reading report. translated at 2006.12   Acne management. Institute for Clinical Systems Improvement - Private Nonprofit Organization. 2002 Nov (revised 2006 May). 36 pages.

临床要点
• Patient perception of improvement is the best measure of successful treatment. (Annotation #4)
• 患者自觉的改善体验是衡量治疗成功的最好手段
• Although acne is not a life threatening disease, the clinician must be aware of potentially debilitating psychosocial effects. (Annotation #4)
• 尽管痤疮(青春痘)不危及生命，但临床医师必须注意到其潜在致虚衰的精神社会效应
• Treatment with both a topical retinoid and a topical antibiotic has been found to be an effective course of treatment. (Annotation #5)
• 局部联合使用维A酸类和抗生素药物是一种有效的疗法
• Customize a treatment plan that the patient will be able to follow according to his/her needs. (Annotations #6, 8)
• 根据患者需要，定制他们可以依从的治疗计划
• The patient needs to understand that acne may get worse before it gets better. It typically takes eight weeks of treatment before a response is noted. (Annotation #7)
• 患者需要理解：在痤疮好转之前可能会出现一段时间的恶化。一般需要8周的治疗时间才能看到显著的治疗反应
• Isotretinoin therapy is highly regulated. (Annotation #9)
• 异维A酸疗法需要严格规范

Annotation 注释
1. Patient Presents for Treatment of Acne/Provider Observes Acne 患者要求治疗痤疮/医师发现有痤疮
When presented with acne in office visit scheduled for other reason, identify comfort with condition and desire for treatment.

2. Review Possible Contributing Factors 回顾痤疮的可能归因
Hormonal激素
Signs of androgen excess would include:雄激素过多的体征包括
• Precocious puberty 性早熟
• Hirsutism 多毛症
Possible causes of androgen excess would include:雄激素过多的可能成因
• Polycystic ovary disease 多囊卵巢病
• Adrenal tumor 肾上腺肿瘤
• Ovarian tumor 卵巢肿瘤
• Pituitary tumor 垂体肿瘤
Mechanical 物理
On occasions physical occlusion may contribute to acne. For example: hockey masks; oil-based cosmetics (although most cosmetics today are water based).
有时物理性阻塞也可导致痤疮。比如：曲棍球遮罩，油基化妆品等（尽管现今大多数化妆品是水基的）。
Evidence supporting this recommendation is of classes: D, R
Medications药物
There are many medications that may contribute to the development of acne. In addition to treating the acne, consideration may be given to discontinuing these medications. Refer to the original guideline document for a list of medications that may contribute to the development of acne.
许多药物促成痤疮形成。在治疗痤疮时，需要考虑停用这些药物。
Evidence supporting this recommendation is of classes: D, R

3. Assess Objective Severity of Acne 评估痤疮的客观严重度
Acne severity is the most important clinical diagnostic tool in studies reviewed. For simplification, the guideline developer is following the Agency for Healthcare Research and Quality's (AHRQ) recommendation to divide acne into three severity grades: mild, moderate, and severe. There are a number of other ways of grading acne that are used clinically and in research. None, however, is universally accepted. Additionally, psychological impact or the presence of scarring may play a role in assigning a severity grade to the patient.
The following diagnostic tool was designed as a guideline for three lesion counts on the face but may be applicable to grading the severity of acne on the trunk as well.
在综述研究中痤疮的严重度是重要的临床诊断指标。为了就简，本指南采用医疗保健研究与质量学会Agency for Healthcare Research and Quality(AHRQ)的建议，将痤疮严重度分三级：轻、中、重度。在临床和科研中有许多种痤疮分级方法。但是没有一种被广泛接受。另外，精神打击或瘢痕形成所带来的压力也是严重度分级评估的一部分。
以下的诊断指标按颜面部三类皮损的计数划分，也适于评估躯干部的痤疮严重程度。

a. Mild Acne:轻度 ：以粉刺（少于20个）为特点，或者颜面部炎性丘疹少于15个，或者粉刺/丘疹总计数少于30个。
Mild acne is characterized by predominance of comedones (fewer than 20), or fewer than 15 inflammatory papules, or a comedone/papule count of fewer than 30 on the face.
b. Moderate Acne: 中度：以丘疹和脓疱（约15－50个皮损）为特点，伴有粉刺和极少数囊肿。颜面部总皮损（粉刺、脓疱、囊肿）计数在30－125个之间。
Moderate acne predominantly exhibits papules and pustules (about 15-50 lesions) with comedones and rare cysts. Total lesion (comedone, papule, pustule) count may range from 30 to 125 on the face.
c. Severe Acne: 重度：以炎性结节和囊肿的出现为特征，伴随有粉刺、丘疹和脓疱或颜面部总皮损计数大于125个。
Severe acne is characterized primarily with the presence of inflammatory nodules and cysts. Also present are comedones, papules, and pustules or total lesion count of greater than 125 on the face.

