients in order to reduce relapse rates (7/8).48

Isotretinoin is a known teratogen and has the potential to cause other adverse events.44,49–57 For these reasons, when isotretinoin was first released, the recommendation was that it be prescribed only by physicians (dermatologists) who were trained to manage the dosage and side effects of the drug.58 As time has passed, and the research pharma (Roche®), lost the patent, in many countries, the regulations have been historically relaxed, and many other medical specialties, and even primary care physicians are prescribing the drug. Our group considers that oral isotretinoin continues to be safely prescribed with informed consent signed by patients and only by physicians with experience in monitoring it (dermatologists) (8/8). This is still the rule in most developed countries and in several Latin American countries such as Brazil and Chile, and has been recommended in Colombia and Ecuador.44,48,52,59–61

The region of Latin America and the Caribbean (LAC) is currently facing a major health problem closely linked to dietary habits, with significant economic, health, and social costs. Changes in dietary patterns have been far-reaching, with a marked increase in the consumption of unhealthy, nutrient-poor foods and sugary drinks, a shift towards eating out and snacking, and a rapid rise in the prevalence of overweight and obesity in all age groups.62

This particular diet, characterized by a high glycemic load and increased intake of dairy products, results in elevated levels of insulin and IGF-1, which is a type of endocrine signaling that can contribute to acne. These hormonal changes can lead to an increased rate of sebocyte proliferation, and heightened sebum production, and ultimately result in greater skin inflammation.63

Regarding the use of probiotics, although there are some studies evaluating the use of oral probiotics in the treatment of acne, their prescription is still not part of the routine for patients until better evidence is available (8/8).

Our group agreed that although data on diet and acne need further study, it is important to provide the most up-to-date information on the topic, such as the negative relationship with foods with a high glycemic index/load, dairy products including whey protein, and the need to eat more fruits and vegetables (8/8).

Acne hyperpigmentation is a common problem. It is now known that visible light is involved in the increase of melanin, aggravating conditions such as melasma and post-inflammatory hyperpigmentation, also common in acne. Even more recent data indicate a synergistic pro-pigmentation effect between UVA and visible light, thus requiring the effective blocking of both wavelengths to prevent and optimize the treatment of these conditions.64

Being tropical, most Latin American countries receive large amounts of solar radiation throughout the year. This affects the treatment of hyperchromia induced by acne.65

Furthermore, due to migratory factors and the huge presence of miscegenation in Latin America, most patients have acne-induced hyperpigmentation and want a quick improvement (8/8).

Daily sunscreen use is also important for higher phototyped patients, especially those with Post-Inflammatory Hyperpigmentation (PIH).66

Regular and isolated use of sunscreen for eight weeks during the summer months resulted in improvement of PIH in African American and Hispanic women. In this study, 81% of patients noted a lightening of pre-existing hyperpigmented macules, while 59% noted a decrease in the number of macules.67

In the treatment of acne hyperchromia, it is important to interrupt the inflammatory process early and effectively. Whitening agents can be added to the treatment to accelerate the process. It is very important that patients are warned about the possible risks and duration of use of each type of whitening cream, especially when using hydroquinone.68

There are now new options with excellent safety profiles that can be used alone or in combination with other treatments, such as thiamidol-containing dermocosmetics.69

There are many medical procedures available for the treatment of acne/scarring, including intense pulsed light, microdermabrasion, peels, intralesional corticosteroids, cryotherapy, and comedone extraction. For most of these procedures, the available evidence is very scarce and of very low quality. Therefore, they should be considered as adjuncts to treatment and their true benefit in acne therapy cannot be determined.73–77

Light therapies, including laser and photodynamic therapy, have shown promising results, but there is not enough evidence to recommend them for routine use. There are also no established guidelines on the optimal dose, device, timing, and frequency of use.78

Based on currently available data, our expert panel agreed that dermatologic procedures, such as peels and lasers, may be associated with the treatment of acne and pigmentation, but they are not mandatory and significantly increase costs for patients (8/8).