BlueCross and BlueShield of Montana Medical Policy/Codes
Acne Management
Chapter: Therapies
Current Effective Date: October 25, 2013
Original Effective Date: September 01, 2007
Publish Date: October 25, 2013
Revised Dates: March 1, 2010; July 12, 2013
Description

Acne is an inflammatory disease of the skin caused by changes in the pilosebaceous units (skin structures consisting of a hair follicle and its associated sebaceous gland).  The most common form of acne is known as “acne vulgaris”, which means common acne.  Excessive secretion of oils from the glands combine with naturally occurring dead skin cells to block the hair follicles.  Oil secretions build up beneath the blocked pore, providing a perfect environment for the skin bacteria Propionibacterium acnes (P. acnes) to multiply uncontrolled.  In response, the skin inflames, producing the visible lesion.  The face, chest, back, shoulders and upper arms are especially affected.

The typical acne lesions are comedones, papules, pustules and cysts.  More inflamed rashes take the form of pus-filled or reddish bumps, even boil-like tender swellings.  After resolution of the lesions, prominent unsightly scars may remain.

Acne affects a large percentage of humans at some stage in life and usually appears during adolescence, when people already tend to be most socially insecure.  The condition is common in puberty as a result of an abnormal response to normal levels of the male hormone testosterone.  The response for most people diminishes over time and acne tends to disappear, or at least decrease, after thirty.  There is, however, no way to predict how long it will take for it to disappear entirely, and some individuals will continue to suffer from acne decades later, into their thirties and forties and even beyond.  Aside from scarring, its main effects are psychological, such as reduced self-esteem and depression.

It is unknown as to why some people get acne and others do not.  It is known to be partly hereditary.  Several factors are known to be linked to acne:

  • Stress;
  • Hormonal activity;
  • Hyperactive sebaceous glands;
  • Accumulation of dead skin cells;
  • Bacteria in the pores;
  • Skin irritation or scratching of any sort;
  • Anabolic steroids;
  • Any medications containing halogens (iodides, chlorides, bromides), lithium, barbiturates, or androgens;
  • Exposure to high levels of chlorine compounds, particularly chlorinated dioxins, can cause severe, long lasting acne, known as chloracne.

Types of Acne

Acne Vulgaris is the most common type of acne, 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.

Acne Conglobata (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.

Acne Fulminans (AF), also known as acne maligna, was originally described as acute febrile ulcerative acne conglobata (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.

Acneiform eruptions may consist of comedones, papulopustules, cysts, or nodules that resemble acne vulgaris.  Occasionally, this may lead to their initial misdiagnoses.  Acne like disorders occur from a wide variety of diseases, including infections, growth anomalies, 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.

Eosinophilic Pustular Folliculitis (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 and in 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).

Policy

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 exclusion 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.

Coverage

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.

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 unproven:

  • Cryoslush therapy (solid CO² mixed with acetone);
  • 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®).

Rationale

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. The guidelines state: "There is very little evidence from clinical trials published in the peer-reviewed literature supporting the efficacy of peeling regimens.  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. made the statement that the role of microdermabrasion in the treatment of dyschromias and acne vulgaris is limited.

Pulse Laser

Two recently published RCT on pulse laser for the treatment of acne (in which significant acne therapies withheld from patients for a period prior to and during the course of trials) have reported conflicting results.  Seaton and colleagues reported on a double-blind RCT of 41 adults with mild to moderate facial inflammatory acne (patients had a 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 twelve weeks, Leeds acne scores fell from 3.8 to 1.9 in the treatment group and 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 and control groups 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.”

Orringer and colleagues reported on a single-blind, split-face RCT of 40 patients (age 13 or older with a Leeds acne score of two or greater) 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 twelve 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 part 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.”   

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), 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 HP and Krautheim A comment that:  “Photodynamic therapy has not yet been proven efficacious in controlled studies,” while Harper JC states that: “Controlled clinical trials are lacking at this time.”

Ultraviolet Radiation or Laser Phototherapy

The ClearLight™ and Clear Touch™ System has been approved by the U.S. Food and Drug Administration (FDA) under the 510(k) process for the treatment of moderate, inflammatory acne vulgaris.  The FDA also approved the Smoothbeam™ for the treatment of mild to moderate inflammatory acne vulgaris in 2003. 

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.

The American Academy of Dermatology states on its web site that 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.  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, long-term effectiveness has not been proven.  Additionally, in a recent review in the Journal of the American Academy of Dermatology, the author noted that while lasers are being used in individuals with acne, clinical trials are few in number and offer no long term follow-up. 

