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Home Formulary 13.0 Skin 13.6 Acne and rosacea 13.6.1. Acne

13.6.1. Acne

Offer people with acne a 12-week course of 1 of the following according to severity:

Any severity

ChoiceDrug
Formulary choicesEpiduo® gel 0.1%/2.5% or 0.3%/2.5% (Adapalene,benzoyl peroxide)
or
Treclin 1%/0.025% gel (Clindamycin,tretinoin)

Mild to moderate acne

ChoiceDrug
Formulary choicesAs per any severity - see table above
or

Benzoyl peroxide 3% / Clindamycin 1% gel,                                                        Benzoyl peroxide 5% / Clindamycin 1% gel                                                  (originator brand Duac® Once Daily)

Moderate to severe acne

ChoiceDrug
Formulary choicesAs per any severity-see table above
OR
Topical preparation
plus an oral antibiotic		Epiduo® gel 0.1%/2.5% or 0.3%/2.5% (Adapalene,benzoyl peroxide)
plus lymecycline 408mg capsules
or
plus doxycycline 100mg capsules
OR
Azelaic acid 20% (Skinoren®) cream
plus lymecycline 408mg capsules
or
plus doxycycline 100mg capsules

Prescribing Notes

  • For full prescribing information refer to NICE NG198.
  • Treatment courses should be of 12 weeks duration (positive effects can take 6 to 8 weeks to become noticeable).
  • Do not prescribe a combination of a topical antibiotic and an oral antibiotic.
  • Do not use monotherapy to treat acne.
  • Topical benzoyl peroxide monotherapy should only be considered as an alternative treatment if the above treatments are contraindicated, or the patient wishes to avoid using a topical retinoid, or an antibiotic (topical or oral).
  • Topical treatment should be applied sparingly to all the affected areas, not just the spots.
  • To reduce the risk of skin irritation associated with topical treatments start with alternate-day or short-contact application (for example washing off after an hour). If tolerated, progress to using a standard application.
  • Exposure to sunlight or UV radiation should be avoided or minimized during treatment.

In those with childbearing potential:

  • Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy, an effective contraception must be used or an alternative treatment chosen.
  • If a person being treated for acne wishes to use hormonal contraception, consider a combined oral contraceptive pill in preference to the progestogen-only pill. See 7.3.1 for COC choices.

 

Review first-line treatment at 12 weeks and

  • in people whose treatment includes an oral antibiotic:
    • if their acne has completely cleared consider stopping the antibiotic but continuing the topical treatment
    • if their acne has improved but not completely cleared, consider continuing the oral antibiotic, alongside the topical treatment, for up to 12 more weeks
    • if acne fails to respond adequately consider referral to a consultant dermatologist-led team.
  • in people whose treatment does not include an oral antibiotic:
    • if their acne has completely cleared consider stopping treatment. If required, an appropriate maintenance treatment is a fixed combination of topical adapalene and topical benzoyl peroxide
    • if the acne fails to respond adequately:
      • mild to moderate: offer a different option from the choices above. If this also fails consider referral to a consultant dermatologist-led team.
      • moderate to severe: offer a different option which includes an oral antibiotic from the choices above.
    • Only continue treatment 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

Oral retinoids

  • Oral isotretinoin should only be used for severe forms of acne resistant to adequate courses of standard therapy with systemic antibacterials and topical therapy – see MHRA alert
  • Oral isotretinoin is a RED list medication and is only prescribable by a specialist dermatology team in secondary care

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