Medical Policies - Therapy


Acne Management

Number:THE801.028

Effective Date:10-15-2017

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

This medical policy does NOT address Gender Reassignment Services (Transgender Services). This medical policy IS NOT TO BE USED for Gender Reassignment Services. Refer to SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery and Related Services

Lesion Severity Definition:

Comedonal Acne - No inflammatory lesions.

Mild inflammatory acne - inflammatory papules and comedones.

Moderate inflammatory acne - greater number of lesions than mild inflammatory acne.

Nodulocystic acne - comedones, inflammatory lesions and large nodules > 5 mm in diameter.

The following treatments, whether used alone or in combination, may be considered medically necessary for the treatment of active nodulocystic acne:

Surgical interventions such as marsupialization, opening or removal of multiple milia, comedones, cysts, and pustules that have not responded to conventional therapies or treatments;

Deep dermal chemical peels for cases that are unresponsive to conventional therapies or treatments.

The following treatments are considered not medically necessary for the treatment of active acne and/or acne scarring:

Chemical exfoliation;

Dermabrasion;

Dispensing of exfoliants and other topical treatments from the physician’s office.

NOTE: See Medical Policy SUR716.018, Chemical Peels

The treatment of scarring and cosmetic complications of acne such as hyperpigmentation are considered cosmetic.

The following treatments for acne are considered experimental, investigational and/or unproven:

Cryoslush therapy;

Liquid nitrogen therapy;

The ClearLight™ and Clear Touch™ System;

Phototherapy using red light or high intensity blue spectrum (407-420 nm) light or photodynamic therapy (PDT);

Infliximab (Remicade®).

NOTE: See Medical Policy RX501.050, Biologic Response Modifiers (BRMs) for the Treatment of Rheumatoid Arthritis (RA) and Other Chronic Inflammatory Diseases

NOTE: See Medical Policy THE801.027 Photodynamic Therapy (PDT) for the Treatment of Actinic Keratoses (AK) and Other Skin Lesions

NOTE: Topical and systemic treatments of acne such as oral antibiotics, retinoids and other prescription products would be subject to the Pharmacy benefit.

Description:

Acne is a common disorder of the pilosebaceous follicles that primarily affects adolescents and young adults and may be classified as inflammatory or noninflammatory. Acne is characterized by comedones, nodules, and eruptions of papules, pustules, and nodulocystic lesions. Lesions are found in areas with the greatest concentration of sebaceous glands, i.e., the face, neck, and upper part of the trunk. The 4 causal factors of acne are androgen-mediated sebaceous gland hyperplasia and excess sebum production; abnormal follicular keratinization, which results in plugging of the follicles, and comedo formation; proliferation of propionibacterium acnes (P. acnes); and inflammation resulting from the chemoattractant and proinflammatory byproducts of P. acnes. Genetic factors, diet, and stress may also contribute to the development and severity of acne. Treatment of active acne usually consists of good skin care regimen, benzoyl peroxide, antibiotics, and retinoids. Active acne is distinct from acne scarring, which may occur from tissue damage after inflammatory lesions subside.

Types of Acne

Acne Vulgaris (AV)

The most common type of acne is acne vulgaris, which affects 85-100% of people at some time in their life. It is characterized by non-inflammatory follicular papules or comedones and by inflammatory papules, pustules, and nodules in its more severe forms. Acne vulgaris affects the areas of skin with the densest population of sebaceous follicles. These areas include the face, the upper part of the chest, and the back. (9)

Acne Conglobata (AC)

AC is an uncommon and unusually severe form of acne characterized by burrowing and interconnecting abscesses and irregular scars (both keloidal and atrophic), often producing pronounced disfigurement. The comedones often occur in a group of two or three and cysts contain foul-smelling seropurulent material that returns after drainage. The nodules often fuse forming unusual shapes of several centimeters. The formation of nodules begins in early puberty and the severity increases until late adolescence or beyond. Active nodule formation may persist for years and usually continues until the fourth decade of life. Isolation of coagulase-positive staphylococci is common in the lesions. As the nodules break down, crusts may form over a deep ulcer, which extends centrifugally, but tends to heal centrally. This process is persistent and slow healing is characteristic. A conspicuous feature of the disease is the blackheads that appear in pairs or groups on the neck and trunk, and sometimes involve the upper arms or the buttocks. (10)

