Acne vulgaris

Definition/Description

Please note ⚠︎: This pathway has not yet undergone checks for consistency with ICB commissioning and prescribing policies, as published in the APC Formulary. Until such checks are completed, where there is a discrepancy, the ICB commissioning policy or APC Formulary overrides the pathway.

General Points

If more than 1 treatment is required:
- Use agents with different properties
- Don’t use topical antibiotic and oral antibiotics together.
- Benzoyl peroxide is a good agent for preventing resistance to antibiotics, a frequent - problem with long term use, so add this to regimes wherever tolerated (see below).
Warn that treatment will be slow:
- About 3 months for a 50% improvement (although not all patients recognise improvement at this stage, (patient can take photos before treatment to help monitoring).
- Improvement is recognised by fewer new lesions but the inflammation from previous lesions can take several months to settle.
- Improvement can continue for 9-12months after starting regimes

Red Flag Symptoms

None provided

Guidelines on Management

Management

Encourage smoking cessation
Encourage weight loss (if appropriate)
Topical therapy alone is usually effective-most will cause a drying effect which is part of the way that they work, use a light moisturiser if required at a different time of day.
Advise patient to cover all the acne prone areas, not to treat individual spots. Topicals work by preventing new spots from forming, hence the delay in improvement. Regular use is required, and perseverance-reinforce this.

Management of Mild Acne - comedones, small superficial papules and pustules

Benzoyl peroxide (BPO) - 5% strength is only strength required/commissioned. If 5% not tolerated at the usual once a night dose, experiment with 2-3 x/week initially, or for 1-4 hours, then wash off and increase exposure time gradually. Fair skins less tolerant than dark. Major benefit of reducing resistant bacteria on the skin. This benefit is specific to benzoyl peroxide. Also works to reduce comedones and inflammation. Warn patient regarding bleaching effect (fabrics and hair, not skin), only occurs when the treatment is wet.
- BPO washes, 2.5% and 10% are not commissioned
- BPO 5% cream as Panoxyl® 5% cream = £1.89 per 40g BPO
- 5% gel as Panoxyl® 5% Aquagel = £1.92 per 40g
Topical retinoids - keratolytic (especially useful if comedones are a marked feature).
- First line = isotretinoin 0.05% gel (Isotrex® is £5.94 per 30g)
- Second line = adapalene 0.1% cream or gel (Differin® is £16.43 per 45g) (cream less irritant)
- Build up tolerance as per benzoyl peroxide if required.
- Warn teratogenicity and can increase sun sensitivity.

Combination treatment –for mild to moderate acne:

Either:

BPO + retinoid First line – BPO 5% and adapalene in combination – as Epiduo® (£15.92 per 25g) - Apply once a day

Or:

Drying agent/keratolytic + topical antibiotic zinc plus erythromycin in combination as Zineryt® (£10.28 per 30ml) Apply twice daily
- BPO plus clindamycin gel in combination as Duac® (£13.14 per 30g) Apply at night.
- Topical tretinoin with topical clindamycin
- Topical antibiotics should not be used alone – the zinc or BPO help to prevent antibiotic resistance.

Management of Moderate Acne - larger papules/pustules, or milder acne not responding to above

1. Add oral antibiotic in addition to non-antibiotic topical treatment above or in addition to topical azelaic acid (15% or 20%) applied twice daily.

Doxycycline 100mg od (£3.40 per 28 days); or lymecycline 408mg od (£8.16 per 28 days) - good absorption even with food/milk and well tolerated.
Tetracyclines not in pregnancy, breast feeding mothers or children under 12, warn teratogenicity. All can cause sun sensitivity.
Minocycline is not recommended/not commissioned – expensive AND has increased risk of significant side effects and needs blood monitoring with long term use.
Erythromycin is an alternative if tetracyclines are poorly tolerated or contraindicated (such as in pregnancy) 500mg bd
Trimethoprim 200-300mg bd (unlicensed use). 6monthly FBC.
Do not prescribe an oral antibiotic alone.
Do not combine a topical antibiotic with an oral antibiotic.
NICE guidance: Only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances. Review at 3-monthly intervals, and stop the antibiotic as soon as possible
Switching antibiotics-if no response after 3months. Use BPO daily for 2 weeks to clear resistant bacteria before starting another antibiotic, and continue during antibiotic use if tolerated.

2. Hormonal

Combined oral contraceptives - particularly if contraception required also. Ideally NOT progesterone only contraceptives, any progesterone containing Rx may exacerbate acne including IUS, implant, depomedrone, POPs Co-cyprindiol - MHRA, 2013 has recommended that co-cyprindiol should only be prescribed when topical therapy or systemic therapy has failed.
Co-cyprindiol has a 1.5–2 times statistically significant increase in venous thromboembolism (VTE) risk compared with levonorgestrel-containing pills. It is thought that this risk is similar to that of contraceptives that contain desogestrel, gestodene, or drospirenone. If used, continue until good control achieved for 3months then step-down.
Step-down to alternative combined oral contraceptive – as per the Humber and North Yorkshire formulary – e.g. ethinylestradiol 30micrograms/ levonorgestrel 150micrograms (Rigevidon® - £2.82 per 63); ethinylestradiol 30micrograms/ desogestrel 150micrograms (Gedarel® 30/150 - £4.19 per 63), 3rd generation COCP may be more beneficial for acne so appropriate to discuss pros/cons with patient. There is no evidence that Yasmin® - ethinylestradiol 30micrograms and drospirenone 3mg is superior in acne and it is considerably more expensive (£14.70 per 63). It is not routinely commissioned.

Management of Severe Acne

Severe acne-nodules, cysts, significant scarring
Start on treatment as above, early referral.
Referral for consideration of a course of oral isotretinoin (Roaccutane®)
Inform patient that acne is more responsive to primary care treatment options after a course of oral isotretinoin than it was previously. Patients may believe they need another course of oral isotretinoin when primary care treatment may suffice. Referral for an additional course of oral isotretinoin may also be appropriate, depending on severity.If re-referring, orgaise another series of blood tests, and contraception for females (see above for details).
Stopping Rx-Step down treatment once control is good for 3-6months-stop oral antibiotics first, continuing topical treatment alone for another 6 months at least

Referral Criteria/Information

Referral Criteria

Minimum of 6 months treatment with topical Rx and oral antibiotics (2 types for 3 months each) or co-cyprindiol. Refer if inadequate response to above treatments at adequate dosages over adequate periods of time with good compliance to oral and topical treatments.
Earlier referral for those with nodulocystic acne or evidence of scarring (textural changes, not just erythema) or if extreme psychological reaction to their acne.
Refer acne cysts.
Those with persistent pigmentary changes (more troublesome in darker skins)
Those where their acne is contributing to, or causing, significant mental health difficulties or psychological distress.
Refer if needing longer-term treatment e.g. patients in their mid-twenties or older.

Information to include in referral letter

Include treatment – current and past, include duration and dosages.
Details of contraception in females, or detail sexual history. There is an expectation that contraception will be organized in primary care prior to consideration of oral isotretinoin.
Relevant past medical/surgical history
Current regular medication
BMI/smoking status

Investigations prior to referral

FBC, U/E, LFT, fasting cholesterol and triglycerides.
Organise contraception in all sexually active females (or those likely to become so shortly) before referral if oral isotretinoin may be considered. Can be combined with any oral contraceptive.