Acne Vulgaris: Management

Overview

This Guidelines summary covers the management of acne vulgaris in primary care. It includes advice on topical and oral treatments (including antibiotics and retinoids), treatment using physical modalities, and the impact of acne vulgaris on mental health and wellbeing. This guideline was commissioned by NICE and developed in partnership with the Royal College of Obstetricians and Gynaecologists. NICE worked with the British Association of Dermatologists to develop this guideline.

This Guidelines summary does not include recommendations on photodynamic therapy treatment, the use of intralesional corticosteroids, or treatments available in a consultant dermatologist-led setting. For recommendations in these areas, refer to the full guideline.

Information and Support for People with Acne Vulgaris

• Give people with acne clear information tailored to their needs and concerns. Topics to cover include:
  • the possible reasons for their acne
  • treatment options, including over the counter treatments if appropriate
  • the benefits and drawbacks associated with treatments
  • the potential impact of acne
  • the importance of adhering to treatment (see also the section on providing information in the NICE guideline on medicines adherence)
  • relapses during or after treatment, including:
    • when and how to obtain further advice
    • treatment options should a relapse occur.

See also the NICE guideline on patient experience in adult NHS services (particularly recommendations 1.5.11–1.5.19) for advice on how to tailor information and communication based on the person’s needs.

• Include parents and carers in discussions if the person with acne would like them to be involved, or when support is needed (for example, for a person with cognitive impairment).

Skin Care Advice

• Advise people with acne to use a non-alkaline (skin pH neutral or slightly acidic) synthetic detergent (syndet) cleansing product twice daily on acne-prone skin.
• Advise people with acne who use skin care products (for example, moisturisers) and sunscreens to avoid oil-based and comedogenic preparations.
• Advise people with acne who use make-up to avoid oil-based and comedogenic products, and to remove make-up at the end of the day.
• Advise people that persistent picking or scratching of acne lesions can increase the risk of scarring.

Diet

• Advise people that there is not enough evidence to support specific diets for treating acne.

For general advice about a balanced diet and how it could contribute to wellbeing see Public Health England’s Eatwell Guide.

Referral to Specialist Care

• Urgently refer people with acne fulminans on the same day to the on-call hospital dermatology team, to be assessed within 24 hours.
• Refer people to a consultant dermatologist-led team if any of the following apply:
  • there is diagnostic uncertainty about their acne
  • they have acne conglobata
  • they have nodulo-cystic acne.
• Consider referring people to a consultant dermatologist-led team if they have:
  • mild to moderate acne that has not responded to 2 completed courses of treatment (see Table 1)
  • moderate to severe acne that has not responded to previous treatment that contains an oral antibiotic (see Table 1)
  • acne with scarring
  • acne with persistent pigmentary changes.
• Consider referring people to a consultant dermatologist-led team if their acne of any severity, or acne-related scarring, is causing or contributing to persistent psychological distress or a mental health disorder.
• Consider referral to mental health services if a person with acne experiences significant psychological distress or a mental health disorder, including those with a current or past history of:
  • suicidal ideation or self-harm
  • a severe depressive or anxiety disorder
  • body dysmorphic disorder.
• When considering referral, take into account the person’s potential treatment options (for example, oral isotretinoin). Also see the NICE guidelines on depression children and young people for advice on recognition, depression in adults for advice on recognition and assessment, and self-harm for advice on self-harm.
• Consider condition-specific management or referral to a specialist (for example, a reproductive endocrinologist), if a medical disorder or medication (including self-administered anabolic steroids) is likely to be contributing to a person’s acne.

Managing Acne Vulgaris

The recommendations in this section cover mild to moderate and moderate to severe acne.

First-line Treatment Options

• Offer people with acne a 12-week course of one of the following first-line treatment options, taking account of the severity of their acne and the person’s preferences, and after a discussion of the advantages and disadvantages of each option (see Table 1):
  • a fixed combination of topical adapalene with topical benzoyl peroxide for any acne severity
  • a fixed combination of topical tretinoin with topical clindamycin for any acne severity
  • a fixed combination of topical benzoyl peroxide with topical clindamycin for mild to moderate acne
  • a fixed combination of topical adapalene with topical benzoyl peroxide, together with either oral lymecycline or oral doxycycline for moderate to severe acne
  • topical azelaic acid with either oral lymecycline or oral doxycycline for moderate to severe acne.