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.

2011 Update

A search of peer reviewed literature through September 2011 identified no new publications or any additional information that would change the coverage position of this medical policy.

A study by Laheta 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 two weeks for six 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).

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 three RCTs comparing light therapy to topical treatment of acne.  The authors commented that studies of light therapy tended to be small (all had fewer than 50 participants), were of short duration and of variable quality, and 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 that most of the studies had suboptimal methods.  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 be 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.

Pulsed dye laser (PDL) therapy is designed to destroy small blood vessels under the first layer of skin without affecting surrounding tissue and, is typically used to treat vascular lesions.  PDL has been investigated for the mild-to-moderate treatment of acne.   Several small RCTs with small patient populations and short-term follow-up have assessed the safety and effectiveness of PDL for this indication.

In a small RCT (n=45) in 2009 that compared the outcomes of three groups of patients whose acne vulgaris was treated with PDL, topical preparations or chemical peels.  After 12 weeks of treatment there was a significant improvement of the lesions within each group.  However, there were no significant differences detected between the three treatment protocols after the treatment period.  Remission in the follow-up period was found to be higher in the PDL.

Sami et al. conducted a small RCT comparing the effectiveness of PDL, intense pulse laser (IPL), and light-emitting diode (LED) phototherapy for the treatment of moderate to severe acne vulgaris.  Patients treated with the PDL reached a > or = 90% clearance of their inflammatory lesions after a mean of 4.1 +/- 1.39 sessions, while patients treated with IPL required a mean of

6 +/- 2.05 sessions.  Patients treated with the LED required a mean of 10 +/- 3.34 sessions.  At the mid-point evaluation, the percent reduction in acne lesions treated with the PDL was 90% or more, in cases of IPL and the LED, the percent reductions were 41.7% and 35.3%, respectively.  Laser and light phototherapy sessions were well tolerated with minimal adverse events experienced as being mild and usually self-limiting. 

PDT is characterized by the use of visible light in conjunction with topical application of a photosensitizer (i.e., 5-aminolevulinic acid (ALA) or methyl aminolaevulinate [MAL]) that is intended to amplify the response to light therapy.  Studies including case series and RCTs (n=10–44) have reported a 60%─80% improvement of acne lesions after treatment with ALA-PDT.

Ingram et.al. summarized clinical findings gathered by systematic review from RCTs (n=62 studies), systematic reviews (n=3) and a single guideline, all on the management of acne vulgaris.  It was found that “PDT, phototherapy and laser therapy cannot be recommended universally for acne until minimal post-inflammatory pigmentation and longer-term benefit can be shown”.

At this time, the published, peer-reviewed scientific literature contains insufficient supportive evidence for the use of PDT in the treatment of acne vulgaris.

Modern acne therapy uses anti-comedogenic, anti-microbial, anti-inflammatory, and anti-androgenic substances.  In recent years, treatments have been developed based on the application of electromagnetic radiation.  Visible light or infrared wave lengths are utilized by most techniques, including blue light lamps, intense pulsed light (IPL), PDT and lasers.  These methods were assessed in regard to their efficacy and current role in management of acne. 

Ultraviolet radiation was frequently used in the past to treat acne; it is now regarded as obsolete due to the unfavorable risk-benefit ratio.  Visible light, especially of blue wavelengths, appears to be suitable for the treatment of mild-to-moderate inflammatory acne.  Photodynamic therapy is effective, but, due to considerable side effects, it is usually reserved only for selected situations.   IPL and lasers, despite promising observations need to be evaluated in further studies, before they can be recommended.

IPL devices use flashlamps and bandpass filters to emit polychromatic incoherent high-intensity pulsed light of determined wavelength spectrum, fluence, and pulse duration.  Similar to lasers, the basic principle of IPL devices is a more or less selective thermal damage of the target.  The combination of prescribed wavelengths, fluences, pulse durations, and pulse intervals facilitates the treatment of a wide spectrum of skin conditions.  A systematic search IPL on several electronic databases, including Medline and PubMed was carried out.  The conclusion was that most comparative trials believe IPLs similar in effectiveness to lasers (level of evidence: 2b to 4, depending on the indication).  However, large controlled and blinded comparative trials with an extended follow-up period are necessary.

Available studies are limited by small size, and limited follow-up.  Few of these studies have compared effectiveness of visible light to that of established treatments for acne vulgaris.  There is insufficient evidence to support the use of ultraviolet radiation or visible light for the treatment of acne vulgaris.

