Treatment

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 (1).

Goals of managing acne vulgaris include clearing or reducing the skin lesions, preventing scarring and managing psychological distress. Reassure the patient 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 (1).

• mild: cleansing followed by the application of antiseptics and keratolytics:
  • options for topical treatment include (1):
    
    • 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 benzoyl peroxide to preparations with topical antibiotics reduces risk of development of bacterial resistance
      
      
    • azelaic acid - an antimicrobial with mild comedolytic and anti-inflammatory properties - may be considered as an adjunct to systemic antibiotic therapy for the treatment of moderate to severe inflammatory acne (1) (2)
• 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 (1). If topical therapy is required in pregnancy then topical benzoyl peroxide and topical erythromycin are usually considered safe in pregnancy (1).

Prescribing an oral macrolide antibiotic in any trimester is associated with an increased risk of genital malformations, so oral erythromycin should not be prescribed for the treatment of acne in women who are pregnant (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 (1).

During treatment with prescribed medications, patients should use bland facial washes and moisturizers (1).

NICE defines management in terms of mild, moderate and severe acne.

NICE suggest (1):

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

Effects of the different agents used to treat acne (4)

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:

1. National Institute for Health and Care Excellence. Acne vulgaris; management. Dec 2023 [internet publication].

2. Zaenglein AL et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33.

3. Fan H et al. Associations between macrolide antibiotics prescribing during pregnancy and adverse child outcomes in the UK: population based cohort study. BMJ. 2020 Feb 19;368:m331.

4. Dawson AL1, Dellavalle RP. Acne vulgaris.BMJ. 2013 May 8;346:263