Archives of Dermatological Research

, Volume 306, Issue 3, pp 269–277 | Cite as

Clinical practice guidelines for treatment of acne vulgaris: a critical appraisal using the AGREE II instrument

  • Gloria Sanclemente
  • Jorge-Luis Acosta
  • Maria-Eulalia Tamayo
  • Xavier Bonfill
  • Pablo Alonso-Coello
Original Paper


A significant number of clinical practice guidelines (CPGs) about the treatment of acne vulgaris in adolescents and adults have been published worldwide. However, little is known about the quality of CPGs in this field. The aim of this study was to appraise the methodological quality of published acne vulgaris CPGs. We performed a systematic review of published CPGs on acne vulgaris therapy from July 2002 to July 2012. Three reviewers independently assessed each CPG using the AGREE II instrument. A standardized score was calculated for each of the six domains. Our search strategy identified 103 citations but just six met our inclusion criteria. Agreement among reviewers was very good: 0.981. The domains that scored better were: “scope and purpose” and “clarity and presentation”. Those that scored worse were “stakeholder involvement”, “rigor of development”, and “applicability”. The European and the Malaysian CPGs were the only recommended with no further modifications. In addition, the Mexican, Colombian and the United States guidelines were recommended with provisos, with lower scores regarding stakeholder involvement, rigor of development and applicability. Only two guidelines clearly reported outcome measures for evaluating efficacy or included quality of life outcomes. CPGs varied regarding the consideration of light/laser therapy or consideration of complementary/alternative medicines. None of them included cost considerations of drugs such as systemic isotretinoin. In conclusion, published acne vulgaris CPGs for acne therapy vary in quality with a clear need to improve their methodological rigor. This could be achieved with the adherence to current CPGs development standards.


