Warning

Treat acne based on whether it is inflammatory (red/tender papules and pustules) or non-inflammatory (blackheads and whiteheads with minimal redness) and severity.

A stepwise approach is needed with adequate time between to assess effectiveness. However, it is appropriate to choose a starting point based on severity.

 

Non-inflammatory comedonal acne

Initial treatment
  • Topical retinoid e.g. Differin®, Isotrex® (treatments normally dry the skin, start with 2-3 nights a week and gradually increase the frequency of applications.
  • Azelaic acid (Finacea gel, Skinoren cream) well tolerated in preteens and teenagers.

If not improving, use combination of benzoyl peroxide (BPO) and topical retinoid, Epiduo®

Review at 8 week then every 4 months

If inadequate response treat as for inflammatory acne

Mild inflammatory

  • Benzoyl peroxide (BPO) or topical retinoid or in combination Epiduo® (apply 2-3 times per week then increase frequency gradually)

  • BPO/ topical retinoid in combination with topical antibiotic Duac® (BPO 3%+clindamycin 1%), Treclin® (tretinoin 0.025%+clindamycin 1%)

Review at 8 weeks then every 4 months.

If inadequate response treat as moderate below.

Moderate inflammatory

  • Use systemic antibiotics with topical agents (BPO, Epiduo, Differin, Azelaic acid). (Tetracyclines are contra-indicated in
    pregnancy and patients aged under 12)
    • Lymecycline 408mg OD
    • Oxytetracycline 500mg BD
    • Doxycycline 100mg OD
    • Erythromycin 500mg BD
  • For female patients, please consider Dianette® in combination with topical agents. Once sustained improvement is seen, patient can be transferred to a combined oral contraceptive

If,

  • moderate acne only partially responsive and starting to scar, or
  • inadequate response to at least 2 systemic antibiotics PLUS topical agents (as above), each given for a minimum of 3 months

Then refer for specialist assessment as for severe acne below.

Severe inflammatory

Refer all patients with severe acne for specialist assessment.

Ensure women are using appropriate contraception (see BAD leaflet below) before referral for consideration of isotretinoin treatment (please check FBC, U&E, LFT and lipid screen)
BAD have a patient leaflet here which it would be useful to give the patient so they are well informed.

Refer patients who are systemically unwell or have nodulocystic acne urgently.

Editorial Information

Last reviewed: 01/12/2022

Next review date: 01/12/2024

Reviewer name(s): Lindsey Yeo.