Acne

Acne can be classified as either inflammatory or non-inflammatory.

Inflammatory acne includes red and tender papules and pustules, while non-inflammatory acne consists of blackheads and whiteheads with minimal redness.

The condition presents differently depending on its severity, and a stepwise approach is recommended, with adequate time between interventions to assess effectiveness.

Management should always include topical treatments, with the choice based on the type and severity of acne:

• Initial treatment for non-inflammatory acne:
  • Topical retinoid (e.g., Differin®), starting with 2-3 nights per week and increasing frequency as tolerated.
  • Azelaic acid (e.g., Finacea gel, Skinoren cream), which is well tolerated in preteens and teenagers.
• Inadequate response to initial treatment:
  • Combination of Benzoyl peroxide (BPO) and topical retinoid (e.g., Epiduo®).
  • Review after 8 weeks, then every 4 months.
  • If still no response treat as inflammatory acne below.

• Initial treatment for inflammatory acne:
  • Benzoyl peroxide (BPO) or
  • Topical retinoid (e.g., Differin®), starting with 2-3 nights per week and increasing frequency as tolerated or
  • Combination of Benzoyl peroxide (BPO) and topical retinoid (e.g., Epiduo®).
  • BPO and topical antibiotic (Duac) or retinoid/antibiotic (Treclin)
• Moderate inflammatory acne:
  • Systemic antibiotics in combination with topical agents (BPO, Epiduo®, Differin®, or Azelaic acid). Tetracyclines are contraindicated in pregnancy and under 12s.
    • Lymecycline 408 mg OD,
    • Oxytetracycline 500 mg BD,
    • Doxycycline 100 mg OD,
    • Erythromycin 500 mg BD
  • For female patients, Dianette® can be considered in combination with topical agents.

• Severe inflammatory acne:
  • Refer all patients with severe acne for specialist assessment and consideration of oral isotretinoin 
  • If the patient is female, ensure they are using appropriate contraception prior to referral for isotretinoin.

• Moderate acne: If the patient has moderate acne that is partially responsive, starting to scar, or has had an inadequate response to at least two systemic antibiotics and topical agents, each given for a minimum of three months, refer for specialist assessment.
• Severe acne: Refer all patients with severe acne for specialist assessment.
• Urgent referral: Patients who are systemically unwell or present with nodulocystic acne should be referred urgently.

Referral preparation

There are significant restrictions to prescription of oral isotretinoin which is a dermatologist only medication with significant side effects and risks but is a very effective treatment.

There is a lot for the patient to consider before deciding to take this treatment and there is a good leaflet available from BAD.

It is helpful to print off or direct the patient to this leaflet via QR code and document in the referral that you have done so (this means dermatology don't need to send the leaflet from DGRI)

Ensure relevant blood tests (FBC, U&E, LFT, and lipid screen) are done prior to referral.

Female patients of childbearing age must be on adequate contraception, ideally LARC. This is a good opportunity to encourage LARC if appropriate.

Document current contraception on referral letter.

• Patients whose acne is mild and can be managed with primary care treatments outlined above should not be referred unless there is evidence of scarring or inadequate response to treatment.