Acne vulgaris Critical appraisal Clinical practice guidelines AGREE II 


  1. 1.
    Agence Française de Sécurité Sanitaire des Produits de Santé (2007) Recommandations de bonne pratique traitement de l’acné par voie locale et générale. Agence Française de Sécurité Sanitaire des Produits de Santé. Accessed July 2012
  2. 2.
    Agency for Healthcare Research and Quality (2012) Guideline Summary NGC-5809, Acne. Accessed Jul 2012
  3. 3.
    Alonso-Coello P, Irfan A, Solà I, Gich I, Delgado-Noguera M, Rigau D, Tort S, Bonfill X, Burgers J, Schunemann H (2010) The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies. Qual Saf Health Care 19:e58PubMedGoogle Scholar
  4. 4.
    Alonso P, Bonfill X (2007) Guías de práctica clínica (II): búsqueda y valoración crítica. Radiologia 49:23–27PubMedCrossRefGoogle Scholar
  5. 5.
    Archer CB, Cohen SN, Baron SE, British Association of Dermatologists and Royal College of General Practitioners. (2012) Guidance on the diagnosis and clinical management of acne. Clin Exp Dermatol 37 Suppl 1:1–6Google Scholar
  6. 6.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, Consortium ANS (2010) AGREE II: advancing guideline development, reporting and evaluation in health care. J Clin Epidemiol 63:1308–1311Google Scholar
  7. 7.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B,Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. (2010) AGREE II: advancing guideline development,reporting, and evaluation in health care. Prev Med 51:421–424Google Scholar
  8. 8.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Graham ID, Hanna SE, Makarski J, Consortium ANS (2010) Development of the AGREE II, part 1: performance, usefulness and areas for improvement. CMAJ 182:1045–1052PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Hanna SE, Makarski J, Consortium ANS (2010) Development of the AGREE II, part 2: assessment of validity of items and tools to support application. CMAJ 182:E472–E478PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium.(2010) AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 182: E839–842Google Scholar
  11. 11.
    Centre Belge d′ïnformation Pharmacotherapeutique (2005) Traitement de l’acne vulgaire. Accessed July 2012
  12. 12.
    Dréno B, Bettoli V, Ochsendorf F, Layton A, Mobacken H, Degreef H, Acne EEGoOAi (2004) European recommendations on the use of oral antibiotics for acne. Eur J Dermatol 14:391–399PubMedGoogle Scholar
  13. 13.
    Dréno B, Bettoli V, Ochsendorf F, Perez-Lopez M, Mobacken H, Degreef H, Layton A (2006) An expert view on the treatment of acne with systemic antibiotics and/or oral isotretinoin in the light of the new European recommendations. Eur J Dermatol 16:565–571PubMedGoogle Scholar
  14. 14.
    Francke AL, Smit MC, de Veer AJ, Mistiaen P (2008) Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak 8:38PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Garcia-Gutierrez JF, Bravo-toledo R (2001) Guias de practica clinica en internet. Aten Primaria 28:74–79PubMedCrossRefGoogle Scholar
  16. 16.
    Goodfield MJ, Cox NH, Bowser A, McMillan JC, Millard LG, Simpson NB, Ormerod AD (2010) Advice on the safe introduction and continued use of isotretinoin in acne in the UK 2010. Br J Dermatol 162:1172–1179PubMedCrossRefGoogle Scholar
  17. 17.
    Grilli R, Magrini N, Penna A, Mura G, Liberati A (2000) Practice guidelines developed by specialty societies: the need for a critical appraisal. Lancet 355:103–106PubMedCrossRefGoogle Scholar
  18. 18.
    GUIPCAR Group (2001) Clinical Practice Guideline for the Management of Rheumatoid Arthritis in Spain. Spanish Society of Rheumatology. Madrid, pp: 301Google Scholar
  19. 19.
    Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schünemann HJ, Group GW (2008) What is “quality of evidence” and why is it important to clinicians? BMJ 336:995–998PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, Group GW (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336:924–926PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Hayward RS, Guyatt GH, Moore KA, McKibbon KA, Carter AO (1997) Canadian physicians’ attitudes about and preferences regarding clinical practice guidelines. CMAJ 156:1715–1723PubMedCentralPubMedGoogle Scholar