Definitions:定义：
• Closed Comedone (whitehead): non-inflamed (non-red) follicular opening containing a keratotic plug with a thin overlying epidermal membrane
• 闭合性粉刺（白头粉刺）：非炎性（不发红）的小滤泡，开口处为上皮膜覆盖的角化栓。
• Open Comedone (blackhead): non-inflamed (non-red) follicular opening containing a keratotic plug that appears black
• 开放性粉刺（黑头粉刺）：非炎性（不发红）的小滤泡，开口处为黑色的角化栓（皮脂氧化所致）。
• Papule: small round to oval red elevation of the skin (1-4 mm)
• 丘疹：圆形或软圆形的红色皮肤小隆起（1-4mm）
• Pustule: resembles a papule with a central pocket of pus
• 脓疱：类似于丘疹，但顶端包有脓液。
• Nodule/Cyst: poorly marginated red tender, sometimes draining 0.2- to 3.0-cm indurated mass in the skin
• 结节/囊肿：边界不清、触之柔软的红色皮肤包块，有时为浸润皮下的0.2-3.0cm的硬结。
Evidence supporting this recommendation is of classes: M, R

4. Assess Psychosocial Impact of Acne 评估痤疮的精神社会影响
It is important to assess the psychosocial effect of acne. Studies using "quality of life" surveys show a variety of significant impacts, most frequently, anxiety and depression. Decreased self-esteem, social withdrawal, anger, conduct disorders, and decreased employability have been reported in other studies. The clinical severity of the acne does not always predict the severity of the psychosocial impacts. Effective treatment of acne can decrease these negative effects.
评估痤疮的精神社会影响是非常重要的。运用生命质量量表调查显示大量显著的精神社会影响，最常见的是紧张和抑郁。在其他研究中还报道有自尊心下降、社交回避、愤怒、行为紊乱以及职业效率下降。临床的痤疮严重度分级并不总与其精神社会影响的严重程度相关。有效的治疗可以消除这些负面影响。
If significant psychosocial effects are present, consider a more aggressive initial treatment (such as combination therapy and closer follow-up) than might be indicated by the objectively observed severity alone. Patient perception of improvement is the best measure of successful treatment.
如果显著的精神社会影响已经显现出来，则需要考虑更为积极的初始治疗（比如联合疗法和更紧密的随访），而不仅仅依据痤疮的客观观察结果。患者自觉的改善体验是衡量治疗效果的最佳手段。
Evidence supporting this recommendation is of classes: C, D, R

5. Choose Treatment Plan 选择治疗计划
There are multiple treatment modalities that have been demonstrated effective in the treatment of acne. [Conclusion Grade I: See Conclusion Grading Worksheet A- Annotation #5 (Choose Treatment Plan) in the original guideline document.]
许多治疗模式都显示对痤疮有效。
Resistance to antibiotics is rising but does not appear to decrease effectiveness of treatment. [Conclusion Grade II: See Conclusion Grading Worksheet B -- Annotation #5 (Resistance to Antibiotics) in the original guideline document.]
虽然抗生素耐药不断增加但是治疗的有效性并未下降
When initiating treatment it is important to consider the goals of therapy. Treatment goals should include:
当开始治疗前确定治疗目标是重要的，治疗目标包括：
• Achieving clearance of acne 清除痤疮
• Prevention of scarring 防止瘢痕形成
• Learning to cope with psychological stress resulting from the acne 学会正确处理痤疮所带来的精神社会压力

Considerations:考虑如下问题
• Patient skin type (oily to dry) 患者的皮肤类型（油性或干性）
• for very oily skin consider a gel or solution
• 对严重的油性皮肤选择凝胶或溶液
• for very dry skin choose creams or lotions
• 对严重的干性皮肤选择霜剂或洗剂
• If more than one topical is being used (for example a retinoid and a topical antibiotic), have patient apply one in the morning and the other at night. 如果局部用药在一种以上（比如维A酸和局部抗生素联合），则患者应在早晚分别使用其中一种，以错开时间。
• If multiple agents are used, they should be from different classes. For example, a benzoyl peroxide and a topical antibiotic. 如果所用药剂不止一种，则它们应是属于不同类别的药物。比如过氧化苯甲酰和局部抗生素制剂。
• Customize treatment to enhance adherence. For example, can the patient reach their back to apply the product? Importance of avoiding food, especially dairy products, one hour before or two hours after taking tetracycline. 个体化治疗以提高依从性。比如：患者可否够得着背部以使用药剂？以及食物禁忌的重要性，特别是在服用四环素前一个小时或是服用后两小时后食用奶制品。

