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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, the back, and the chest. 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.
Treatment of acne should be commenced as early as possible to prevent scarring with patients reassessed every two to three months initially. 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. Stress to patients the importance of good compliance. Treatment should not be used for longer than necessary. If acne returns, reuse the same drug if the previous response was satisfactory with that agent.
Patients presenting with acne with a suspected endocrinological cause should be referred to an endocrinologist rather than a dermatologist.
In mild acne (predominantly facial), open and closed comedones (blackheads and whiteheads) predominate but papules and pustules may also be present. Although the physical severity of the condition is limited and scarring is unlikely, the psychosocial impact may be disproportionate in some people, which is an indication for more aggressive treatment.
Treat initially with a single topical agent; drug choice depends on whether comedonal or inflammatory lesions predominate.
Benzoyl peroxide or topical retinoids are first choice agents for mild comedonal acne whereas benzoyl peroxide is the topical agent of choice for mild inflammatory acne.
The lower concentrations of benzoyl peroxide seem to be as effective as higher concentrations in reducing inflammation. It is usual to start with a lower strength and to increase the concentration of benzoyl peroxide gradually. Adverse effects include local skin irritation, particularly when therapy is initiated, but the scaling and redness often subside with treatment continued at a reduced frequency of application.
Azelaic acid has antimicrobial and anticomedonal properties. It may be an alternative to benzoyl peroxide or to a topical retinoid for treating mild to moderate comedonal acne, particularly of the face. Some patients prefer azelaic acid because it is less likely to cause local irritation than benzoyl peroxide. Azelaic acid can lighten the colour of the skin, but this is rarely problematic in practice (it also has a role in reducing post-inflammatory hyperpigmentation in people with dark skin).
Preparations containing sulphur and abrasive agents (such as aluminium oxide) are not considered beneficial for acne. Topical corticosteroids should not be used in acne. Salicylic acid is a common ingredient in over the counter acne treatments, but it is considered less effective than the topical retinoids.
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 of these 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.
For guidance on the application of topical retinoids, refer to section
13.7 Rosacea and acne.
Assess response to treatment after a period of about 6–8 weeks, and continue treatment if the drug has had a positive effect. The decision to continue treatment should be made on an individual basis. Factors to consider include the original severity of the acne, the psychological disability caused by the acne, and adverse effects of treatment. Benzoyl peroxide and topical retinoids may be used indefinitely (either alone or in combination together) provided adverse effects do not occur. It may be possible to reduce application to alternate days or less frequently during maintenance.
If no improvement is seen after 6–8 weeks, check adherence to treatment. If adherence is poor, this may be because the treatment is poorly tolerated. Consider:
If adherence is adequate, consider:
In moderate acne, inflammatory lesions (papules and pustules) predominate. The acne may be widespread involving the upper torso, there may be a risk of scarring, and there may be considerable psychosocial morbidity, all of which are indications for aggressive treatment.
For moderate acne, or mild acne that has failed to respond to initial treatment, a combination product is recommended. A topical antibiotic combined with benzoyl peroxide or a topical retinoid is the preferred regimen, as it is proven to be effective and may limit the development of bacterial resistance. Where possible, a topical antibiotic course should be limited to a maximum of 12 weeks. Topical retinoid combined with benzoyl peroxide is an alternative.
If no response, initiate oral antibiotics withdrawing the topical antibiotic but continuing with topical retinoid or benzoyl peroxide monotherapy as appropriate.
Also consider an oral antibiotic combined with either a topical retinoid or benzoyl peroxide if there is acne on the back or shoulders that is particularly extensive or difficult to reach, or if there is a significant risk of scarring or substantial pigment change.
Duac Once Daily® (clindamycin plus benzoyl peroxide)
Treclin® (tretinoin plus clindamycin)
Epiduo® (adapalene plus benzoyl peroxide)
Isotrexin® (isotretinoin plus erythromycin)
An oral antibiotic combined with either a topical retinoid or benzoyl peroxide should be considered if there is acne on the back or shoulders that is particularly extensive or difficult to reach, or if there is a significant risk of scarring or substantial pigment change.
Oral antibiotics are the mainstay of systemic therapy, but should not be used in isolation. Oral antibiotics should be combined with retinoids or benzoyl peroxide to make use of their useful synergistic properties. If acne returns, reuse the same drug if the previous response was satisfactory with that agent.
Topical antibiotics should not be used at the same time as oral antibiotics owing to the increased likelihood of the development of bacterial resistance.
The response to oral antibiotic treatment should be assessed after a period of about 6–8 weeks:
If the person has not responded adequately, continue for a minimum of 3 months before assuming treatment is ineffective. At this stage, consider seeking specialist advice or referring to a dermatologist, and see also advice regarding co-cyprindiol for use in female patients with severe acne refractory to prolonged oral antibiotics.
Minocycline is associated with a greater risk of lupus erythematosus-like syndrome and may cause irreversible pigmentation. Monitoring is required every 3 months for hepatotoxicity, pigmentation and for systemic lupus erythematosus. Due to the lack of therapeutic advantage over tetracyclines and concerns over its safety it is no longer recommended for the treatment of acne. This is in line with national guidance from NHS England (click here for more information); prescribers should not initiate minocycline for acne for any new patient.
In women the use of a contraceptive which may improve the acne is an option. If the woman is experiencing worsening acne after starting a contraceptive then consider a switch to an oral contraception containing progestin with low androgenic activity. Lizinna® is recommended as the first choice contraceptive due to the lower VTE risk associated with norgestimate, and Gedarel® 30/150 and Lucette® may be offered as alternative treatment options (see section 7.3 Contraceptives ).
This can also be considered in women whose acne is refractory to prolonged antibiotic therapy. It should be noted that the thrombotic risk differs between progestogens, with desogestrel and drospirenone having a higher risk than norgestimate (Gedarel® 30/150, Lucette® and Lizinna® respectively) as reported by the Faculty of Sexual and Reproductive Healthcare. Patients therefore must be counselled and advised accordingly prior to commencing treatment.
If this treatment fails co-cyprindiol may be considered as it contains an anti-androgen. Co-cyprindiol is included in the formulary as a treatment option for severe acne (see below). It is specifically licensed for severe acne refractory to prolonged oral antibiotics. Co-cyprindiol should not be used solely for contraceptive purposes. Time to relief of symptoms is at least three months. The need to continue treatment should be evaluated periodically by the treating physician, with a view to withdrawing treatment once the skin condition has improved. The patient can then be switched to a conventional combined hormonal contraceptive with low androgenic tendencies (e.g. Lizinna®, Gedarel® 30/150 or Lucette®), but repeat courses of co-cyprindiol may be given if the condition recurs.
In severe acne, there are nodules and cysts (nodulocystic acne), as well as a preponderance of inflammatory papules and pustules. There is a high risk of scarring (or scarring may already be evident), and there is likely to be considerable psychosocial morbidity.
A patient with confluent or nodular lesions, usually with significant scarring, or significant psychological disorder irrespective of clinical grade should be referred to secondary care.
Secondary care referrals for severe nodulocystic acne patients should be as soon as possible in order to lessen the risk of scarring.
Any blood results available and sent with the referral letter will assist in the consultation.
Co-cyprindiol (cyproterone, ethinylestradiol)