Offer people with acne a 12-week course of 1 of the following according to severity:
Any Severity
| Choice | Drug | Dosage |
|---|---|---|
| Formulary choices | Adapalene 0.1%/benzoyl peroxide 2.5%, adapalene 0.3%/benzoyl peroxide 2.5% (Epiduo®) gel | Dose: Apply thinly once daily in the evening |
| or | ||
| Clindamycin 1%/tretinoin 0.025% (Treclin®) gel | Dose: Apply thinly once daily in the evening |
Mild to moderate acne
| Choice | Drug | Dosage |
|---|---|---|
| Formulary choices | As per any severity | |
| or | ||
| Clindamycin 1% /benzoyl peroxide 5%; Clindamycin 1%/ benzoyl peroxide 3% - (Duac®) gel | Dose: Apply once daily in the evening |
Moderate to severe acne
| Choice | Drug | Dosage |
|---|---|---|
| Formulary choices | As per any severity | |
| or | ||
| Topical preparation plus an oral antibiotic | Adapalene 0.1%/benzoyl peroxide 2.5%, adapalene 0.3%/benzoyl peroxide 2.5% (Epiduo®) gel | Dose: Apply thinly once daily in the evening |
| plus lymecycline 408mg capsules | Dose: | |
| 408mg daily | ||
| or | ||
| plus doxycycline 100mg capsules | Dose: | |
| 100mg daily | ||
| or | ||
| Topical preparation plus an oral antibiotic | Azelaic acid 20% (Skinoren®) cream | Dose: |
| Apply twice a day | ||
| plus lymecycline 408mg capsules | Dose: | |
| 408mg daily | ||
| or | ||
| plus doxycycline 100mg capsules | Dose: | |
| 100mg daily |
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 includes an oral antibiotic:
-
- if their acne has completely cleared consider stopping treatment. If appropriate, 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 (Roaccutane®) is a teratogenic drug which is only prescribable by a consultant dermatologist. For this reason, oral isotretinoin is a RED list medication in Northern Ireland.
- Women and girls of childbearing potential taking oral retinoids to treat dermatological conditions must be supported by a pregnancy prevention programme.
- Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin (see the MHRA alert on isotretinoin).