Relative Cost Value相对的花费
Costs for treatment modalities may vary significantly and should be considered in treatment selection. Refer to the original guideline document for cost ranges and key for a 30-day supply.使用30天所需的花费
$ = $1.00 - $20.99
$$ = $21.00 - $40.99
$$$ = $41.00 - $60.99
$$$$ = $61.00 - $99.99
$$$$$ = $100.00+

• Topical Treatment of Acne 痤疮的局部治疗
An example of treatment for mild acne may include benzoyl peroxide, a topical antibiotic, or a combination product one to two times daily; or a topical retinoid once daily in addition to the above. See tables in this annotation in the original guideline document for description of medications.
轻度的痤疮可以使用包括过氧化苯甲酰、局部抗生素或二者的复方制剂，1-2次/天；或者在上述药物基础上加用维A酸类，1次/天。
Over-the-counter Topical Products局部非处方产品
A wide variety of over-the-counter (OTC) topical products are available to the patient for self-treatment of acne. A complete listing is beyond the scope of this publication. The most common ingredient in OTC products is benzoyl peroxide in concentrations up to 10%. (Many of the expensive acne systems advertised contain benzoyl peroxide and offer no advantages over commercial products.) Salicylic acid in concentrations of 0.5% to 2% is a keratolytic found in many OTC acne products. Products may also contain glycolic acid (an alpha-hydroxy acid), sulfur, or resorcinol. When evaluating a new patient it is helpful to know which products they may have tried.
有大量的非处方局部痤疮用药供患者选用。这些商品中最普遍的成分是浓度为10％以上的过氧化苯甲酰（许多昂贵的痤疮广告产品包含过氧化苯甲酰，但并不比一般的痤疮商品来得有效）。许多非处方产品还包含0.5％-2%的水杨酸，还可能包含羟基乙酸（一种α羟酸），硫磺或者间苯二酚。当评估一个新病人时，清楚的知道何种商品他们已经试用过是有所帮助的。

Benzoyl Peroxide过氧化苯甲酰 $$(普通) $$$（品牌）
Benzoyl peroxide is available without a prescription in products such as Clearasil® and by prescription in the products listed in the original guideline document. It is also available in combination with antibiotics (see "Topical Antibiotics" table in the original guideline document).

Topical Retinoids for Acne局部的维A酸类 $$$-$$$$$
Topical retinoids (see "Topical Retinoids" table in the original guideline document) increase the turnover of follicular epithelial cells促进滤泡上皮细胞的更新, promote drainage of comedones加快粉刺排出, and inhibit new comedone (blackhead, whitehead) formation阻止粉刺形成. Topical retinoids are generally applied in the evening局部的维A酸一般在夜间使用.

Azelaic Acid 壬二酸 $$$
Azelaic acid is a naturally occurring dicarboxylic acid二羟酸which has been shown to be effective in reducing both inflammatory and non-inflammatory acne lesions 对减少炎性及非炎性痤疮均有效(see "Azelaic Acid" table in the original guideline document.)

Topical Antibiotics for Acne局部用抗生素 $$-$$$$
Propionibacterium acnes 短小棒状杆菌(P. acnes) is an anaerobic bacterium厌氧菌 present within the pilosebaceous 毛[囊]皮脂腺follicles. It is thought that this microorganism plays a role in acne-associated inflammation. The antibiotics used to treat acne have been shown to reduce colonization of P. acnes and may also possess direct anti-inflammatory effects抗生素抑制短小棒状杆菌繁殖并有直接的抗炎效应. In-vitro resistance of P. acnes to commonly used antibiotics has been increasing but the clinical significance of this is uncertain.由于抗生素滥用体外的短小棒状杆耐药性增加但临床意义尚不明确However, it has been recommended that antibiotics be used with either topical retinoids or benzoyl peroxide不管如何，仍然推荐局部联合使用抗生素与过氧化苯甲酰或维A酸类制剂. (See "Single Drug Products" and "Combination Products" tables in the original guideline document.)