Although preliminary evidence suggests that laser therapy may result in improvement of acne symptoms, larger, well-designed studies with long term follow-up are needed to determine the role of this therapy in the treatment of acne vulgaris.

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.

Summary

Acne is the most common skin disorder in the United States, affecting 40 million to 50 million Americans.  Nearly 85 percent of all people have some level of acne at some point in their lives, most often on the face, chest, and back.  Acne is a chronic inflammatory dermatosis most notable for open and/or closed comedones (blackheads and whiteheads) and inflammatory lesions including papules, pustules, or nodules.  Acne typically affects those areas of the body that have the greatest number of sebaceous glands, including the face, neck, chest, upper back and upper arms.  Recognized and accepted treatments for acne include topical therapies such as antimicrobials, retinoids and systemic therapies such as antibiotics, isotretinoin and hormonal medications.  Even with the appropriate treatment, scarring and hyperpigmentation are common complications.  The goal in treating the aftermath of acne is an improvement of appearance.  Interventions such as dermabrasion, autologous fat replacement, cryotherapy or cryo-peeling are generally considered cosmetic when performed for treatment of these sequelae and are not considered appropriate for treatment.

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. 

ICD-9 Codes
86.3, 706.0, 706.09, 706.1, 706.2, 709.09, 709.2
ICD-10 Codes

L70.0 - L73.0, L90.5

Procedural Codes: 10040, 10060, 10061, 11900, 11901, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 17000, 17003, 17106, 17107, 17108, 17340, 17360, 96567, 96900, 96910, 96920, 96921, 96922, E0202, J1745, J7308, S8948
References
  1. Cunliffe, W.J., and S. Shuster:  Pathogenesis of acne. Lancet (1969 April 5) 1(7597):685-7
  2. Leyden, J.J., Mills, O.H., et al.  Cryoprobe treatment of acne conglobata.  British Journal of Dermatology (1974 March) 90(3):335-41.
  3. Cunliffe, W.J, Holland, K.T.  The effect of benzoyl peroxide on acne. Acta dermato-venereologica (1981) 61(3):267.
  4. Heydenreich G: Testosterone and anabolic steroids and acne fulminans. Archives of Dermatology (1989 April) 125(4):571-2.
  5. Bottomley, W.W., Cunliffe, W.J.  Oral trimethoprim as a third-line antibiotic in the management of acne vulgaris.  Dermatology (1993) 187(3):193-6.
  6. Eady, E.A., Jones, C.E., et al: Tetracycline-resistant propionibacteria from acne patients are cross- resistant to doxycycline, but sensitive to minocycline.  British Journal of Dermatology (1993 May) 128(5):556-60.
  7. Layton, A.M., Yip, J., et al.  A comparison of intralesional triamcinolone and cryosurgery in the treatment of acne keloids.  British Journal of Dermatology (1994 April) 130(4):498-501.
  8. Fitzpatrick, R.E., Goldman, M.P., et al.  Clinical advantage of the CO² laser superpulsed mode.  Treatment of verruca vulgaris, seborrheic keratoses, lentigines, and actinic cheilitis.  Journal of Dermatologic Surgery and Oncology (1994 July) 20(7):449-56.
  9. Jeong, S., Lee, C.W:  Acne conglobata: treatment with isotretinoin, colchicine, and cyclosporin as compared with surgical intervention. Clinical and Experimental Dermatology (1996 November) 21(6):462-3.
  10. Doshi, A., Zaheer, A., et al.  A comparison of current acne grading systems and proposal of a novel system.  Int. J. Dermatol. 36, 416-418 (1997).
  11. O'Brien, S.C., Lewis, J.B., et al. The Leeds revised acne grading system. J. Dermatolog. (1998) Treat. 9: 215-220.
  12. Fulton, J.E., Fulton, J.E. Jr.  Complications of laser resurfacing.  Methods of prevention and management. Dermatologic Surgery (1998 January) 24(1):91-9.
  13. Fulton, J.E., Silverton, K., et al.  Resurfacing the acne-scarred face.  Dermatologic Surgery (1999 May) 25(5):353-9.
  14. Fernandez-Obregon AC: Azithromycin for the treatment of acne.  International Journal of Dermatology (2000 January) 39(1):45-50.
  15. Rattana-Apiromyakij, N., and P.Kullavanijaya.  Eosinophilic pustular folliculitis: report of seven cases in Thailand.  Journal of Dermatology (2000 March) 27(3):195-203
