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13.6.1. Acne

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

Any Severity

ChoiceDrugDosage
Formulary choicesAdapalene 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

ChoiceDrugDosage
Formulary choicesAs 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

ChoiceDrugDosage
Formulary choicesAs 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 capsulesDose:
408mg daily
or
plus doxycycline 100mg capsulesDose:
100mg daily
or
Topical preparation plus an oral antibiotic Azelaic acid 20% (Skinoren®) cream Dose:
Apply twice a day
plus lymecycline 408mg capsulesDose:
408mg daily
or
plus doxycycline 100mg capsulesDose:
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).