• Topical Treatment and Oral Antibiotics for Acne 局部治疗和口服抗生素 $-$$$$
An example for moderate/severe acne may include examples listed in section 5a of the original guideline document with the addition of an oral antibiotic while continuing with the topical treatment. (See "First Line Antibiotics" and "Second Line Antibiotics" tables in the original guideline document for descriptions of products.)
Antibiotics such as azithromycin and others are being used in acne but studies are preliminary and concrete recommendations regarding their use cannot be made at this time.
Evidence supporting this recommendation is of classes: A, C, D, R

6. Patient Education 病患教育
Successful management of acne is dependent on a successful partnership between the health care team and the patient. Non-adherence is one of the biggest causes of treatment failure. Clear guidelines regarding treatment, possible adverse effects, and realistic expectations of treatment outcomes should be given to the patient to achieve the best possible outcome. Ongoing patient education, follow-up, encouragement, and maintaining a positive approach are vital. Because acne can be so devastating for many, early intervention with a proactive treatment plan may well prevent some of the long-term physical and psychosocial consequences.

Myths & Facts 传言 & 事实
An integral component of the prevention and treatment of acne is discussion of the facts and expulsion of the myths.
MYTH: Any acne medication works immediately.痤疮用药可以立即起效
FACT: It can take at least eight weeks of a prescribed treatment regimen for the patient to see any improvement. Acne may even get worse before it gets better.正规治疗的患者至少需要8周时间才能看到改善。痤疮在好转之前甚至会出现恶化。
MYTH: Acne is a result of poor hygiene.不讲卫生导致痤疮
FACT: As a result of this myth, people tend to overwash their skin, often scrubbing hard with abrasive cleansers. Cleaning the skin too often may aggravate acne and cause flare-ups. Wash face twice per day with a mild soap; pat dry, and use appropriate acne treatment. Acne is not caused by dirt or surface oil.由于这样的传言，人们倾向于过勤地清洗皮肤，经常使用磨砂清洗剂生硬地洗涤。过勤的皮肤清洗会激惹痤疮导致其突然发作。每天用温和的香皂洗脸两次就足够了，轻拭干，使用合适的痤疮治疗。痤疮并非由灰尘和体表的油引发的。
MYTH: Washing many times a day will diminish acne.一天多清洗几遍可消除痤疮。
FACT: Under normal circumstances, wash no more than two times a day with mild soap and lukewarm, not very hot or very cold, water.在正常情况下，每天用温和的香皂和温水（不烫不冷）清洗不超过两次。
MYTH: Washing with abrasive soaps, cleansing granules, astringents, vigorous scrubbing, or a buff puff will clear up acne on the face.用磨砂皂，清洁颗粒，收敛剂，用尽搓洗或抛光粉扑可以清楚颜面痤疮。
FACT: Using your fingertips or a soft wash cloth is best.用你的指腹或柔软的毛巾是最好的。
MYTH: Picking your acne will make it go away.挤掉痤疮就可以解决它
FACT: This may cause scarring. Do not pick at acne lesions.这会导致瘢痕形成，不要在痤疮皮损处挤压。
MYTH: Once acne has cleared up, it will be gone forever.一旦痤疮消除，便永远不会复发。
FACT: There is no cure for acne. If acne medication is discontinued, acne will probably flare.痤疮无法完全治愈，只要停用痤疮药物，痤疮可能复燃。
MYTH: Stress causes acne.精神压力导致痤疮。
FACT: Stress alone does not cause acne but may exacerbate psychological reaction to the acne. Acne is caused by overactive oil glands stimulated by androgens mixing with dead skin cells. This is particularly true during the teenage years when androgen production is at its highest.单独的精神压力本身并不导致痤疮，但它加重痤疮的精神社会效应。痤疮是由于雄激素刺激下的皮脂腺过度分泌混合死亡的表皮细胞而形成的。所以在雄激素最为旺盛的青春期显得特别突出。
MYTH: Eating chocolate and sugar will cause acne.食用巧克力和糖会导致痤疮。
FACT: There is no evidence to support this. Certain foods may make some patients' acne worse and obviously should be avoided. No specific food has been proven to worsen acne. No diet has been shown to be beneficial.并没有证据证明这个观点。某些食物会使一些人的痤疮加重，很明显地应该避免使用这些食物。至今尚无证据表明某种特定食物会使痤疮恶化。而节食也是无益的。
MYTH: Teenagers are the only ones affected by acne.只有青年人会得痤疮。
FACT: Acne affects adults as well as children. The body produces androgens throughout life. The circumstances around adult acne may be a little different than in teens, particularly in women. Women between 18 and 40 years may have breakouts that occur most frequently when they are premenstrual.痤疮也累及成人及儿童。人整个一生身体都在分泌雄激素。但是体内环境不同使得成人的痤疮与青年人有点区别，特别在妇女。18-40岁的妇女经常在月经前出现皮疹。
Evidence supporting this recommendation is of class: R

