The Personalised Acne Care Pathway—Recommendations to guide longitudinal management from the Personalising Acne: Consensus of Experts

Background Acne is a chronic disease with a varying presentation that requires long-term management. Despite this, the clinical guidelines for acne offer limited guidance to facilitate personalized or longitudinal management of patients. Objectives To generate recommendations to support comprehensive, personalized, long-term patient management that address all presentations of acne and its current and potential future burden. Methods The Personalising Acne: Consensus of Experts panel consisted of 13 dermatologists who used a modified Delphi approach to reach consensus on statements related to longitudinal acne management. The consensus was defined as ≥75% voting “agree” or “strongly agree.” All voting was electronic and blinded. Results Key management domains, consisting of distinct considerations, points to discuss with patients, and “pivot points” were identified and incorporated into the Personalised Acne Care Pathway. Long-term treatment goals and expectations and risk of (or fears about) sequelae are highlighted as particularly important to discuss frequently with patients. Limitations Recommendations are based on expert opinion, which could potentially differ from patients' perspectives. Regional variations in health care systems may not have been captured. Conclusions The Personalised Acne Care Pathway provides practical recommendations to facilitate the longitudinal management of acne, which can be used by health care professionals to optimize and personalize care throughout the patient journey.


INTRODUCTION
Acne, one of the most common skin conditions treated by dermatologists and other health care professionals (HCPs), generally affects adolescents and young adults, but it can persist later in adulthood despite treatment. [1][2][3][4][5] Clinically, acne typically presents in various forms, with truncal acne presenting in more than half of the patients with facial involvement. [6][7][8][9][10][11] Despite its varying presentations and chronic nature, current guidelines offer little guidance to facilitate personalized or longitudinal management of patients. 6,12,13 Personalized care is important in chronic skin conditions, where treatment success is highly dependent on patient adherence to ongoing treatment regimens. 14 Adherence to treatment can be influenced by numerous factors, including the patients themselves (their characteristics and beliefs), the HCP-patient relationship, and treatment-related factors such as effectiveness, acceptability, side-effect profile, tolerability, frequency of use, duration, and administration routes. 15 Moreover, disease chronicity and the disease itself (including its anatomic location) play an important role, as can the health care system in which the patient is receiving care (eg, appointment availability and treatment costs). 11,15,16 Low adherence can be due to a perceived lack of response or low treatment satisfaction, highlighting the need for HCPs to consider and discuss patients' concerns, set realistic expectations, and dispel misconceptions throughout their treatment journey. 17,18 Ongoing care is also important in managing acne effectively to minimize disease relapse. 19 It is additionally needed due to the prolonged nature of the treatment, generally taking several months to achieve optimal results. 20 Patients often misperceive their acne as a short-term condition, emphasizing the need for open and candid communication between HCPs and patients to clarify the long-term nature of management. 21 Devising and implementing longterm care plans that consider the risk and presence of acne sequelae early in the treatment journey may also mitigate this additional burden on patients. 22 Management strategies that optimize short-term and long-term outcomes have also been identified by consensus between clinicians and patients as a key research priority, providing a further rationale for developing a care pathway that facilitates longitudinal patient management. 23 As a part of the 2020-2021 consensus project, the Personalising Acne: Consensus of Experts (PACE) panelists have developed a care pathway based on expert recommendations to support comprehensive, personalized, longitudinal management of acne considering both the current and potential future burden of disease.

Expert panel
The expert panel consisted of 13 dermatologists from Canada (n = 2), France (n = 1), Germany (n = 1), Italy (n = 1) the United Kingdom (n = 1), and the United States (n = 7). Two chairpersons from the main panel oversaw the process and were involved in panel selection and Delphi design.

The modified Delphi process
The modified Delphi process used by the PACE panel has been described previously. 24,25 Between February 2020 and November 2020, 5 e-surveys were conducted to gather information and capture voting responses, with a virtual group meeting held between the third and fourth e-survey. The PACE panelists attended 2 virtual meetings to refine the pathway further and completed a workmat activity in between (Fig 1). An initial literature search was conducted to inform the e-survey content and is described in detail in the Supplementary Material (available via Mendeley at https://data.mendeley. com/datasets/fy6mnvt7t7/1).

