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Acne Vulgaris

 

  • Mild/moderate acne = any number of comedones, up to 34 inflammatory lesions (papules/pustules), up to two nodules
     
  • Moderate/severe = either of 35 or more inflammatory lesions (with or without non-inflammatory lesions e.g. comedones)  OR three or more nodules

 

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
     
  • No evidence re specific diets

 

 

MEDICAL TREATMENT

Mild acne:

Single rx: (available OTC)

  • Retinoid = Adapalene (Differin®)
  • Benzoyl peroxide

 

Mild/moderate acne:

(Use for 3-4/12 minimum - Treatments can take up to 8 weeks before they start working and should be reviewed at 12 weeks)

Combination rx:

  • Topical Benzoyl peroxide and Clindamycin (Duac®) OD
  • Topical Adapalene and Benzoyl peroxide (Epiduo®) OD evening
  • Topical Clindamycin and Tretinoin (Treclin®) apply thinly OD evening

* Under 12yrs or unable to tolerate clindamycin - Topical Erythromcyin and BPO (Zineryt® ) (reserve for this group as increasing resistance)

 

Moderate/severe acne:

(Use for 3-4/12 minimum - Treatments can take up to 8 weeks before they start working and should be reviewed at 12 weeks)

1st line: Oral Lymecycline (408mg OD)/Doxycycline 100mg OD

2nd line (0r 1st line if pregnant/under 12 years):  Oral Erythromycin 500mg bd/Clarithromycin 250mg BD  

BOTH PLUS- topical adapalene/azelaic acid

DO NOT PRESCRIBE MINOCYCLINE – dermatology have advised its use can make acne resistant to other treatments. (Also Minocycline is not recommended for use in acne as it is associated with an increased risk of adverse effects such as drug induced lupus, skin pigmentation and hepatitis).

 

 

Combined contraceptive pill (females):

  • If no response to oral antibiotics after 3-4 months or other need for contraception consider adding COCP. 
  • Start with safer levonorgestrel-containing pills (e.g. Rigevidon/Microgynon)

 

2. If these fail after at least 3-4/12 you can trial Yasmin. Dianette** can also be trialled but see MRHA warning below regarding restricted use3.

*A Cochrane review concluded COCPs were effective in reducing acne facial lesions but there was limited evidence of efficacy of one over others5. Third generation progestins (desogestrel, gestodene, and norgestimate) or fourth generation progestins (drospirenone) are more acne friendly than the older pills but have a higher VTE risk so this must be born in mind.)

** Cyproterone acetate(Dianette®) – Only licensed for severe acne/hirsuitism3. This pill has increased risk of VTE (similar to 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.

 

PREGNANCY and BREASTFEEDING

  • Avoid topical retinoids and tetracyclines in pregnancy or breastfeeding
  • Mild/moderate acne: topical benzoyl peroxide, azelaic acid, glycolic acid
  • Severe acne:  Topical antibiotics (erythromycin/clindamycin) or oral erythromycin

 

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%

 

REFERRAL CRITERIA:

  • Same day review: Acne fulminans
  • Urgent referral: Acne congolobata or nodulo-cystic acne (see: https://dermnetnz.org/topics/nodulocystic-acne)

Consider referring:

  • 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 after 3-4 months (if no contraindications). Or refer earlier if extreme psychological distress.
  • Moderate/severe acne not responded to 1 courseof treatment

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).

 

PATIENT INFORMATION LEAFLET:

https://www.bad.org.uk/patient-information-leaflets/acne

 

 

REFERENCES:

  1. https://www.nice.org.uk/guidance/ng198
  2. https://www.guidelines.co.uk/supplements/managing-acne-well-a-summary-of-the-2021-nice-guideline/456410.article
  3.  https://www.gov.uk/drug-safety-update/cyproterone-acetate-with-ethinylestradiol-co-cyprindiol-balance-of-benefits-and-risks-remains-positive
  4.  Dawson AL and Dellavalle RP. Acne Vulgaris. BMJ 8th May 2013;346:f2634 doi:10.1136/bmj.f2634 http://www.bmj.com/content/346/bmj.f2634
  5. Arowojolu AO, Gallo MF, Lopez LM, et al. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev 2012;CD004425
  6. https://dermnetnz.org/topics/acne-in-children

 

 

Review date                 March 2022

Next review due           March 2023

Reviewing GP              Dr Madeleine Attridge