  22. 22.
    Hoomans T, Evers SM, Ament AJ, Hübben MW, van der Weijden T, Grimshaw JM, Severens JL (2007) The methodological quality of economic evaluations of guideline implementation into clinical practice: a systematic review of empiric studies. Value Health 10:305–316PubMedCrossRefGoogle Scholar
  23. 23.
    Hospital General de Mexico (2005) Guias de Diagnostico y Tratamiento. Acne vulgar. Accessed June 2012
  24. 24.
    Institute of Medicine (1990) Clinical Practice Guidelines: Directions for a New Program. National Academy Press, Washington DCGoogle Scholar
  25. 25.
    Institute of Medicine (2011) Clinical Practice Guidelines We Can Trust. National Academy Press, Washington DCGoogle Scholar
  26. 26.
    Kalla AA, Stanwix A, Gotlieb D, Asherson RA, Mody GM (2003) Rheumatoid arthritis: clinical guideline 2003. S Afr Med J 93:991–1012PubMedGoogle Scholar
  27. 27.
    Kaminsky A, Saraceno E, Airaudo M et al (2005) Consenso sobre Acné. Sociedad Argentina de Dermatología. Accessed July 2012
  28. 28.
    Knutsen-Larson S, Dawson AL, Dunnick CA, Dellavalle RP (2012) Acne vulgaris: pathogenesis, treatment, and needs assessment. Dermatol Clin 30:99–106 Viii–ixPubMedCrossRefGoogle Scholar
  29. 29.
    Kramer MS, Feinstein AR (1981) Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 29:111–123PubMedCrossRefGoogle Scholar
  30. 30.
    Kubba R, Bajaj AK, Thappa DM, Sharma R, Vedamurthy M, Dhar S, Criton S, Fernandez R, Kanwar AJ, Khopkar U, Kohli M, Kuriyipe VP, Lahiri K, Madnani N, Parikh D, Pujara S, Rajababu KK, Sacchidanand S, Sharma VK, Thomas J, (IAA) IAA (2009) Acne in India: guidelines for management—IAA consensus document. Indian J Dermatol Venereol Leprol 75(Suppl 1):1–62PubMedGoogle Scholar
  31. 31.
    Kung J, Miller RR, Mackowiak PA (2012) Failure of clinical practice guidelines to meet institute of medicine standards: two more decades of little, if any progress. Arch Intern Med 172:1628–1633PubMedCrossRefGoogle Scholar
  32. 32.
    Ledingham J, Deighton C, British Society for Rheumatology Standards GiaAWG (2005) Update on the British Society for Rheumatology guidelines for prescribing TNFalpha blockers in adults with rheumatoid arthritis (update of previous guidelines of April 2001). Rheumatology (Oxford) 44:157–163Google Scholar
  33. 33.
    Malaysia Ministry of Health, Dermatological Society of Malaysia, Academy of Medicine Malaysia (2012) Clinical practice guidelines: Management of acne. Accessed July 2012
  34. 34.
    Mikkelsen CS, Hansen SR, Kroon S (2011) Local treatment of acne. Tidsskr Nor Laegeforen 131:33–34PubMedCrossRefGoogle Scholar
  35. 35.
    Nast A, Bayerl C, Borelli C, Degitz K, Dirschka T, Erdmann R, Fluhr J, Gieler U, Hartwig R, Meigel EM, Möller S, Ochsendorf F, Podda M, Rabe T, Rzany B, Sammain A, Schink S, Zouboulis CC, Gollnick H, (BVDD) GSoDDatAoGD (2010) S2 k-guideline for therapy of acne. J Dtsch Dermatol Ges 8(Suppl 2):s1–s59PubMedGoogle Scholar
  36. 36.
    Nast A, Dréno B, Bettoli V, Degitz K, Erdmann R, Finlay AY, Ganceviciene R, Haedersdal M, Layton A, López-Estebaranz JL, Ochsendorf F, Oprica C, Rosumeck S, Rzany B, Sammain A, Simonart T, Veien NK, Zivković MV, Zouboulis CC, Gollnick H, Forum ED (2012) European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol 26(Suppl 1):1–29PubMedCrossRefGoogle Scholar
  37. 37.
    Nast A, Rosumeck S, Sammain A, Sporbeck B, Rzany B (2012) Methods report on the development of the European S3 guidelines for the treatment of acne. J Eur Acad Dermatol Venereol 26(Suppl 1):e1–e41PubMedCrossRefGoogle Scholar
  38. 38.
    National Institute for Clinical Excellence (2002) Guidance on the use of etanercept and infliximab for the treatment of rheumatoid arthritis: technology appraisal guidance no. Accessed July 2012
  39. 39.
    Niessen LW, Grijseels E, Koopmanschap M, Rutten F, Health DMo (2007) Economic analysis for clinical practice–the case of 31 national consensus guidelines in the Netherlands. J Eval Clin Pract 13:68–78PubMedCrossRefGoogle Scholar
  40. 40.
    Orozco B, Campo ME, Anaya LA, Atuesta J, Ávila MJ, Balcázar LF et al (2011) Guías colombianas para el manejo del acné: una revisión basada en la evidencia por el Grupo Colombiano de Estudio en Acné. Rev Asoc Colomb Dermatol 19:129–158Google Scholar