E-survey development and administration
Consensus statements were structured to assess the level of agreement using the response range: Despite the varying presentations and frequently chronic nature of acne, established clinical guidelines offer little guidance to facilitate its personalized and longitudinal patient management d Based on consensus recommendations, the Personalized Acne Care Pathway panel has developed a Personalized Acne Care Pathway to support comprehensive, personalized, and long-term management of acne ''strongly disagree,'' ''disagree,'' ''agree,'' ''strongly agree,'' or ''unable to answer.'' The consensus was defined as $75% voting ''agree'' or ''strongly agree.'' Some questions were posed as multiple-choice where several responses could be selected, for which results are presented as consensus when chosen by $75% of panelists. Some questions were open-ended to allow for the development of consensus statements in a subsequent round of voting. The programming, administration, and response collation of the e-surveys was performed by Ogilvy Health UK to maintain blinding. Longitudinal management and patient types were 2 of the 4 major topics explored and will be the focus of this manuscript. Acne sequelae and truncal acne were also covered and have been previously reported. 24,25

Definition of consensus recommendations
Consensus statement voting information is provided in parentheses (eg, 12/13 voted ''agree'' or ''strongly agree''). Some panel members occasionally voted ''unable to answer''; these votes were not included in the denominator. Complete statements are available in the Supplementary Material.
Elements that were considered but not voted on are included in the ''Discussion points'' below.

Baseline demographics
When the panelists were asked about clinical practice guidelines, 38% (n = 5) did not find them useful for long-term management strategy, and 62% (n = 8) did not find them useful for the management of different patient types.

Current challenges and gaps in the longitudinal management of acne
The PACE panel highlighted several challenges in the longitudinal management of acne, including the variable presence of clinical lesions, presence of sequelae, multifactorial pathophysiology, and lack of a definitive treatment target to utilize in a treat-totarget approach. The panelists agreed that there is a need for educational materials for patients on the longitudinal nature of acne management to help them make informed decisions around choice and modification of treatment (13/13).

Overview of the Personalised Acne Care Pathway
Key management domains were identified across the acne patient journey, consisting of distinct considerations, points to discuss with patients, and ''pivot points'' (defined as a central point on which a management decision depends). The 7 identified management domains were mapped against the patient journey to form the Personalised Acne Care Pathway (PACP) (Fig 2).  Self-management and entry into the medical pathway Discussion points. Patients frequently attempt to treat their acne with over-the-counter medications or home remedies recommended by friends and family, or on social media, for some time before presenting to an HCP. Patients eventually present to a dermatology specialist through various pathways, including internet searches, advertising (eg, television or social media), word of mouth, or referral from a primary care practitioner or pharmacist.

Determining patient profile
Detailed considerations and discussion points for HCPs to determine patient profiles are provided in Table I.
Discussion points. Early and comprehensive assessment of the patient's profile is important for optimizing care. Many of the factors concerning patient history could bed and often aredcompleted before the patient enters the consultation. Several factors such as acne location, patient demographics/ specific clinical presentations, medical and family history, skin phototype, and prognostic risk factors can be assessed relatively quickly in a consultation. More time-consuming elements include building and strengthening the HCP-patient rapport, explaining the multifactorial and chronic nature of acne, managing treatment expectations, and ensuring that patients are satisfied with their treatment, feel supported, and understand that the HCP is invested in helping their acne improve.

Topics to consider for discussion at each consultation
Topics that HCPs should consider discussing with patients at each consultation are provided in Table II.
Discussion points. The panel identified several patient-related factors, including patient-reported satisfaction, treatment goals and expectations, and   HCPs should prioritize discussion topics based on how the individual patient is responding to the prescribed treatment and should enquire about any important changes to their daily routine.

Treatment initiation/modification phase
The treatment initiation/modification phase is defined as the regimen (which may include a number of different treatments) undertaken to achieve a primary goal before maintenance therapy. Gaps and Table IV. Maintenance treatment/modification phasedgaps and detailed considerations, discussion points, and pivot points Gaps d There is a need for guidance on the most appropriate time to initiate maintenance therapy* (12/13) d Clinical practice guidelines do not provide sufficient guidance on the choice of acne maintenance treatment* (12/13) d Clinical practice guidelines do not provide sufficient guidance on when to escalate, switch, or de-escalate acne maintenance treatment* (13/13) d There is a need for high-quality evidence for when to escalate, switch, or de-escalate both acne initiation and maintenance treatment* (12/13) d 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)

Pivot points
d In an ideal situation, patients should be followed up at least twice a year during the maintenance phase of treatment d 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 d 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 d Switching treatment B 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) d Switching from maintenance back to initiation treatment B 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).
detailed considerations, discussion points, and pivot points for the treatment initiation/modification phase are included in Table III. Discussion points. It was highlighted that during this phase there is also a need to allow for an adjustment period to a medication. As such, the period over which the prescribed medication would be expected to have an effect is an additional factor to consider when determining how frequently to follow-up with patients. In some cases, treatment deescalation can also be considered in patients when an adequate response has been achieved.

Maintenance treatment/modification phase
The maintenance phase is defined as the regimen (which may include a number of different treatments) undertaken to maintain the response achieved by initiation treatment (13/13). Gaps and detailed considerations, discussion points, and pivot points for the maintenance treatment/modification phase are included in Table IV.
Discussion points. Tele-visits are an acceptable platform for follow-up visits if patients are progressing well on maintenance treatment.