Table 1: Treatment Choices for Mild to Moderate and Moderate to Severe Acne Vulgaris

• Consider topical benzoyl peroxide monotherapy as an alternative treatment to the options in Table 1, if:
  • these treatments are contraindicated, or
  • the person wishes to avoid using a topical retinoid, or an antibiotic (topical or oral).
• For people with moderate to severe acne who cannot tolerate or have contraindications to oral lymecycline or oral doxycycline, consider replacing these medicines in the combination treatments in Table 1 with trimethoprim or with an oral macrolide (for example, erythromycin). 

Factors to Take Into Account During Consultations

• Take into account that acne of any severity can cause psychological distress and mental health disorders.
• Discuss the importance of completing the course of treatment, because positive effects can take 6 to 8 weeks to become noticeable (see also the section on supporting adherence in the NICE guideline on medicines adherence).

Factors to Take Into Account when Choosing a Treatment Option

• Take into account that the risk of scarring increases with the severity and duration of acne.
• To reduce the risk of skin irritation associated with topical treatments, such as benzoyl peroxide or retinoids, start with alternate-day or short-contact application (for example, washing off after an hour). If tolerated, progress to using a standard application.
• When discussing treatment choices with a person with childbearing potential, cover:
  • that topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy and
  • that they will need to use effective contraception, or choose an alternative treatment to these options.
• If a person receiving treatment for acne wishes to use hormonal contraception, consider using the combined oral contraceptive pill in preference to the progestogen-only pill (if oral isotretinoin treatment is likely to be used, also see the section Oral isotretinoin treatment).
• If clinical judgement indicates a person may need treatment with oral isotretinoin for their acne in future:
  • be aware that oral isotretinoin should not be used unless adequate courses of standard therapy with systemic antibiotics and topical therapy have been tried, in line with the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on important risks and precautions for isotretinoin and
  • take this into account when choosing any initial treatment option.
• Do not use the following to treat acne:
  • monotherapy with a topical antibiotic
  • monotherapy with an oral antibiotic
  • a combination of a topical antibiotic and an oral antibiotic.

Factors to Take Into Account at Review

• Review first-line treatment at 12 weeks and:
  • assess whether the person’s acne has improved, and whether they have any side effects
  • in people whose treatment includes an oral antibiotic, if their acne has completely cleared consider stopping the antibiotic but continuing the topical treatment
  • in people whose treatment includes an oral antibiotic, if their acne has improved but not completely cleared, consider continuing the oral antibiotic, alongside the topical treatment, for up to 12 more weeks.
• Only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances; review at 3-monthly intervals, and stop the antibiotic as soon as possible.
• Be aware that the use of antibiotic treatments is associated with a risk of antimicrobial resistance (see the NICE guideline on antimicrobial stewardship).
• If a person’s acne has cleared, consider maintenance options (also see the section on maintenance).
• If acne fails to respond adequately to a 12-week course of a first-line treatment option and at review the severity is:
  • mild to moderate: offer another option from the table of treatment choices (see Table 1)
  • moderate to severe, and the treatment did not include an oral antibiotic: offer another option that includes an oral antibiotic from the table of treatment choices (see Table 1)
  • moderate to severe, and the treatment included an oral antibiotic: consider referral to a consultant dermatologist-led team.
• If mild to moderate acne fails to respond adequately to 2 different 12-week courses of treatment options, consider referral to a consultant dermatologist-led team.

