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Treatment

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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

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

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:

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