Treatment discontinuation
Treatment discontinuation can be considered when the treatment goals that have been mutually developed and agreed by the clinician and patient have been met.

Sequelae management
Detailed considerations, discussion points, and pivot points for sequelae management are included in Table V.
Discussion points. Sequelae management has been previously reported in detail. 25 Additional considerations for patients with specific clinical presentations Patient types that require additional considerations for their acne management are provided in Table VI.
Discussion points. All patients should be managed using an individualized approach; however, the panel identified a number of specific clinical presentations that may require additional considerations.

DISCUSSION
This PACP represents a consolidated effort to provide expert recommendations for the longitudinal management of acne. It incorporates patientcentered goals, reviewing, assessing, and modifying treatment, a transition from initiation to maintenance therapy, and guidance on how to manage patients in cases of relapse or remission. Alternative terminology has been previously used to describe the treatment initiation/modification phase in the PACP (eg, induction treatment); however, the recommendations for this treatment phase remain the same. 6 Current clinical guidelines for acne recommend treatment primarily based on disease-related factors, such as the type of acne and severity of disease, at fixed time points during the treatment journey, and almost exclusively focus on facial acne, with little guidance regarding the treatment of truncal acne. 6,12,13 The PACP complements clinical guidelines by addressing all presentations of acne and providing a framework to manage patients in a dynamic and holistic way, taking into consideration treatment-and patient-related factors as well as the current and future burden of disease. The PACE panel has previously provided recommendations to improve the management of truncal acne and acne sequelae. 24,25 These recommendations highlighted the importance of addressing truncal acne and acne sequelae as early as possible in the patient journey to mitigate the additional physical and psychosocial burden imposed on patients. 26,27 In addition, given that understanding patient expectations and mutually determined goals is inextricably linked to a positive HCP-patient relationship, the PACP is designed to cultivate a shared commitment to care personalized to each patient. 15,17,28 As such, it is important to emphasize that the PACP is not intended to act as a substitute for clinical guidelines and advise on specific treatment recommendations but instead is intended to provide guidance in optimizing the process of care in clinical practice. Patient satisfaction with treatment is one of the most important aspects to consider in ongoing management to improve adherence to treatment regimens; however, this is multifactorial and includes whether patients are satisfied with the improvement in their acne with the treatment regimen and whether they are satisfied with their appearance. 15,17,18 Currently, the majority of treatment algorithms in national and regional clinical management guidelines do not incorporate patient-oriented treatment goals or patient satisfaction as an outcome. 6,12,13,[29][30][31][32][33][34][35][36][37][38][39] Thus the PACE panel has recommended addressing patient satisfaction in consultations to improve adherence and ultimately improve patient outcomes.
A limitation is that the recommendations outlined in the PACP are based on the experiences of the expert panel and reflect HCP perspectives on the important topics to discuss with patients, which could potentially differ from patients' perspectives. 28 In addition, although the PACP integrates recommendations from an international group of experts, it only represents the health care systems in which the PACE panel has the experience and may not account for nuances in other regions. 40,41 Similar strengths and limitations of the Delphi method apply, as previously reported. 24,25 The PACP represents a simple, clear, and comprehensive overview of the acne patient journey, which emphasizes the multistep nature of acne management. Future applications for the PACP could include the development of iterations of the pathway for different audiences, for example, a version for patients, primary care practitioners, or nurses. This could be particularly helpful for patients (especially Table VI. Additional factors to consider for patients with specific clinical presentations Patients with specific clinical presentations Consider adolescents) to emphasize that their journey with acne could be an ongoing and dynamic process. Patient cases to demonstrate the use of the pathway could also be a valuable tool and have been used previously in other dermatologic conditions, such as rosacea. 42 Practical applications of the PACP include potential use by HCPs as an ''acne care road map'' while treating patients to accompany the patient through their acne journey and to determine individual pivot points in partnership with the patient. Feedback on the use of the PACP in clinical practice will be required to inform future updates and the development of practical tools to facilitate its use. Digital forms of the road map could also be developed to allow real-time support and feedback for HCPs during discussions with patients.

CONCLUSION
The PACE panel has developed the PACP to provide practical and actionable recommendations to facilitate personalized, longitudinal management of patients with acne. These recommendations can inform local guideline development and patient consultations, thus helping to optimize and personalize care throughout the patient journey.
Medical writing and administrative support were provided by Paolo Reveglia, MBiochem, Katie Harris, PhD, Ellie Hughes, PhD, James Pickford, BSc, and Victoria Smith, BSc at Ogilvy Health UK.