  41. 41.
    Ozolins M, Eady EA, Avery AJ, Cunliffe WJ, Po AL, O’Neill C, Simpson NB, Walters CE, Carnegie E, Lewis JB, Dada J, Haynes M, Williams K, Williams HC (2004) Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomised controlled trial. Lancet 364:2188–2195PubMedCrossRefGoogle Scholar
  42. 42.
    Piquero-Martin J (2005) Libro Online de Dermatologia Accessed July 2012
  43. 43.
    Poitras S, Rossignol M, Avouac J, Avouac B, Cedraschi C, Nordin M, Rousseaux C, Rozenberg S, Savarieau B, Thoumie P, Valat JP, Vignon E, Hilliquin P (2010) Management recommendations for knee osteoarthritis: how usable are they? Jt Bone Spine 77:458–465CrossRefGoogle Scholar
  44. 44.
    Poolman RW, Verheyen CC, Kerkhoffs GM, Bhandari M, Schünemann HJ, Group IE-BOSW (2009) From evidence to action: Understanding clinical practice guidelines. Acta Orthop 80:113–118 Google Scholar
  45. 45.
    Purriños L (2011) Acne. Fisterra Guias Clinicas Accessed July 2012
  46. 46.
    Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P, BoTotGI Network (2012) Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med 156:525–531PubMedCrossRefGoogle Scholar
  47. 47.
    Ramos-e-Silva M, Carneiro SC (2009) Acne vulgaris: review and guidelines. Dermatol Nurs 21:63–68 quiz 69PubMedGoogle Scholar
  48. 48.
    Secretaria de Salud, Gobierno de Mexico (2009) Resumen de evidencias y recomendaciones. Diagnostico y tratamiento de acné. Guía de Practica Clínica. accessed July 2012
  49. 49.
    Shaneyfelt TM, Mayo-Smith MF, Rothwangl J (1999) Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 281:1900–1905PubMedCrossRefGoogle Scholar
  50. 50.
    Sinclair W, Jordaan HF, Global Alliance to Improve Outcomes in Acne (2005) Acne Guideline 2005 Update. S Afr Med J 95:881–892Google Scholar
  51. 51.
    Instituto Hondureño de Seguridad Social (2009) Guias Clinicas del II y III Nivel. Tomo III Medicina Interna. Acne. Accessed June 2012
  52. 52.
    Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, Siegfried EC, Thiboutot DM, Van Voorhees AS, Beutner KA, Sieck CK, Bhushan R, Association AAoDAAoD (2007) Guidelines of care for acne vulgaris management. J Am Acad Dermatol 56:651–663PubMedCrossRefGoogle Scholar
  53. 53.
    Tan JK, Wolfe BJ, Bulatovic R, Jones EB, Lo AY (2010) Critical appraisal of quality of clinical practice guidelines for treatment of psoriasis vulgaris, 2006–2009. J Invest Dermatol 130:2389–2395PubMedCrossRefGoogle Scholar
  54. 54.
    Torres V, Gollnick H, Campo MH, de-Castro L, Cordero A, Talarico S, Gomez M et al (2008) Reporte final de la Primera Reunión de la Alianza Global para mejorar el Tratamiento del Acné (Global Alliance to Improve Outcomes in Acne). Capítulo Latinoamérica. “GALA” Cartagena, Colombia. Mayo 6–7, 2007. Dermatología Rev Mex 52:S1–S40Google Scholar
  55. 55.
    Vale L, Thomas R, MacLennan G, Grimshaw J (2007) Systematic review of economic evaluations and cost analyses of guideline implementation strategies. Eur J Health Econ 8:111–121PubMedCrossRefGoogle Scholar
  56. 56.
    Wimpenny P, van Zelm R (2007) Appraising and comparing pressure ulcer guidelines. Worldviews Evid Based Nurs 4:40–50PubMedCrossRefGoogle Scholar
  57. 57.
    Zaenglein AL, Thiboutot DM (2006) Expert committee recommendations for acne management. Pediatrics 118:1188–1199PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Gloria Sanclemente
    • 1
    • 5
  • Jorge-Luis Acosta
    • 2
  • Maria-Eulalia Tamayo
    • 3
  • Xavier Bonfill
    • 4
  • Pablo Alonso-Coello
    • 4
  1. 1.Group of Investigative Dermatology (GRID), School of MedicineUniversity of AntioquiaMedellínColombia
  2. 2.Public Health DepartmentUniversidad del NorteBarranquillaColombia
  3. 3.Pediatrics Department, School of MedicineUniversity of AntioquiaMedellínColombia
  4. 4.Iberoamerican Cochrane Center, IIB- Sant Pau, CIBERESP, Universitat Autònoma de BarcelonaBarcelonaSpain
  5. 5.PhD Program in Salud Pública y Metodología de la Investigación Biomédica of the Departament de Pediatria, d’Obstetrícia i Ginecologia i de Medicina PreventivaUniversitat Autònoma de BarcelonaBarcelonaSpain

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