This guideline (also available as a visual summary) is aimed at supporting clinicians in primary care to manage acne from 12 years of age. In addition, the British Association if Dermatologists has a useful leaflet on acne for patients. Also NICE guideline NG198 covers management of acne vulgaris in primary and specialist care. It includes advice on topical and oral treatments (including antibiotics and retinoids), treatment using physical modalities, and the impact of acne vulgaris on mental health and wellbeing.
Step 1: Initial GP treatment for acne
Also check for acne-inducing medication such as the progesterone only pill.
Mild to moderate acne: Topical treatments for 3 months:
- Fixed combination of adapalene 0.1% or 0.3% with benzoyl peroxide 2.5% (Epiduo®) or
- Fixed combination of 0.025% tretinoin with 1% clindamycin (Treclin®) or
- Fixed combination of benzoyl peroxide 3% or 5% with 1% clindamycin (Duac®)
Note: Epiduo® or Treclin® may also be used as monotherapy for moderate to severe acne where oral antibiotics inappropriate.
Moderate to severe acne: Topical and oral treatment for 3 months:
- Fixed combination of adapalene 0.1% or 0.3% with benzoyl peroxide 2.5% (Epiduo®) PLUS oral lymecycline 408mg once daily or doxycycline 100mg once daily (warn regarding photosensitivity).
- If tetracyclines contraindicated or not tolerated use erythromycin 500mg twice daily or clarithromycin 250mg twice daily. Erythromycin is slightly preferred in pregnant or breastfeeding patients.
Note: Oral antibiotics can take 6 to 8 weeks to have an effect.
Step 2: Review at 3 months
Acne cleared:
- Stop antibiotics and continue topical treatment.
Acne improved but not clear:
- Patient on topical treatment only: Add in an oral antibiotic as outlined above for moderate acne.
- Patient on oral and topical treatment: Continue oral antibiotic and topical therapy for a further 3 months. Do not use oral antibiotics for more than 6 months unless exceptional circumstances (consider specialist advice and guidance in this scenario).
No response to standard oral antibiotics and topical treatment:
- Refer to dermatology team who may consider off label trimethoprim, or oral isotretinoin as hospital only options.
Step 3: When to refer
Refer:
- All patients with severe acne (nodulocystic acne or systemically unwell, please refer urgently).
- Inadequate response to above treatment.
- Acne causing significant scarring or pigmentation.
- Severe psychological distress regardless of physical signs.
Note: Consider seeking specialist advice and guidance for patients who relapse following successful treatment with isotretinoin.
Please ensure women who are sexually active are on a reliable form of contraception (combined oral contraceptive pill or long acting reversible contraception) in addition to a barrier method before referral for consideration of oral isotretinoin treatment. If only the progesterone only pill (POP) is tolerated, they can wait to see the consultant dermatologist first.
Oral isotretinoin should only be prescribed by a specialist, and is contraindicated in pregnancy.
Key Prescribing and Counselling Information for Healthcare Professional
Topical treatments (general)
- Most suitable for facial acne.
- Apply at night to affected areas to prevent new spots from developing.
- Warn regarding irritancy. Advise to use a gentle product to wash the face and a moisturiser in the morning. Consider washing off the acne cream after an hour and using on alternate days initially, prior to gradually increasing the exposure time and frequency of use to daily.
Note: Combination products are recommended first line (see step 1). Non-combination products can be used if combination products not tolerated.
Topical retinoids (contraindicated in pregnancy):
- Have anticomedonal properties.
- Counsel women of childbearing age to use effective contraceptive.
- Warn regarding irritancy, photosensitivity (wash off before direct sunlight) peeling or dryness and need to moisturise.
Topical benzoyl peroxide:
- Have keratolytic and antimicrobial properties (can be purchased from community pharmacy).
- No evidence for increased efficacy with concentrations higher than 5%.
- Warn patients that it can bleach bedding and clothing and advise using white towels and sheets.
Combination topical treatments:
- See the above advice for treatments containing retinoids & benzoyl peroxide.
Topical antibiotics:
- Should only be used in combination with a retinoid or benzoyl peroxide.
- Avoid concomitant use with oral antibiotics.
Systemic treatments (general)
- Prescribe benzoyl peroxide with or without topical retinoid (example adapalene) alongside oral agents to reduce the development of Propionibacterium acnes (P.acnes) resistance.
- Avoid concomitant use of oral and topical antibiotics.
Tetracyclines (contraindicated in pregnancy and breastfeeding)
- Absorption of tetracyclines is affected by antacids. Take two to three hours apart.
- Avoid use of antibiotics as sole treatment; use in combination with benzoyl peroxide to prevent resistance.
- Lymecycline: First line choice.
- Doxycycline: May cause more photosensitivity than lymecycline, especially in higher doses and fair skinned individuals. Use of non-comedogenic sunscreens may prevent this (ask patients to purchase sunscreens rather than prescribe them where possible).
- Minocycline is no longer considered an appropriate therapy due to associated serious side effects.
Macrolides
- For example, erythromycin, clarithromycin. Can be used if intolerance or contraindication to tetracyclines.
- First line systemic oral antibiotic treatment for pregnant women; erythromycin not known to be harmful in breastfeeding.
Oral contraceptive pills (OCP)
- If there are other reasons to take a combined oral contraceptive pill such as contraception and menstrual control, then these may be used instead of oral antibiotics.
- Consider using a combined OCP or co-cyprindiol (brands include Dianette®, Clairette®, Teragezza®) in patients with polycystic ovarian syndrome who do not respond to treatment with oral antibiotics and topical agents.
- Combined OCP containing third generation progestins (desogestrel, gestodene, and norgestimate), for example Gedarel®, Millinette®, Cilique® or fourth generation progestins (drospirenone) are less comedogenic than older pills. For cost-effective brand choices, contact your medicines optimisation team.
- More information on the OCP choice and potential side effects (e.g. venous thromboembolism, meningioma with co-cyprindol) can be found on the NICE CKS website
Document History
Version: V1.0
Approval date: April 2022