Home Care Recommendations 家庭护理推荐
• Topical medications should be applied to dry skin. 应在干燥的皮肤上使用局部药物。
• Try to avoid abrasive soaps, cleansing granules, astringents, and vigorous scrubbing. 避免使用磨砂皂，清洁颗粒，收敛剂及用尽搓洗。
• Under normal circumstances, wash no more than two times a day with your fingertips or a soft wash cloth. 在正常情况下，每天使用你的指腹或软毛巾洗脸，且不要超过两次。
• Patients who are treated with acne medications often develop dry skin. Use fragrance-free, non-comedogenic, oil-free moisturizers. These moisturizers will not clog pores and therefore should not cause black- or whiteheads. 使用痤疮治疗药物会使得皮肤变得干燥。则可以使用无芳香剂、不致粉刺的非油性滋润剂。这种滋润剂不会堵塞毛孔导致白头或黑头。
• For patients who choose to use makeup to cover their acne lesions, a water-based, non-comedogenic makeup should be used. Avoid oil-based cosmetics. Use makeup sparingly. 如果你想用化妆品覆盖在痤疮皮损以遮暇，则选用水基的、不致粉刺的化妆品。避免使用油基化妆品。且应尽可能少用化妆品。
• Do not cover acne with bandages or tight fitting clothing.不要使用绷带或胶贴覆盖与痤疮表面。
• If a topical retinoid or photosensitizing antibiotics are prescribed, recommend staying out of the sun as much as possible and stress the use of sunscreens.如果你正在使用局部的维A酸类药物或光敏性抗生素，则尽可能地远离阳光，并强调使用遮光用具。
Evidence supporting this recommendation is of class: R

7. Follow-Up 6-12 Weeks/Satisfactory Response? 6-12周的随访/是否满意？
There is no clear evidence to support a specific duration of any treatment for acne. However, clinical experience and clinical trials suggest that a minimum treatment period of 6 to 12 weeks is needed before an improvement will be noted in most patients.

8. Assess Outcome and Adherence 评估疗效和依从性
Asking non-threatening, open-ended questions during patient interviews can be a useful method of assessing medication adherence. The interview should include probes for factors that contribute to non-adherence including adverse reactions, misunderstandings of asymptomatic or chronic disease treatment, depression, cognitive impairment, complex dosing regimens, and financial constraints.
A. Assess the patient's knowledge of his/her medication and medical condition.
B. Assess the patient's medication administration process.
C. Assess the patient's barriers to adherence.
To view sample assessment questions, refer to the original guideline document.
Evidence supporting this recommendation is of class: R