Acne Fulminans (AF),

AF is also known as acne maligna, was originally described as acute febrile ulcerative AC. In 1958, at a meeting of the Detroit Dermatological Society, Burns and Colville presented a 16-year-old boy with acute febrile disease and AC. Many similar cases have been reported since then. The primary features of this disease include sudden onset, severe and often ulcerating acne, fever, polyarthritis, and failure to respond to antibacterial therapy; the response to debridement in combination with steroid therapy is good. It can be the dermatologic manifestation of the synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome. Acne fulminans is a syndrome of fulminant, necrotizing acne associated with bone lesions, constitutional symptoms, and laboratory abnormalities. (11)

Acneiform Eruptions

While acne vulgaris typically consists of comedones, acneiform eruptions (such as acneiform drug eruptions) usually lack comedones clinically. Acneiform eruptions are dermatoses that resemble acne vulgaris. Lesions may be papulopustules, nodular, or cystic. Acne-like disorders occur from a wide variety of diseases, including infections, hormonal or metabolic abnormalities, genetic disorders, and drug reactions. Those entities included in this discussion are nevus comedonicus, eruptive hair cysts, tuberous sclerosis, amineptine acne, steroid acne, chloracne, acneiform drug eruptions, gram-negative folliculitis, eosinophilic pustular folliculitis, Pityrosporum folliculitis, coccidioidomycosis, secondary syphilis, sporotrichosis, rosacea, and perioral dermatitis. (12)

Eosinophilic Pustular Folliculitis (EPF)

EPF is another disease of unknown etiology that usually manifests as a recurrent pruritic papulopustular eruption on the face, trunk, and extremities. Histopathology reveals a predominantly perifollicular infiltration of eosinophils with some mononuclear cells and subcorneal pustules composed of eosinophils. EPF has been described in infants, immunocompromised patients with HIV, and the classic immunocompetent type is known as Ofuji disease (first described by Ofuji in the adult Japanese population). Patients may also demonstrate blood eosinophilia and leukocytosis. Treatment modalities and results vary greatly. Options include topical and systemic corticosteroids, oral antibiotics, indomethacin, dapsone, isotretinoin, and pulsed ultraviolet phototherapy (PUVA). (12)

Treatment of Acne

There are many effective treatments for acne. (13) Treatment may need to be adjusted for each patient, as every treatment is not always successful for every patient. In addition, acne may not be “cured” but may be controlled. Good hygiene and use of over-the-counter products with benzoyl peroxide or salicylic acid often clears the skin. Other treatments that may be used include, but are not limited to:

Topical or oral medications (e.g., antibiotics, hormone therapy, etc);

Lasers and other light therapies;

Drainage and extraction of large acne cysts.

Once acne has cleared, treatment should continue to prevent new breakouts.

The topical therapy of AV includes the use of agents that are available over the counter or prescribed. Therapy may be influenced by age of the patient, site of involvement, extent and severity of disease, and patient preference. Topical therapies may be used as monotherapy, in combination with other topical agents or in combination with oral agents in both initial control and maintenance. (23)

Lasers have been used to treat acne scarring, and may also be useful for active acne. Various types of laser treatments are available, including pulsed and non-pulsed devices, and differing wavelengths of emitted light. Lasers may improve active acne by killing propionibacterium acnes (P. acnes) and/or by reducing inflammation.

Pulsed dye laser has been used in the treatment of acne scarring; however, more recently, lasers have been investigated for the treatment of active inflammatory acne. Laser therapy at various irradiation levels or fluences (e.g., low- and mid-level irradiation lasers and long-pulse diode lasers) has been used to destroy active acne lesions and enlarged sebaceous glands. Lasers are believed to improve active acne lesions by reducing the presence of P. acnes, which contain porphyrins that are destroyed by exposure to light of specific wavelengths (i.e., blue light of 405–420 nm). Lasers may also have anti-inflammatory affects (i.e., red light of 660 nm) that may improve active acne. Low fluence pulsed dye lasers are less ablative and purpuric and may be preferred in active acne treatment to limit tissue damage and potential treatment-related scarring. Laser treatment of active acne lesions may also reduce potential acne scarring that can occur in severe cases.

