Aims of Treatment

  1. Prevent scarring
  2. Limit duration
  3. Reduce the psychological impact on the individual

Assessment

Duration, site, aggravating (stress, pre-menstrual, oral contraceptive) and relieving factors (sun), family history, past and present treatment and severity


Grading of acne severity and treatment

  Mild acne Moderate acne Severe acne
Description Open and closed comedones (whiteheads and blackheads), a few papules and pustules Comedones, more frequent papules and pustules, but minimal scarring; can be subdivided into mainly comedonal or mainly inflammatory acne Comedones, more pustules, and pustules plus nodular abscesses with more extensive scarring
First line treatments • Topical retinoid
• Benzoyl peroxide (BP)
• BP + topical antibiotic		 Comedonal:
• BP + topical retinoid
Inflammatory:
• BP + topical antibiotic		 As for moderate acne, plus referral to a dermatologist for oral isotretinoin
Second line treatments • Azelaic acid • Oral antibiotic + BP ± topical retinoid
• Azelaic acid
• Consider combined oral contraceptive pill for female patients		 As for moderate acne, plus referral to a dermatologist for oral isotretinoi

Acne vulgaris BMJ 2009

 

Management

Summary of principles:

  1. Topical treatments are effective for mild/moderate acne. Advise patients to use treatment as a spot preventer not just spot remover.
  2. Oral antibiotics (and antiandrogens for women) are necessary for moderate acne.
  3. For severe acne use high dose antibiotics and at the same time instigate referral for isotretinoin which has a rapid effect and high rate of long term remission.
  4. Early treatment and regular review to present scarring.
  5. Clarify your expectations regarding speech of action and the suppressive and preventative nature of treatment.

Initial visit

Further visit

Follow Up

This should be tailored to the need of the patient and the expected rate of change. In the early phase of treatment more frequent visits are required to review progress and encourage compliance. Maintain treatment for 8 to 12 weeks as the response with oral and topical preparations may be slow.

Topical Treatment for Mild Acne (see BNF section 13.6)  Notes
Benzoyl peroxide 2.5 - 10% once daily Can be used long term and with oral antibiotics
Tretinoin 0.1 - 0.25% once daily Avoid in pregnancy
Isotretinoin 0.05% once/twice daily Avoid in pregnancy
Clindamycin 1% twice daily Suitable for greasy skins
Erythromycin 2% & 4% + zinc acetate twice daily Suitable for greasy skins 
Less bacterial resistance

 

Treatment for Moderate Acne (see BNF section 13.6) Notes
1st line treatments Oral antibiotics Use for a minimum of 3 months 
Expect improvement in 2-8 weeks
Oxytetracycline 500 mg bd Over 14 years old, half hour before food, no milk or iron
Erythromycin 500 mg bd Frequent resistance of P. acnes and Staph
Trimethoprim 100 mg bd  
2nd line treatments Doxycycline 100 mg daily P. acnes resistance occurs
Minocycline 100 mg daily Low incidence of pigmentation, arthralgia and hepatic damage; bacterial resistance unknown.
Cyproterone acetate + ethinyloestradiol (Dianette) Suitable for contraception in presence of acne.

Indications for Hospital Referral

NICE referral guidelines

 

NICE referral guidelines 2001

Key Standards in referral Letter