All information is correct at time of printing and is subject to change without notice. The Devon Formulary and Referral Website is not in any way liable for the accuracy of any information printed and stored by users. For the most up-to-date information, please refer to the website.
Page last updated:
21 November 2024
The following recommendations are largely based on NICE Clinical Guideline (NG198) Acne vulgaris: management (2021, last updated 2023) and NICE CKS (Last revised November 2023).
Acne is a chronic skin condition in which blockage or inflammation of the hair follicles and accompanying sebaceous glands occurs. It principally affects the face (99% of cases), back (60% of cases) and chest (15% of cases). Acne affects most adolescents and two-thirds of adults. It causes a major psychological health burden that is linked with the chronicity and severity of the disease.
NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is mild acne.
Many products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
Advice for people with acne:
If a person receiving treatment for acne wishes to use hormonal contraception, consider using the combined oral contraceptive pill in preference to the progestogen-only pill. Oral progesterone-only contraceptives or progestin implants with androgenic activity may exacerbate acne, ethinylestradiol with desogestrel, ethinylestradiol with norgestimate, or ethinylestradiol with drospirenone are generally preferred.
See section 7.3.1 Combined hormonal contraceptives (CHC)
For people with polycystic ovary syndrome and acne:
See section 13.6.2 Oral preparations for acne
There is no universally agreed grading system for acne, but it is often categorised by lesion type and severity into:
Within this guidance, treatment recommendations are based on the following descriptions use by NICE:
Mild to moderate acne includes people who have one or more of:
Moderate to severe acne includes people who have either or both of:
Treatment of acne should be commenced as early as possible to prevent scarring. Patients should be counselled that treatments are effective, but an improvement might not be seen for at least a couple of months, and products may cause irritation to the skin at the start of treatment.
To reduce the risk of skin irritation associated with topical treatments, such as benzoyl peroxide or retinoids, start with alternate-day or short-contact application (for example washing off after an hour). If tolerated, progress to using a standard application.
Stress to patients the importance of good compliance. Treatment should not be used for longer than necessary.
Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy.
Offer people with acne a 12-week course of one of the following first-line treatment options, taking account of the severity of their acne and the person's preferences, and after a discussion of the advantages and disadvantages of each option (see here):
Benzoyl peroxide plus clindamycin
Epiduo (Adapalene plus benzoyl peroxide)
Treclin (Clindamycin plus tretinoin)
Please see section: 13.6.1 Topical preparations for acne
Epiduo or Treclin (as above)
OR topical treatment plus oral antibiotic for 12 weeks:
Epiduo once daily OR Azelaic acid (15% gel or 20% cream) twice daily, PLUS either
Please see section: 13.6.1 Topical preparations for acne, 5.1.3 Tetracyclines, 5.1.8 Sulfonamides and trimethoprim, 5.1.5 Macrolides, and 7.3.1 Combined hormonal contraceptives (CHC)
If the first-line treatments above are contraindicated, or the person wishes to avoid using a topical retinoid, or an antibiotic (topical or oral):
Benzoyl peroxide 5% gel
Review treatment at 12 weeks.
In people whose initial treatment did not include an oral antibiotic, consider no further treatment / self-care only, or maintenance therapy (see below).
In people whose initial treatment included an oral antibiotic:
If acne fails to respond adequately to a 12-week course of a first-line treatment option and at review the severity is:
If acne responds adequately to a course of an appropriate first-line treatment but then relapses, consider either:
After completion of treatment (above), maintenance treatment is not always necessary.
Consider maintenance treatment in people with a history of frequent relapse after treatment.
Review maintenance treatments after 12 weeks to decide if they should continue.
Epiduo (Adapalene plus benzoyl peroxide)
If Epiduo is not tolerated or is contraindicated, consider topical monotherapy:
Adapalene 0.1% cream or 0.1% gel
Azelaic acid 15% gel or 20% cream
Benzoyl peroxide 5% gel
Trifarotene 50micrograms/g cream
Please see section 13.6.1 Topical preparations for acne
Refer all people with severe acne.
Consider referring people if they have:
Consider referral to mental health services if a person with acne experiences significant psychological distress or a mental health disorder.
Patients presenting with acne with a suspected endocrinological cause should be referred to an endocrinologist rather than a dermatologist.
Clinical Referral Guidelines (CRGs):