Drainage and extraction to remove a large acne cyst is a procedure that helps when the cyst does not respond to medicine. (13)

Cryotherapy is used for the treatment of nodulocystic acne. In the cryoslush method, solid carbon dioxide is crushed and a few drops of acetone are added to make a paste. This paste is rapidly applied to the lesions with a gauze ball for 2-10 seconds. Superficial peeling is achieved due to epidermal necrosis, which causes desquamation of comedones, resolution of inflammatory papules, pustules, nodules and cysts. In the cryopeel method, a spray of liquid nitrogen is used for 2-3 seconds, instead of a CO 2 slush. However, pigmentary changes are commonly observed, particularly in darker skinned patients. Persistent erythema and scarring may also occur. (24)

Regulatory Status

A number of laser and focused light devices have received marketing clearance for the treatment of acne via the U.S. Food and Drug Administration’s (FDA’s) 510(k) mechanism. These include lasers that emit light at 1320 nm (Candela Smoothbeam™ and CoolTouch®); intense pulsed light systems, which emit light in the range of 590 to 1200 nm (Radiancy ClearTouch™, MED flash II and Ellispse I2PL); pulsed dye lasers (ICN Photonics NLite System); and lasers or high-intensity light devices, which emit violet or blue (around 414 nm) and red (around 633 nm) light (Aura™, Clearlight and Dermillume). The specific indications for these devices vary; Candela Smoothbeam™ is indicated solely for the treatment of acne on the back, others are indicated for the treatment of inflammatory acne or for mild to moderate acne with no location specified. In 2006, a thermal device (ThermaClear™) was cleared for marketing for the “treatment of individual acne pimples in persons with mild to moderate inflammatory acne” in both a practitioner’s office environment and a consumer home-use environment.

Rationale:

Light Therapies

Laser Treatment

Two systematic reviews of light therapies for treatment of active acne were identified. Both reviews included studies on photodynamic therapy, as well as light and laser therapy. Neither review conducted any pooled analyses of laser treatment studies due to heterogeneity between studies (e.g., different wavelengths of light were used). The two systematic reviews had similar assessments of the literature. Hamilton and colleagues identified 10 randomized controlled trials comparing light therapy to placebo and 3 RCTs comparing light therapy to topical treatment of acne. (1) The authors commented that studies of light therapy tended to be small (all had fewer than 50 participants), of short duration and of variable quality, and that a few compared light therapy to conventional treatment. They concluded: “our review found only limited or no benefit is given by light therapies alone…Further trials comparing light therapy with usual treatment, using a larger effect size in the power calculations, would be helpful to determine the usefulness of light therapy in treating acne.” The other systematic review by Haedersdal and colleagues included 11 RCTs on light treatments (other than photodynamic therapy) and stated that most of the studies had suboptimal methods. (2) For example, few studies described their randomization method and most had large losses to follow-up without intention to treat analysis. The authors state, “Based on the present best available evidence, we conclude that optical treatments with lasers, light sources and PDT possess the potential to improve inflammatory acne on a short-term basis with the most consistent outcomes for PDT. We recommend that patients are informed of the existing evidence, which denotes that optical treatments for acne today are not included among first-line treatments” There is no separate conclusion focusing on laser therapy. The systematic reviews identified a number of side effects from optical treatments, and these include pain, erythema, edema, crusting, hyperpigmentation, and pustular eruptions.

Key individual RCTs with at least 40 participants are described as follows:

Seaton et al., 2003: This trial was a double-blind RCT of 41 adults with mild to moderate facial inflammatory acne (i.e., Leeds acne severity score of between 2 and 7). Patients were randomized to receive a single low fluence pulsed dye laser treatment or sham treatment. At 12 weeks, Leeds acne scores fell from 3.8 to 1.9 in the treatment group and from 3.6 to 3.5 in the control group. Total lesion counts fell by 53% and 9% and inflammatory lesion counts fell by 49% and 10% in the laser treatment group and control group, respectively. While the authors reported statistically significant improvements, they concluded that “laser treatment should be further explored as an adjuvant or alternative to daily conventional pharmacological treatments.” (3)

Orringer et al., 2004: The article reported on a single-blind, split-face RCT of 40 patients (aged 13 years or older with a Leeds acne score of 2 or greater) who were randomized to receive either one or two sessions of pulsed dye laser treatment (3 J/cm2 fluence) to half of the face with the opposite, non-treated side serving as the control. At 12 weeks, changes in lesion counts (including pustules, comedones, macules, cysts, and papules) and mean Leeds acne scores were not significantly different for the treated versus untreated sides of the face. The authors concluded that “…additional well designed studies are needed before the use of pulse dye laser becomes a part of acne therapy.” (4)

