Severe acne

Severe acne in patients aged 18 years or older:

For severe acne - such as nodulo-cystic acne, acne conglobata, acne fulminans, or acne at risk of permanent scarring - a course of oral isotretinoin for 15 to 20 weeks is the treatment of choice but this should only be considered once adequate courses of standard treatment with systemic antibiotics and topical therapy have failed (1,2,5)

Adverse effects can be severe, and regular monitoring during treatment is required, including assessing lipids and liver function tests (3).

Women also require monthly pregnancy tests to continue treatment with isotretinoin (3)

A 2017 meta-analysis revealed no increased risk of depression while on isotretinoin and an improvement in depressive symptoms after treatment, although rare cases of mood exacerbation have been reported in patients who are clinically unstable (4)

In the UK, the National Institute for Health and Care Excellence recommends that isotretinoin is only prescribed by a consultant team. (5) There should be:

• two independent prescribers who agree with the initiation of oral isotretinoin in patients under 18 years
• counselling of people about potential mental health and sexual function side effects
• assessment of mental health and sexual function before starting treatment and monitoring of mental health and sexual function during treatment
• guidance on roles and responsibilities for healthcare professionals
• use of regulatory risk minimisation materials. (5)

Other reasons for referral to a dermatologist regarding acne treatment include: (2) (5)

• scarring, pigmentation, poor treatment response, unpleasant side effects from current treatment regime, late onset acne
• failure to respond to two different courses of antibiotics
• diagnostic uncertainty
• if there is significant psychological distress is associated with acne - this is regardless of severity primary care based acne therapies should be initiated

Examples of other treatments that may be initiated by a specialist include (3) (5)

• Physical treatments
  • consider photodynamic therapy for people aged 18 and over with moderate to severe acne if other treatments are ineffective, not tolerated or contraindicated
• Intralesional corticosteroids
  • consider treating severe inflammatory cysts with intralesional injection of triamcinolone acetonide (0.1 ml of triamcinolone acetonide per cm of cyst diameter, at 0.6 mg/ml diluted in 0.9% sodium chloride). This should be done by a member of a consultant dermatologist-led team
  • in June 2021 this was an off-label use for triamcinolone acetonide
• Oral corticosteroid therapy
• this may be used in conjunction with isotretinoin, or prior to initiating isotretinoin, to treat the systemic and cutaneous manifestations of acne fulminans and for prevention and treatment of isotretinoin-induced acne flare, respectively.​​ In these instances, oral corticosteroids are generally used for 1 to 4 months to avoid relapse

The summary of product characteristics should be consulted before prescribing any of the drugs mentioned

Notes:

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

Reference:

1. European Dermatology Forum. EDF guidelines and consensus statements​. 2016 [internet publication].

2. Huang CY et al. Comparative efficacy of pharmacological treatments for acne vulgaris: a network meta-analysis of 221 randomized controlled trials. Ann Fam Med. 2023 Jul-Aug;21(4):358-69.

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

4. Habeshian KA, Cohen BA. Current Issues in the Treatment of Acne Vulgaris. Pediatrics. 2020 May;145(Suppl 2):S225-S230.

5. National Institute for Health and Care Excellence. Acne vulgaris: management. Dec 2023