  16. Yeon, H.B., Lindor, N.M., et al.  Pyogenic arthritis, pyoderma gangrenosum, and acne syndrome maps to chromosome 15q.  American Journal of Human Genetics (2000 April) 66(4):1443-8.
  17. Cunliffe, W.J., and V. Goulden:  Phototherapy and acne vulgaris. British Journal of Dermatology (2000 May) 142(5):855-6.
  18. Papageorgiou, P., Katsambas, A., et al.  Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. British Journal of Dermatology (2000 May) 142(5):973-8.
  19. Cunliffe, W.J., Holland, D.B., et al.  Comedogenesis: some new aetiological, clinical and therapeutic strategies. British Journal of Dermatology (2000 June) 142(6):1084-9.1
  20. Jick, S.S., Kremers, H.M., et al.  Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide. Archives of Dermatology (2000 Oct) 136(10):1231-6.
  21. Fung, M.A., Berger, T.G., A prospective study of acute-onset steroid acne associated with administration of intravenous corticosteroids. Dermatology (2000) 200(1):43-4.
  22. Kalbarczyk K, Ciupinska M: Complications during treatment with Roaccutane, acne fulminans 2001. Dermatology Klinics (Wroclaw) (2001) 3 (Supplement 1):130.
  23. Leybishkis, B., Fasseas, P., et al.   Hidradenitis suppurativa and acne conglobata associated with spondyloarthropathy.  American Journal of Medical Science (2001 March) 321(3):195-7.
  24. Roldan, J.C., Terheyden, H., et al: Acne with chronic recurrent multifocal osteomyelitis involving the mandible as part of the SAPHO syndrome: case report.  British Journal of Oral and Maxillofacial Surgery (2001 April) 39(2):141-4.
  25. Center for Medicare and Medicaid Services.  Cryotherapy for Acne.  Region VII, Midwest. Kansas. (2001 December 1):LMRP L2717.  
  26. Lloyd, J.R.  The use of microdermabrasion for acne.  Dermatologic Surgery (2001 Apr) 27(4):329-31.
  27. Jacobs, D.G., Deutsch, N.L., et al: Suicide, depression, and isotretinoin: is there a causal link? Journal of the American Academy of Dermatology (2001 Nov) 45(5):S168-75.
  28. Paithankar, D.Y., Ross, E.V., et al.  Acne treatment with 1,450 nm wavelength laser and cryogen spray cooling.  Lasers in Surgery and Medicine (2002) 31(2):106-14.
  29. eMedicine.com – Revis, Don R., Jr.  Seagel, M.B.  Skin resurfacing: Dermabrasion.  June 29 2002.  eMedicine (9 September 2005) http://www.emedicine.com .
  30. Kogan BG, Stepanenko VI, Gorgol VT: Substantiation of a rational system of examination algorithms and standards of comprehensive treatment of patients with rosacea, demodecosis and perioral dermatitis. Ukrainian Journal of Dermatology and Venereol (2003) 2(9):17-27.
  31. Tuchin, V.V., Genina, E.A., et al.  A pilot study of ICG laser therapy of acne vulgaris: photodynamic and photothermolysis treatment.  Lasers in Surgery and Medicine (2003) 33(5):296-310.
  32. Gollnick, M.P., Krautheim, A.  Topical treatment in acne: current status and future aspects.  Dermatology (2003 January) 206(1):29-36.
  33. Birnkrant, M.J., Papadopoulos, A.J., et al.  Pyoderma gangrenosum, acne conglobata, and IgA gammopathy.  International Journal of Dermatology (2003 March) 42(3):213-6.
  34. Seaton, E.D., Charakida, A., et al.  Pulsed-dye laser treatment for inflammatory acne vulgaris: randomized controlled trial.  Lancet (2003 October 25) 362(9393):1347-52.
  35. Taub AF. Photodynamic therapy for the treatment of acne: a pilot study. J Drugs Dermatol. (2004 Nov-Dec; 3(6 Suppl):S10-4.
  36. Goldman, M.P., and S.M. Boyce.  A single-center study of aminolevulinic acid and 417 NM photodynamic therapy in the treatment of moderate to severe acne vulgaris. J Drugs Dermatol. (2003 August) 2(4):393-6.
  37. Charakida, A., Seaton, E.D., et al.  Phototherapy in the treatment of acne vulgaris:  what is its role?  American Journal of Clinical Dermatology (2004) 5(4):211-6.
  38. Witkowski, J.A., and L.C. Parish.  The assessment of acne: an evaluation of grading and lesion counting in the measurement of acne. Clin. Dermatol. (2004) 22, 394-397.
  39. 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.
  40. 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.
  41. Choi, M.J., Kim, J.W., et al.  Solitary premature sebaceous hyperplasia associated with acneiform eruption.  Acta Dermato Venereologica (2004) 84(6):483-4.
