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Medical > Dermatology > Acne Vulgaris


Acne Vulgaris

  

Acne vulgaris (or simply acne)

Reviewed on : 7 Mar 2019

Reviewed by : Dr Abbie Martin - GP Gateway Co-Editor

Expires : 1 Jun 2029

  • Prescribing Considerations:

• Pregnancy – limited treatment options. Avoid topical retinoids and oral tetracyclines and consider for patients of childbearing potential as effective contraception may be needed.
• Patient preference – frequency of application, potential for photosensitivity, skin irritation, bleaching of hair and fabrics etc.
• To reduce the risk of skin irritation, start topical treatments e.g. benzoyl peroxide or retinoids, with alternate day or short-contact application (e.g. wash off after an hour).
• Patients should be advised on sun protection if using oral tetracyclines and topical retinoids as both increase photosensitivity.

Initial Primary Care Management

Please see link to C&W APC guideline for management advice for Acne vulgaris: RD065-Primary Care Acne Pathway.pdf

Mild

1 or more of:
• Any number of comedones
• Up to 34 inflammatory lesions
• Up to 2 nodules

 → Offer a 12-week course of one of the following, apply once daily in the evening:

If mainly comedonal acne-

• Topical 0.1% adapalene
(Differin®)

OR
• Topical 0.005% trifarotene
(Aklief®)

 

For combination acne

Topical 0.1% or 0.3% adapalene with 2.5% benzoyl peroxide (Epiduo®)

OR
• Topical 0.025% tretinoin with 1% clindamycin (Treclin®)

OR
• Topical 3% or 5% benzoyl peroxide with 1% clindamycin (Duac®)

OR
• Topical 1% clascoterone (Winlevi®)

  • Not responded to 2 courses of treatment: offer first line alternative from moderate to severe options including an oral antibiotic for 12 weeks; refer to dermatology services if no response
↓
Moderate To Severe

• 35 or more inflammatory lesions
• 3 or more nodules
AND/OR
Acne involving chest &/or back

 → Offer a 12-week course of one of the following:

Topical 0.1% or 0.3% adapalene with 2.5% benzoyl peroxide (Epiduo®) WITH oral antibiotic

Topical 0.025% tretinoin with 1% clindamycin (Treclin®) WITH oral antibiotic

Topical azelaic acid 15% (Finacea®) or 20% (Skinoren®) WITH oral antibiotic

Topical 0.005% trifarotene (Aklief®) WITH oral antibiotic

Topical 1% clascoterone (Winlevi®) WITH oral antibiotic

Do not use monotherapy with a topical or oral antibiotic

 

Antibiotic Choices (> 12 years and over)

Oral lymecycline 408mg once daily

Oral doxycycline 100mg once daily

If tetracyclines contraindicated, consider oral erythromycin 500mg twice daily

 

If further advice needed, refer to specialist dermatology services
↓
→ Combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women.

• Co-cyprindiol or other ethinylestradiol/cyproterone acetate-containing products may be considered where other treatments have failed

Discontinue 3 months after acne has been controlled.
Maintainence →
  • Consider maintenance options if patient experiences frequent
    relapse
  • Consider:
    Topical adapalene and benzoyl
    peroxide (Epiduo®). If not tolerated, consider:
  • adapalene
  • OR azelaic acid
  • OR
    benzoyl peroxide (OTC) monotherapy
  • Review maintenance after 12 weeks
Specialist Referral Criteria

→

 Mild to moderate acne that hasn’t responded to 2 completed courses of treatment OR moderate to severe acne that hasn’t responded to previous treatment containing oral antibiotic.

• Refer to a consultant-led dermatology team or GPwER if patient presents with any of the following:

o Nodulo-cystic acne or acne conglobata acne with scarring (refer at presentation and commence treatment as below)

o Acne with persistent pigmentary changes.

o If acne (any severity) or related scarring is contributing to psychological distress or mental health disorder.

  • Consider current/history of self-harm, suicidal ideation, severe
    depressive or anxiety disorder, body dysmorphic disorder.
  • o If medication (including self-administered anabolic steroids) or a medical disorder (e.g. Polycystic Ovarian Syndrome (PCOS) likely contributing to a person’s acne

o Diagnostic difficulty (uncommon)

o Severe variant of acne e.g. acne fulminans – very rare severe inflammatory acne systemically unwell (fever, malaise and joint symptoms) urgent dermatology referral within 24hrs

If patient is referred to dermatology at initial presentation e.g. acne conglobata, nodulo-cystic acne – Commence topical adapalene and benzoyl peroxide (Epiduo) OR topical azelaic acid,
PLUS oral antibiotic

 
Skincare advice

 

 Avoid over-cleaning the skin (may cause dryness/irritation)

Use a non-alkaline synthetic detergent twice a day on acne prone skin

Avoid oil based comedogenic skin care products

Persistent picking or scratching can increase risk of scarring

Maintain a healthy diet

 

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