Orringer et al., 2007: This RCT assessed the efficacy of a 1320-nm laser (CoolTouch II) in 46 patients in a split-face design. Laser treatment was given once every 3 weeks, with blinded evaluation by a panel of 3 dermatologists (from photographs taken at 7 and 14 weeks). Thirty patients completed the 14-week assessment (35% dropout); data were carried forward to adjust for subjects who may have dropped out of the study due to lack of effect. The authors report that the treated side remained unchanged at 0.22 cysts (10 total cysts in 46 subjects) while the untreated side increased from 0.27 to 0.70 cysts. Subjective patient reports (of 37 who completed at least the 7-week assessment; not blinded to treatment) favored the treated side over the control side for a decrease in acne (59%) and oily skin (54%). No differences were found between the treated and un-treated sides in the number of papules, pustules, open comedones, or closed comedones at 14 weeks. (5)

Laheta, 2009: This study included 45 patients with mild to moderate acne who were randomly assigned to one of three groups (15 patients per group). Group A received pulsed dye laser therapy (3 J/cm2 fluence) every 2 weeks for 6 sessions; Group B applied topical treatment with 0.1% tretinoin cream every evening and 5% benzoyl peroxide gel every morning; and Group C underwent chemical peeling using trichloroacetic acid 25%. An assessor blinded to treatment group evaluated outcomes; 41 patients were included in the analysis. There was no significant difference between groups in the acne severity score (0=no acne to 10=severe acne) at the end of the 3-month treatment period. Mean scores were 0.56 ± 0.57 for Group A, 0.65 ± 0.47 for Group B, and 0.68 ± 0.50 for Group C (p=0.38). The analysis of disease severity did not adjust for baseline scores, and standard deviations were large due to the small number of participants in each group. The degree of clinical response (marked or moderate) and side effects (trace, mild, or moderate) also did not differ significantly between the three groups. The proportion of patients with moderate side effects was 23% in Group A, 15% in Group B, and 13% in Group C (overall p value= 0.95). (6)

Photodynamic Therapy

There are very few published reports regarding the use of photodynamic therapy (PDT) in the treatment of acne. Additionally, these involve small numbers of patients (10-22), and utilize differing light sources, and only one study (using red light) was identified that attempted to use an untreated “control” area on the back of the 22 treated patients. According to the investigators, this pilot study, published in August 2000, used an aggressive ALA-photodynamic therapy treatment dose to test the possibility of effects on acne vulgaris. They also noted that each treatment was painful or pruritic, caused acute erythema and edema, occasionally caused blistering and purpura, or caused an acute acneiform eruption (which could last up to three weeks) and usually led to hypopigmentation that faded gradually over weeks or months. Consequently, they state: “To most people, these side-effects would be tolerable in practice only if PDT were able to permanently improve acne, which remains a distinct possibility.” (Note: study follow up period was 20 weeks). The authors go on to say: “Dose-response characteristics for ALA-PDT treatment of acne are unknown. We plan future studies exploring the precise dosimetry.” In separate recent reviews of acne management, Gollnick and Krautheim (14) commented that: “Photodynamic therapy has not yet been proven efficacious in controlled studies,” while Harper (15) stated that: “Controlled clinical trials are lacking at this time.”

Trials on photodynamic therapy are discussed further in policy THE801.027 Photodynamic Therapy (PDT) for the Treatment of Actinic Keratoses (AK) and Other Skin Lesions.

Section Summary

At this time there is insufficient evidence in the published, peer-reviewed scientific literature to support the use of ultraviolet radiation or laser phototherapy in the treatment of acne. Evidence exists primarily in the form of unpublished abstracts, anecdotal information and one very small controlled trial. Well-designed, large population, controlled comparative studies are needed before the role of phototherapy in the management of active acne can be established. Due to the small sample sizes of the published trials, lack of long-term follow-up, small number of studies on any particular type of laser, and paucity of studies comparing light therapy to standard acne treatments, the evidence is insufficient to draw conclusions about the impact of laser treatments on health outcomes in patients with active acne. Therefore, ultraviolet radiation or laser phototherapy is considered experimental, investigational and/or unproven.

