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Acne

 

Introduction

Acne severity varies along a continuum1:

  • Mild to moderate acne
    • any number of comedones
    • up to 34 inflammatory lesions (papules/pustules)
    • up to two nodules
  • Moderate to severe acne
    • 35 or more inflammatory lesions
    • OR three or more nodules

 

In Scope           

  • Acne

 

Not in Scope           

  • Other dermatology conditions

 

Red Flags         

 

Primary Care Management

1.Lifestyle advice

  • Use non-alkaline synthetic detergent (Syndet) twice daily 1,2 (e.g. OTC Dove moisturising bar, Cetaphil gentle cleansing bar, Avène Eau thermal, Aveeno moisturising bar, La Roche Posay: Lipikar Syndet AP+)
  • Avoid oil-based comedogenic preparations
  • Advise those that wear make up to avoid oil based and remove it at the end of the day
  • Advise that persistent picking or scratching can increase risk of scarring
  • Not enough evidence to support specific diets

 

2.Medical Treatment

  • Use for 3-4 months minimum - Treatments can take up to 8 weeks before they start working and should be reviewed at 12 weeks.
  • If failure to one topical agent consider trying a different agent/different class.
  • Warn patients regarding possible irritation to the skin on using topical treatments. Consider recommending gradually increasing the frequency of treatment, for example once or twice a week initially, leading to daily use if tolerated.

 

  • Mild acne:
    • Benzoyl Peroxide (mild forms available over the counter)
    • Retinoid = Adapalene (E.G. Differin®)

 

 

  • Moderate/severe acne:
    • Any of the topical treatments above for mild/moderate acne PLUS oral antibiotics as below:
      • Review after 12 weeks and consider switching or discontinuing if no response.
      • Oral Lymecycline (408mg OD) OR Doxycycline100mg OD
      • 2nd line oral antibiotic (Or 1st line if pregnant/under 12 years):  Oral Erythromycin 500mg bd/Clarithromycin 250mg BD 

 

Do not prescribe the following to treat acne1: Monotherapy with a topical antibiotic, or monotherapy with an oral antibiotic, or a combination of a topical antibiotic and an oral antibiotic.

Do not prescribe Minocyline – Its use can make acne resistant to other treatments and is associated with an increased risk of adverse effects such as drug induced lupus, skin pigmentation and hepatitis.

 

3.Combined contraceptive pill (females) if safe to prescribe:

 

** Cyproterone acetate (Dianette®) – Only licensed for severe acne/hirsuitism3. This pill has increased risk of VTE (similar to third generation COCP containing desogestrel, gestodene, norgestimate) and there is no clear evidence this is better than other COCPs with lower risk. It should only be used where other COCPs have failed and use should be discontinued 3 months after acne has been controlled1.

 

4.Pregnancy/Breastfeeding

  • Avoid topical retinoids and tetracyclines in pregnancy or breastfeeding. Make women of childbearing age aware of risks and to use effective contraception. In the event of pregnancy, these treatments should be discontinued.
  • Mild/moderate acne: topical benzoyl peroxide, azelaic acid, glycolic acid
  • Severe acne:  Topical antibiotics (erythromycin/clindamycin) or oral erythromycin

 

5.Under 12s

  • Treatment generally same as adults except avoid tetracyclines6
  • If acne aged 1-6 years – consider referral to endocrinologist (to exclude hyperandrogenism)
  • If skin very sensitive can use lower dose Benzoyl peroxide E.G 2.5%

 

Advice and Guidance

Available via e-RS

 

Investigations prior to referral

  • Bloods: FBC, U&E, LFTs, fasting lipids

 

Referral Criteria

·Same day referral to Dermatology:

 

·Urgent referral:

 

·Routine referral

  • Mild/moderate acne not responded to 2 courses (4-6 months) of treatment (tetracyclines should be tried in addition to a topical retinoid).
    • A COCP should also have been trialled in females (if no contraindications).
    • Consider earlier referral if extreme psychological distress.
  • Moderate/severe acne not responded to 1 course of treatment (at least 3-6 months oral antibiotic plus topical treatment)
  • Acne that is leading to scarring
  • Acne with persistent pigmentary changes

 

Referral Instructions

Please include in referral letter:

  • previous treatment and duration
  • presence/absence of scarring
  • in females details of contraception
  • request bloods prior to referral (FBC, U&E, LFTs, fasting lipids).

 

Supporting Information

Patient

 

Professional

 

References

 

Page Review Information

Review date           14 April 2026

Next review due      14 April 2028

GP Sifter                 Dr Kate Northridge

Contributors            Dr Alexander Anderson, Consultant Dermatologist, Royal Cornwall Hospital Trust

                              Sonya Walker, Dermatology Clinical Nurse Specialist, Royal Cornwall Hospital Trust

                              Dr Hayder Ahmed, Consultant Dermatologist Royal Cornwall Hospital Trust

                              Dr Caroline Hill, Specialty Doctor in Dermatology, Royal Cornwall Hospital Trust