treatment

Last edited 05/2023 and last reviewed 05/2023

Patient information is available from the British Association of Dermatologists

Treatment should be considered in terms of the severity of the condition. Acne can be mild, moderate or severe (2).

Goals of managing acne vulgaris include clearing or reducing the skin lesions, preventing scarring and managing psychological distress. Reassure the patients that acne is very common and it can be effectively treated, although there might be an initial deterioration in the condition during the treatment, before improvement. Advice on good skin care must be provided (2).

• mild: cleansing followed by the application of antiseptics and keratolytics:
• options for topical treatment include (1,2,3):
  • topical retinoid (for example adapalene 0.1% once daily- retinoids are contraindicated in pregnancy and breastfeeding)
  • adapalene should be used in preference to other topical retinoids (such as tretinoin and isotretinoin)
  • may be used alone or in combination with benzoyl peroxide
  • topical retinoids are particularly useful for treating comedonal acne - however, when used in combination with other drugs, an effective therapy for all acne variants
    
    
  • topical antibiotic (for example clindamycin 1%) in combination with benzoyl peroxide. The addition of benzoly peroxide to preparations with topical antibiotics reduces risk of development of bacterial resistance
    
    
  • azelaic acid 20% - often recommended as a second-line therapy; mildly effective as a comedolytic, antibacterial, and anti-inflammatory agent
  
  
• moderate-severe: additionally topical or oral antibiotics
• if response to topical preparations alone is inadequate consider adding an oral antibiotic, a tetracycline, such as lymecycline or doxycycline (for a maximum of 3 months)
• to reduce the risk of antibiotic resistance developing - always co-prescribe a topical retinoid (if not contraindicated) or benzoyl peroxide
• if required antibiotic courses can be repeated if flare ups in the future.

Topical corticosteroids should NOT be used.

Topical retinoids should be avoided in pregnant or breast feeding women (2). If topical therapy is re quired in pregnancy then topical benzoyl peroxide and topical erythromycin are usually considered safe in pregnancy (3).

When prescribing the medications, gels can be considered for oily skin, creams for dry skin and lotions when there are large areas of skin to be treated (2).

During treatment with prescribed medications, patients should use bland facial washes and moisturizers (3).

The CKS (2) defines management in terms of mild, moderate and severe acne.

NICE suggest (4):

Treatment choices for mild to moderate and moderate to severe acne vulgaris

Effects of the different agents used to treat acne (5)

Topical retinoids: Comedolytic and sometimes anti-inflammatory

Antibiotics: Antimicrobial and anti-inflammatory

Benzoyl peroxide: Antimicrobial plus weakly anti-inflammatory and comedolytic

Hormonal agents: Sebosuppressive

Oral retinoids: Comedolytic, sebosuppressive, antimicrobial, and anti-inflammatory

Reference:

• MeReC Bulletin (1999); 10 (8): 29-32.
• Clinical Knowledge Summaries.Acne Vulgaris(accessed 28/5/23)
• Feldman S, Careccia RE, Barham KL, Hancox J. Diagnosis and Treatment of Acne. AFP 2004; 69:2123-30, 2135-6.
• NICE (May 2023). Acne vulgaris: management
• Dawson AL1, Dellavalle RP. Acne vulgaris.BMJ. 2013 May 8;346:2634