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Severe acne

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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

Acne severity	Treatment	Advantages	Disadvantages
Any severity	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening	topical does not contain antibiotics	not for use during pregnancy use with caution during breastfeeding can cause skin irritation, photosensitivity, and bleaching of hair and fabrics
Any severity	Fixed combination of topical tretinoin with topical clindamycin, applied once daily in the evening	topical	not for use during pregnancy or breastfeeding can cause skin irritation, and photosensitivity
Mild to moderate	Fixed combination of topical benzoyl peroxide with topical clindamycin, applied once daily in the evening	topical can be used with caution during pregnancy and breastfeeding	can cause skin irritation , photosensitivity, and bleaching of hair and fabrics
Moderate to severe	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening, plus either oral lymecycline or oral doxycycline taken once daily	oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is a Medicines and Healthcare products Regulatory Agency (MHRA) requirement for subsequent oral isotretinoin (see the MHRA alert on isotretinoin for severe acne: uses and effects)	not for use in pregnancy, during breastfeeding, or under the age of 12 topical adapalene and topical benzoyl peroxide can cause skin irritation, photosensitivity, and bleaching of hair and fabrics oral antibiotics may cause systemic side effects and antimicrobial resistance oral tetracyclines can cause photosensitivity
Moderate to severe	Topical azelaic acid applied twice daily, plus either oral lymecycline or oral doxycycline taken once daily	oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin (see the MHRA alert on isotretinoin for severe acne: uses and effects)	not for use in pregnancy, during breastfeeding, or under the age of 12 oral antibiotics may cause systemic side effects and resistance oral tetracyclines can cause photosensitivity

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

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Severe acne

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