Technology Assessments, Guidelines and Position Statements

America Academy of Dermatology (AAD)

An on-line information sheet endorsed by the AAD states “several laser and light treatments are available to treat acne. Some of these laser and light treatments target only one factor that causes acne. For many patients, this is not a comprehensive treatment for resolving their acne. A dermatologist can determine if laser or light treatment is appropriate for a patient. Advantages to laser and light treatments include not having to remember to apply or take any medication and the ability to treat hard-to-reach areas, such as the back. However, laser and light treatments can be quite expensive, and long-term effectiveness has not been proven.” (7)

Chemical peels

Chemical peels are generally performed for cosmetic purposes, it has been suggested that superficial or epidermal peels, using alpha hydroxy acids (AHA), may have a comedolytic effect on comedonal acne lesions by loosening follicular impaction and may be appropriate for individuals with widespread lesions for whom standard treatment has failed. However, the role of superficial peels in the overall management of patients with active acne has not been established through well designed trials. Randomized controlled trials (RCT) directly comparing alpha-hydroxy acids with well-established treatments, such as topical retinoids, are lacking. Evidence supporting this technique exists primarily in the form of anecdotal reports. Superficial and epidermal peels have been shown to exacerbate the inflammation associated with acne.

In their guidelines, the American Academy of Dermatology observed that both glycolic acid-based and salicylic acid-based peeling preparations have been used in the treatment of acne. Further research on the use of peeling in the treatment of acne needs to be conducted in order to establish best practices for this modality.

Dermabrasion

The American Academy of Dermatology Association recommends that patients with active acne be successfully treated for acne before dermabrasion as it has been shown to increase the inflammation associated with active acne.

In an evidence-based review on microdermabrasion, Karimipour et al. (18) stated that the role of microdermabrasion in the treatment of dyschromias and acne vulgaris is limited.

Other Therapies

Treatment of Scarring and Cosmetic Complications of Acne

Even with appropriate treatment, scarring and other unwanted cosmetic changes, such as hyperpigmentation, are common complications of acne. Treating these sequelae is considered cosmetic in nature.

Treatment of Acne with Infliximab

The safety and efficacy of Infliximab for patients diagnosed with acne conglobata, acne vulgaris or severe nodulocystic acne has not been proven effective. At this time there is insufficient evidence in the published, peer-reviewed scientific literature to support the use of Infliximab in the treatment of acne. Evidence exists primarily in the form of case studies, anecdotal information, and a few very small trials that showed some coincidental improvements to a patient’s severe acne while the patient was being treated for other conditions with Infliximab.

Cryoslush Therapy

Cryotherapy with carbon dioxide (CO²), liquid nitrogen, acetone slush, or solid carbon dioxide mixed with acetone is being used to treat inflammatory nodular lesions caused by acne. While these treatments are currently being used in practice, the role of cryotherapy in the treatment of active acne has not been established through well designed trials. Randomized controlled trials comparing the use of cryotherapy treatments with well-established acne treatments are lacking.

2016 Update

In 2016, the AAD guidelines on care for the management of acne vulgaris were updated and maintain the following: “There is limited evidence to recommend the use and benefit of physical modalities for the routine treatment of acne, included pulsed dye laser, glycolic acid peels and salicylic acid peels.” (23) The ADD made no statement on Cryotherapy at this time.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

10040, 10060, 10061, 11900, 11901, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 17000, 17003, 17106, 17107, 17108, 17110, 17111, 17340, 17360, 17999, 96900, 96910, 96920, 96921, 96922

HCPCS Codes

E0202, J1745, J7308, S8948

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Hamilton, F.L., Car, J., et al. Laser and other light therapies for the treatment of acne vulgaris: systematic review. Br J Dermatol (2009) 160: 1273-85. PMID 19239470

2. Haedersdal, M., Togsverd-Bo, K., et al. Long-pulsed dye laser versus long-pulsed dye laser-assisted photodynamic therapy for acne vulgaris: a randomized controlled trial. J Am Acad Dermatol (2008) 58(3):387-94. PMID 18280335

3. Seaton, E.D., Charakida, A., et al. Pulsed-dye laser treatment for inflammatory acne vulgaris: randomised controlled trial. Lancet (2003 October 25) 362(9393):1347-52. PMID 14585635

4. Orringer, J.S., Kang, S., et al. Treatment of acne vulgaris with a pulsed dye laser: a randomized controlled trial. Journal of the American Medical Association (2004) 291(23):2834-9. PMID 15199033

5. Orringer, J.S., Kang, S., et al. A randomized, controlled, split-face clinical trial of 1320-nm Nd:YAG laser therapy in the treatment of acne vulgaris. J Am Acad Dermatol (2007) 56(3):432-8. PMID 17239987

6. Laheta, T.M. Role of the 585-nm pulsed dye laser in the treatment of acne in comparison with other topical therapeutic modalities. J Cesmetic Laser Ther (2009) 11:118-24. PMID 19391056

7. Physical Procedures for Treating Acne. AcneNet. Developed by the American Academy of Dermatology. 2011 Available at < http://www.skincarephysicians.com> (accessed November 5, 2014).