9. Modify Treatment Plan （疗效不佳）改变治疗计划
Consider Different/Additional Medications 考虑不同的药物或加用药物
It may be necessary to switch to a different class of topical acne medication. For example: if the patient is on a benzoyl peroxide product or a combination product and is not responding, consider switching to a once daily topical retinoid and a once daily topical anti-infective. For moderate to severe acne, consider adding an oral antibiotic or switching the current oral antibiotic. Selection is based on patient specific factors.
Consider Adjunctive Therapy 考虑辅助治疗
• Oral contraceptives 口服避孕药
The addition of combination oral contraceptives has been shown to be effective in the treatment of acne. [Conclusion Grade I: See Conclusion Grading Worksheet C - Annotation #9 (Oral Contraceptives) in the original guideline document.]
Treatment with a combined oral contraceptive (estrogen and progestin) is an alternative for women who fail conventional acne therapies. Oral contraceptives are effective for the treatment of acne due to their androgen modulating 雄激素调节properties. It is the estrogen component of combined oral contraceptives that reduces androgen production and decreases the amount of free and active testosterone by increasing the production of sex hormone binding globulin. Progestin-only oral contraceptives are not effective and may worsen acne. Responses may not be seen for 3 to 6 months, with some patients showing a flare of symptoms during early cycles. Although some progestins have exhibited androgenic properties during in vitro and animal studies, all combination oral contraceptives have antiandrogenic properties due to the estrogen component. To ensure adherence with therapy, the ideal product is one that has the lowest incidence of adverse effects for a particular patient. Products with Food and Drug Administration (FDA) indications for acne include Estrostep® and Ortho Tri-cyclen®.
• Spironolactone 螺内酯,安体舒通
Spironolactone is a medication primarily used in the treatment of hypertension. Due to its antiandrogenic effect抗雄激素效应, it has occasionally been used to treat adult-onset acne in women when other treatments have been ineffective. It is the effects of testosterone that are felt to be a contributing factor to the development of acne in adult females. The drug acts by blocking the effects of testosterone on the oil glands and hair follicles of the female patient. The result is a reduction in oil production that may lead to improvement of their acne. The optimal dosage varies, but ranges from 50 to 200 mg daily. Response may take two to three months*. The drug should not be used in pregnancy. Women of child-bearing age should use birth control methods while taking the medication. Side effects are rare, usually related to menstrual irregularity, mild gastrointestinal (GI) upset, or headache. The medication may be taken for one to two years with periodic rest periods.
*Spironolactone can cause decreased sodium and increased potassium. Levels should be initially measured and carefully monitored at appropriate intervals.
• Oral Retinoids 口服维A 酸制剂
Isotretinoin is the only oral retinoid approved for use in acne and is a well established teratogen. Although causality has not been determined for depression and suicide, this is an ongoing concern. In view of these factors its use is highly regulated by the FDA.
Only providers registered with the iPLEDGE program may prescribe Isotretinoin. For information about this program conduct an internet search using: iPLEDGE program. This program is scheduled to start March 1, 2006 and replaces the existing System to Manage Accutane Related Teratogenicity (S.M.A.R.T.) program.
• Intra-lesional injections 皮损内注射
There are rare circumstances in which you may consider injecting large acne cysts大的痤疮囊肿 with a corticosteroid糖皮质激素 for short term cosmetic improvement. Each injection carries a risk of causing skin atrophy有导致皮肤萎缩的风险. Repeated injections are not recommended不推荐反复注射. The concentration of Triamcinolone varies from 2 to 10 mg/cc. The stock 10-, 25- or 40- mg/mL steroid suspension should be diluted with lidocaine and only enough injected through a 1-mL syringe with a 27- or 30- gauge needle to distend the cyst slightly (usually 0.025 mL to 0.1 mL).
• Light Therapy 光疗
There continue to be numerous studies about light treatment for acne, including blue light蓝光 and photodynamic therapy光动力疗法 with and without pretreatment with topical medications. At this time, the evidence is inadequate to make a recommendation about the efficacy and safety of these treatments.

Consider Dermatology Referral 考虑皮肤科专家的意见
Dermatologists treat all forms of acne, particularly severe cases. For those patients with severe inflammatory acne that has not improved with previously described medications, a retinoid, isotretinoin (Accutane), may be considered. Dermatologists may be helpful to guide you in any point of the algorithm.
Evidence supporting this recommendation is of class: A, R
For most current information regarding Isotretinoin:
http://www.fda.gov/cder/drug/infopage/accutane/default.htm

10. Maintenance维持治疗
If stable on current topicals, continue treatment indefinitely.局部用药病情稳定则坚持不间断维持治疗。
If stable on topical and systemic antibiotics, after clearance is achieved for 1 to 3 months consider tapering oral antibiotics and continue topicals indefinitely.如果局部用药加用口服抗生素则在痤疮消除后1-3个月逐步停用口服抗生素，但坚持不间断的局部用药。

Definitions:
Conclusion Grades:
Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of any significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.
Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.
Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusions because of inconsistencies among the results from different studies or because of serious doubts about generalizability, bias, research design flaws, or inadequacy of sample sizes. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.
Grade Not Assignable: There is no evidence that directly supports or refutes the conclusion.
Classes of Research Reports:
A. Primary Reports of New Data Collection:
Class A:
• Randomized, controlled trial
Class B:
• Cohort study
Class C:
• Non-randomized trial with concurrent or historical controls
• Case-control study
• Study of sensitivity and specificity of a diagnostic test
• Population-based descriptive study
Class D:
• Cross-sectional study
• Case series
• Case report
B. Reports that Synthesize or Reflect upon Collections of Primary Reports
Class M:
• Meta-analysis
• Systematic review
• Decision analysis
• Cost-effectiveness analysis
Class R:
• Consensus statement
• Consensus report
• Narrative review
Class X:
• Medical opinion