13.6.1. Acne

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


Choice	Drug
Formulary choices	Epiduo® gel 0.1%/2.5% or 0.3%/2.5% (Adapalene,benzoyl peroxide)

		or
		Treclin 1%/0.025% gel (Clindamycin,tretinoin)


Choice	Drug
Formulary choices	As per any severity - see table above
		or
		Duac® Once Daily 1%/3% gel or 1%/5% gel (Clindamycin, benzoyl peroxide)


Choice	Drug
Formulary choices	As per any severity-see table above

	OR
Topical preparation plus an oral antibiotic	Epiduo® 0.1%/2.5% gel or 0.3%/2.5% gel (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

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.

- 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 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