8. Degitz, K. Phototherapy, photodynamic therapy and lasers in the treatment of acne. J Dtsch Dermatol Ges. (2009 December) 7(12): 1048-54. PMID 19453385

9. Harper, J.C. An update on the pathogenesis and management of acne vulgaris. Journal of the American Academy of Dermatology (2004) 51(1 supplement): S36-8. PMID 15243503

10. Schwartz, R.A., Richard, Z. Acne Conglobata. (2016 May 20). eMedicine Article. Available at <http://www.emedicine.medscape.com> (accessed – 2016 May 31).

11. Ryszard, Z., Schwartz, R.A. Acne Fulminans. (2016 May 20). eMedicine Article. Available at <http://www.emedicine.medscape.com> (accessed – May 31).

12. Kuflik, J.H., Schwartz, R.A. Acneiform Eruptions. (2016 February 08). eMedicine Article. Available at <http://www.emedicine.medscape.com> (accessed – 2016 May 31).

13. Acne: Diagnosis, treatment, and outcome. American Academy of Dermatology (2016). Available at <http://www.aad.org> (accessed – 2016 May 31).

14. Gollnick, M.P., Krautheim, A. Topical treatment in acne: current status and future aspects. Dermatology (2003 January) 206(1):29-36. PMID 12566803

15. Harper, J.C. An update on the pathogenesis and management of acne vulgaris. Journal of the American Academy of Dermatology (2004) 51(1 supplement): S36-8. PMID 15243503

16. Tan, J.K.L. Current measures for the evaluation of acne severity: Methods for grading acne. Expert Review of Dermatology (2008). Medscape. Available at <http://www.medscape.com> (accessed – 2016 June 3).

17. Karimipour, D.J., Karimipour, G., et al. Microdermabrasion: An evidence-based review. Plast Reconstr Surg. (2010) 125(1):372-377. PMID 20048628

18. Ingram, J.R., Grindlay, D.J., et al. Management of acne vulgaris: an evidence-based update. Clin Exp Dermatol. (2010 June) 35(4):351-4. PMID 19874358

19. Babilas, P., Schreml, S., et al. Intense pulsed light (IPL): A review. Lasers Surg Med. (2010) 42(2):93-104. PMID 20166155

20. Orringer, J.S., Sachs, D.L., et al. Photodynamic therapy for acne vulgaris: a randomized, controlled, split-face clinical trial of topical aminolevulinic acid and pulsed dye laser therapy. Journal of Cosmetic Dermatology (2010 March) 9(1):28-34. PMID 20367670

21. Roa, Jaggi. Acne Vulgaris. (2016 May 20). Medscape. Available at <http://www.emedicine.medscape.com> (accessed – 2016 June 3).

22. Strauss, J.S., Krowchuk, D.P., et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. (2007 April) 56(4):651-63. PMID 17276540

23. Zaenglein, A.L., Pathy, A.L., Schlosser, B.J., et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. (2016). PMID 26897386

24. Khunger, Niti. Standard guidelines of care for acne surgery. Indian J Dermatol Venereol Leprol. (2008 January); 74 Suppl: S28-36. PMID 18688101

25. Laser Treatment of Active Acne. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (December 2009 - Archived) Medicine 2.01.69.

Policy History:

Date Reason
10/15/2017 Reviewed. No changes.
11/1/2016 Document updated with literature review. Coverage unchanged.
7/15/2015 Reviewed. No changes.
12/15/2014 Document updated with literature review. Coverage unchanged. Rationale completed revised.
1/1/2012 Document updated with literature review. Coverage change added that the treatment of scarring and cosmetic complications of acne such as hyperpigmentation are considered cosmetic. LEEDs scale was removed from policy.
7/15/2009 Policy updated with literature review. Policy revised to state that Infliximab (Remicade®) for treatment of acne at any stage is considered experimental, investigational and unproven.
3/1/2007 Revised/updated entire document
5/1/2006 New medical document

Archived Document(s):

Title:Effective Date:End Date:
Acne Management06-15-202105-14-2022
Acne Management07-01-202006-14-2021
Acne Management10-15-201706-30-2020
Acne Management11-01-201610-14-2017
Acne Management07-15-201510-31-2016
Acne Management12-15-201407-14-2015
Acne Management01-01-201212-14-2014
Acne Management07-15-200912-31-2011
Acne Management03-01-200707-14-2009
Acne Management05-01-200602-28-2007
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