What is the best course of treatment for severe cystic acne that has not responded to previous treatments at in-network dermatology providers?

Administrative Denial Review: Cystic Acne Treatment at In-Network vs Out-of-Network Dermatology

The administrative denial is appropriate and should be upheld—cystic acne can be effectively treated at GHC-SCW Dermatology using standard evidence-based therapies, and there is no medical indication requiring referral to UW Dermatology. 1, 2

Evidence-Based Treatment Algorithm for Severe Cystic Acne

First-Line Treatment (Available at GHC-SCW Dermatology)

For severe cystic acne, the American Academy of Dermatology recommends initiating oral doxycycline 100 mg daily combined with a topical retinoid (adapalene 0.3% gel or tretinoin 0.1% cream/gel) and benzoyl peroxide 2.5-5% gel as first-line therapy. 1, 2

• Doxycycline should be dosed at 100 mg once daily with food 1, 3
• Topical retinoid should be applied nightly 1, 2
• Benzoyl peroxide should be applied in the morning 1, 2
• Duration of oral antibiotics must be limited to 3-4 months maximum to prevent bacterial resistance 1, 3
• Clinical improvement is expected within 1-2 weeks of treatment initiation 3

Second-Line Treatment (Available at GHC-SCW Dermatology)

If first-line therapy fails after 3-4 months, isotretinoin 0.5-1 mg/kg/day for 15-20 weeks is the definitive treatment for severe or scarring cystic acne. 1, 4, 5

• Isotretinoin dosing: 0.5-1 mg/kg/day given in two divided doses with food for 15-20 weeks 4
• Baseline monitoring requires liver function tests and lipid panel 1
• Must be dispensed in no more than 30-day supplies through iPLEDGE REMS system 4
• In randomized trials, isotretinoin achieved complete clearance in severe recalcitrant nodular acne 6, 5

Adjunctive Therapy for Individual Lesions (Available at GHC-SCW Dermatology)

For individual large, painful cystic lesions, intralesional triamcinolone acetonide 10 mg/mL (diluted to 5 or 3.3 mg/mL) can flatten nodules within 48-72 hours. 1

• This procedure can be performed in any dermatology clinic 1
• Caution is needed to avoid local atrophy, pigmentary changes, and telangiectasias 1

Why Out-of-Network Referral Is Not Medically Necessary

Standard Treatments Are Universally Available

All evidence-based treatments for cystic acne—including oral antibiotics, topical retinoids, benzoyl peroxide, isotretinoin, and intralesional corticosteroids—are standard dermatologic therapies available at any dermatology practice. 1, 2, 5

• There is no specialized equipment, procedure, or expertise unique to UW Dermatology that is required for cystic acne treatment 1, 2
• The American Academy of Dermatology guidelines do not differentiate treatment recommendations based on practice setting 1, 2

Member's Prior Treatment History

Review of the GHC chart back to 2021 shows no documented UW Dermatology visits, suggesting the member has not established care there previously. [Administrative record]

• The member states "I've seen them in the past," but this is not corroborated by medical records [Administrative record]
• If the member was previously treated at GHC Dermatology, continuity of care would be best maintained there [Administrative record]

Alternative Therapies Do Not Require Specialty Referral

Even advanced physical treatments for severe acne (photodynamic therapy, chemical peels, laser therapy) have limited evidence and are not considered standard of care requiring specialty center referral. 7, 8, 9

• A 2022 network meta-analysis found photodynamic therapy effective for moderate-to-severe acne, but this is available at many dermatology practices, not exclusively at academic centers 8
• Chemical peels and photochemical therapy showed effectiveness for mild-to-moderate acne but had high uncertainty in findings 8
• These modalities are not first-line treatments and would only be considered after failure of standard therapies 1, 2, 8

Clinical Recommendation for This Case

The member should be scheduled with GHC-SCW Dermatology for evaluation and initiation of appropriate therapy based on current disease severity. 1, 2

If Member Has Not Yet Tried First-Line Therapy:

• Initiate doxycycline 100 mg daily + topical retinoid + benzoyl peroxide 1, 3
• Reassess after 2 weeks for tolerance and early response 1
• Continue for 3-4 months maximum 1, 3

If Member Has Failed First-Line Therapy:

• Transition to isotretinoin 0.5-1 mg/kg/day for 15-20 weeks 1, 4
• Enroll in iPLEDGE REMS program 4
• Monitor liver function tests and lipid panel 1

Critical Pitfalls to Avoid:

• Never extend oral antibiotics beyond 3-4 months without transitioning to isotretinoin, as this dramatically increases resistance risk 1, 3
• Never use oral antibiotics without concurrent benzoyl peroxide, as resistance develops rapidly 1, 2
• Do not underestimate severity when scarring is present—this indicates need for aggressive treatment (isotretinoin) regardless of lesion count 1, 2

Certificate Language Supports Denial

The member's certificate explicitly states that "if a GHC-SCW Provider or GHC-SCW Clinic offers specialty medical care required by a Member, a Member shall utilize the GHC-SCW Provider or GHC-SCW Clinic." [Certificate Article VI.B.4]

• Cystic acne treatment is standard dermatologic care offered at GHC-SCW Dermatology [Certificate Article VI.B.4]
• No medical exception criteria are met that would justify out-of-network referral [Certificate Article VI.B.4]

The administrative denial should be upheld, and the member should be directed to GHC-SCW Dermatology for evidence-based treatment of cystic acne. 1, 2