Acne

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Also refer to Highland Formulary section 13.6 , National Patient Pathways and British Association of Dermatology patient information leaflet.

Acne can be broadly classified into the following categories:

Mild: The disease consists of open and closed comedones with some superficial papules and pustules.

Moderate: More frequent deeper papules and pustules with mild scarring.

Severe: Includes all of the above plus nodular abscesses and leads to more extensive scarring. 

  • Refer to algorithm.
  • All topical acne treatments should be applied to the whole area affected throughout the course, even during periods of relative quiescence and ‘drug holidays’ from oral antibiotics.
Pathway

 

Always try a topical antibiotic preparation before prescribing oral antibiotics. Do not use antibiotics continuously for more than 6 months without a 3-week drug holiday during which a topical antiseptic, eg benzoyl peroxide, should be applied to help reduce bacterial resistance.  Always combine oral antibiotics with a topical antiseptic (see algorithm).

1. Mild comedonal/non-inflammatory acne

First choice:

Benzoyl peroxide applied once or twice daily. Introduce gradually.  Emphasise that there must be some skin peeling if treatment is going to work, if problematic reduce the frequency of application to alternate days

or

Adapalene (as benzoyl peroxide and adapalene (Epiduo®) gel or adapalene cream) applied once daily, may be less irritant than retinoids (cream is less irritant than gel).  Avoid retinoids and adapalene during pregnancy. Avoid or minimise exposure to sunlight of areas treated with topical retinoids or adapalene.  When exposure cannot be avoided, use a sunscreen product and protective clothing.

2. Mild inflammatory acne

First choice:

Erythromycin and zinc acetate (Zineryt® topical solution) applied once or twice daily.

or

Adapalene (as benzoyl peroxide and adapalene (Epiduo®) gel or adapalene cream) – see above.

3. Oral antibiotics

First choice:

Oxytetracycline 500mg twice daily for at least 3 months

or

Erythromycin 500mg twice daily for at least 3 months

Do not prescribe tetracyclines in children, pregnancy or breast-feeding mothers as they are deposited in growing teeth and bone.  Avoid excess sun exposure when taking tetracyclines (dose-dependent phototoxic reaction).  

Take oxytetracycline tablets with clear fluids at least an hour before food or 2 hours after previous meals. Do not take with iron or antacid preparations which may reduce absorption.  Avoid concomitant use of different systemic and topical antibiotics.  Benzoyl peroxide will reduce the risk of bacterial resistance developing.

Always try a topical antibiotic, antiseptic or retinoid-like preparation before prescribing oral antibiotics and continue to apply one during antibiotic treatment (they are synergistic).   Do not use oral antibiotics continuously for more than 6 months without a 3 week drug holiday during which a topical antiseptic (eg benzoyl peroxide) should be applied to help reduce bacterial resistance.

4. Contraception

Current recommendations are that no additional contraceptive precautions are required when hormonal contraceptives are used with oral oxytetracycline, erythromycin or doxycycline for acne.

Progestogen-only implant use may affect acne in some women. Acne has been shown to occur, improve or worsen with the use of a progestogen-only implant. Where acne fails to improve, consider switching to an oestrogenic contraceptive such as Gedarel 30/150® (https://www.fsrh.org/documents/cec-ceu-guidance-young-people-mar-2010/).

5. Check compliance

If the acne does not show a satisfactory response after 3 months of antibiotic treatment, switch to an alternative antibiotic such as doxycycline 100mg daily for 3 months then re-assess response.  

Doxycycline may be taken with food, this may help to reduce the incidence of GI irritation.  Do not prescribe tetracyclines to children, pregnant women or breast-feeding mothers as they are deposited in growing teeth and bone.  Avoid excess sun exposure when taking tetracyclines (dose-dependent phototoxic reaction).  

6. Co-cyprindiol

Co-cyprindiol is no more effective than oral antibiotic therapy, but is useful in females who also wish to receive oral contraception. It is contra-indicated in pregnancy, so must be taken assiduously.  A pregnancy test is mandatory prior to initiation.

It reduces sebum excretion, which is under androgen control, and so can also help in idiopathic hirsutism.

Co-cyprindiol carries an increased risk for venous embolism. The risk increases with increasing BMI and co-cyprindiol should not be used in patients with a BMI above 35kg/m2.  See CSM advice in BNF section 13.6.2 and https://www.fsrh.org/documents/cec-ceu-statement-dianette-jun-2013/.

Co-cyprindiol provides effective contraception. An additional hormonal contraceptive should not be used in combination with co-cyprindiol.

7. Oral isotretinoin

Oral isotretinoin side-effects include teratogenicity, hyperlipidaemia, dryness and irritation of skin and mucous membranes. Isotretinoin must only be prescribed by or under the supervision of Physicians with expertise in the use of systemic retinoids for the treatment of severe acne and a full understanding of the risk of isotretinoin therapy and monitoring requirements.

Editorial Information

Last reviewed: 31 December 2016

Next review: 31 December 2018

Author(s): Skin Review Group

Version: 8

Approved By: high-uhb.tam@nhs.net