  42. Lee, S., Park, S.G., et al.  Chloracne with acantholytic dyskeratosis associated with herbicides: A new histological variant? Journal of the American Academy of Dermatology (2004 April) 50(4):E8.
  43. Ena, P., Zanetti, S., et al.   Mycobacterium chelonae I infection mimicking acne conglobata in an immunocompetent host.  Clinical and Experimental Dermatology (2004 July) 29(4):423-5.
  44. Smolinsski, K.N., Yan, A.C.  Acne Vulgaris/ET/TH.  Current Opinion in Pediatrics (2004 August) 16(4):385-91.
  45. Pollock, B., Turner, D., et al.  Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action. Br J Dermatol. (2004 September) 151(3):616-22.
  46. Iqbal, M., Kolodney, M.S.  Acne fulminans with synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome treated with Infliximab.  Journal of the American Academy of Dermatology. (2005)  52(5 Supplement 1):S118-20.
  47. eMedicine.com – Harper, J.C., Fulton, J., et al.  Acne Vulgaris.  July 29, 2004. eMedicine Article (9 September 2005) http://www.emedicinecom .
  48. Santos, M.A., Belo, V.G., et al.  Effectiveness of photodynamic therapy with topical 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: comparative study. Dermatol Surg. (2005 August) 31(8 Pt 1):910-5
  49. eMedicine.com – Schwartz, R.A., Richard, Z.  Acne Conglobata. March 9, 2005. eMedicine Article.  (September 9, 2005) http://www.emedicine.com .
  50. Iqbal, M., Kolodney, M.S.  Acne Fulminans with synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome treated with Infliximab.  Journal of the American Academy of Dermatology (2005 May) 52(5 Supplement 1):S118-20.
  51. eMedicine.com – Ryszard, Z., Schwartz, R.A.  Acne Fulminans. May 24, 2005. eMedicine Article. (9 September 2005) www.emedicine.com .
  52. eMedicine.com – Kuflik, J.H., Schwartz, R.A.  Acneiform Eruptions.  August 23, 2005. eMedicine.com. (9 September 2005) www.emedicine.com .
  53. Shirakawa, M., Uramoto, K., et al.  Treatment of acne conglobata with Infliximab. Journal of the American Academy of Dermatology (2006 August) 55(2):344-6.
  54. Wiegell, S.R., and H.C. Wulf. Photodynamic therapy of acne vulgaris using methyl aminolaevulinate: a blinded, randomized, controlled trial. Br J Dermatol. (2006 May) 154(5):969-76.
  55. Horfelt, C., Funk, J. et al. Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study.  Br J Dermatol. (2006 September) 155(3):608-13.
  56. Thiboutot, D.M., Weiss, J., et al.  Adapalene-benzoyl peroxide, a fixed-dose combination for the treatment of acne vulgaris:  results of a multicenter, randomized double-blind, controlled study. 
  57. Journal of the American Academy of Dermatology (2007 November) 57(5):791-9.
  58. 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.
  59. 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.
  60. Ansarin, H., Savabynasab, S., et al.  Doxycycline plus levamisole: combination treatment for severe nodulocystic acne.  Journal of Drugs and Dermatology (2008 August) 7(8):737-40.
  61. 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.
  62. Tan, J.K.L.  Current measures for the evaluation of acne severity: Methods for grading acne. Expert Review of Dermatology (2008) 3(5):595-603.  
  63. 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.
  64. 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.
  65. Degitz, K.  Phototherapy, photodynamic therapy and lasers in the treatment of acne. J Dtsch Dermatol Ges. (2009 December) 7(12): 1048-54.
  66. Bissonnette, R., Maari, C., et al.  Photodynamic therapy with methylaminolevulinate 80 mg/g without occlusion improves acne vulgaris. J Drugs Dermatol. (2010 November) 9(11):1347-52.
  67. Karimipour, D.J., Karimipour, G., et al.  Microdermabrasion: An evidence-based review. Plast Reconstr Surg. (2010)125(1):372-377.
  68. 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.
  69. Babilas, P., Schreml, S., et al.  Intense pulsed light (IPL): A review. Lasers Surg Med. (2010) 42(2):93-104.
  70. 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.
History
July 2013  Policy formatting and language revised.  Policy statement revised to specify the treatment of active nodulocystic acne.  Title changed from "Laser Treatment of Active Acne" to "Acne Management".   
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Acne Management