Oral Isotretinoin Treatment

• Consider oral isotretinoin for people older than 12 years who have a severe form of acne that is resistant to adequate courses of standard therapy with systemic antibiotics and topical therapy (Table 1). For example:
  • nodulo-cystic acne
  • acne conglobata
  • acne fulminans
  • acne at risk of permanent scarring.
• If a person with acne is likely to benefit from oral isotretinoin treatment:
  • Follow the MHRA guidance on important risks and precautions for isotretinoin. 
    • prescribing only by a consultant dermatologist-led team
    • assessing and monitoring mental health
    • assessing and monitoring sexual function.
• Fully inform the person (and their family and carers as appropriate) about the potential risks of isotretinoin treatment as well as the expected benefits before referral to the consultant-dermatologist-led team, and again before prescribing isotretinoin if that is the chosen treatment.
• When considering oral isotretinoin for acne take into account the person’s psychological wellbeing (see the section Referral to specialist care), and refer them to mental health services before starting treatment if appropriate.
• If a person for whom oral isotretinoin treatment is being considered has the potential to become pregnant:
  • explain that isotretinoin can cause serious harm to a developing baby if taken during pregnancy and
  • inform them that they will need to follow the MHRA pregnancy prevention programme.
• Prescribe oral isotretinoin for acne treatment (see the first recommendation in this section) at a standard daily dose of 0.5 to 1 mg/kg.
• Consider a reduced daily dose of isotretinoin (less than 0.5 mg/kg) for people at increased risk of, or experiencing, adverse effects.
• When giving isotretinoin as a course of treatment for acne:
  • continue until a total cumulative dose of 120 to 150 mg/kg is reached, but
  • if there has been an adequate response and no new acne lesions for 4 to 8 weeks, consider discontinuing treatment sooner.
• If a person is taking oral isotretinoin for acne:
  • review their psychological wellbeing during treatment, and monitor them for symptoms or signs of developing or worsening mental health problems or sexual dysfunction
  • tell them to seek medical advice if they feel their mental health or sexual function is affected or is worsening, and to stop their treatment and seek urgent medical advice if these problems are severe.

Use of Oral Corticosteroids in Addition to Oral Isotretinoin

• If an acne flare (acute significant worsening of acne) occurs after starting oral isotretinoin, consider adding a course of oral prednisolone.
• When a person with acne fulminans is started on oral isotretinoin, consider adding a course of oral prednisolone to prevent an acne flare.

Treatment Options for People with Polycystic Ovary Syndrome

• For people with polycystic ovary syndrome and acne:
  • treat their acne using a first-line treatment option (see the section First-line treatment options and Table 1)
  • if the chosen first-line treatment is not effective, consider adding ethinylestradiol with cyproterone acetate (co-cyprindiol) or an alternative combined oral contraceptive pill to their treatment
  • for those using co-cyprindiol, review at 6 months and discuss continuation or alternative treatment options.
• Consider referring people with acne and polycystic ovary syndrome with additional features of hyperandrogenism to an appropriate specialist (for example, a reproductive endocrinologist).

For recommendations on physical treatments and use of intralesional corticosteroids, refer to the full guideline.

Relapse

• If acne responds adequately to a course of an appropriate first-line treatment (see the section First-line treatment options and Table 1) but then relapses, consider either:
  • another 12-week course of the same treatment or
  • an alternative 12-week treatment (see Table 1).
• If acne relapses after an adequate response to oral isotretinoin and is currently mild to moderate, offer an appropriate treatment option (see Table 1).
• If acne relapses after an adequate response to oral isotretinoin and is currently moderate to severe, offer either:
  • a 12-week course of an appropriate treatment option (see Table 1) or
  • re-referral, if the person is no longer under the care of the consultant dermatologist-led team.
• If acne relapses after a second course of oral isotretinoin and is currently moderate to severe, further care should be decided by the consultant dermatologist-led team; if the person is no longer under the care of the consultant dermatologist-led team, offer re-referral.

Maintenance

• Encourage continued appropriate skin care (see the section, Skin care advice).
• Explain to the person with acne that, after completion of treatment, maintenance treatment is not always necessary.
• Consider maintenance treatment in people with a history of frequent relapse after treatment.
• Consider a fixed combination of topical adapalene and topical benzoyl peroxide as maintenance treatment for acne. If this is not tolerated, or if 1 component of the combination is contraindicated, consider topical monotherapy with adapalene, azelaic acid, or benzoyl peroxide (see also the section Factors to take into account when choosing a treatment option on starting topical treatment).
• Review maintenance treatments for acne after 12 weeks to decide if they should continue. 

Management of Acne-Related Scarring

• If a person has acne-related scarring, discuss their concerns and provide information in a way that suits their needs. Topics to cover include:
  • possible reasons for their scars
  • treatment of ongoing acne to help prevent further scarring (see the sections First-line treatment options and Oral isotretinoin treatment)
  • possible treatment options for acne-related scarring
  • the way their acne scars may change over time
  • psychological distress.
• If a person’s acne-related scarring is severe and persists a year after their acne has cleared:
  • refer the person to a consultant dermatologist-led team with expertise in scarring management.