Acne vulgaris: management

Offer people with acne a 12-week course of 1 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.

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).

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).

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 recommendations 1.5.19 and 1.5.20).

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 new safety measures 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.

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 which 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 or a nationally accredited GPwER working within a consultant dermatologist-agreed pathway.

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 or a nationally accredited GPwER working within a consultant dermatologist agreed pathway.

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 new safety measures for isotretinoin. This includes:

  • guidance on roles and responsibilities of referrers (usually the primary care clinician) and prescribers initiating, continuing and monitoring isotretinoin treatment

  • requirements that the initiation of isotretinoin treatment in people under 18 requires agreement by 2 independent healthcare professionals that there is no other appropriate effective treatment before it is prescribed

  • requirements for counselling people about potential mental health and sexual function side effects

  • requirements for assessing and monitoring mental health and sexual function

  • use of compulsory regulatory documents to minimise risk: patient acknowledgement of risk form and reminder card, and pharmacist checklist.
    
    See the Commission on Human Medicines Isotretinoin Implementation Advisory Expert Working Group report for more detail. [2023]

When making a referral to the consultant dermatologist-led team or the nationally accredited GPwER working within a consultant dermatologist-agreed pathway for the consideration of isotretinoin treatment:

• fully inform the person (and their family and carers, as appropriate) about the potential risks of isotretinoin treatment as well as the expected benefits

• provide details of the person's current and past medical history (including all current and previous mental health issues), and any relevant social and family history

• for people under 18, document whether you are willing to become the second approved named healthcare professional who agrees that isotretinoin is the appropriate treatment. [2023]

When considering oral isotretinoin for acne take into account the person's psychological wellbeing (see recommendation 1.4.5), and refer them to mental health services before starting treatment if appropriate. See also MHRA requirements to assess mental health before starting isotretinoin treatment.

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 as detailed on the isotretinoin acknowledgement of risk form.

Prescribe oral isotretinoin for acne treatment (see recommendation 1.5.18) 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 regularly 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. [2023]

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.

Consider photodynamic therapy for people aged 18 and over with moderate to severe acne if other treatments are ineffective, not tolerated or contraindicated.

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 or a nationally accredited GPwER working within a consultant dermatologist-agreed pathway.

In June 2021 this was an off-label use for triamcinolone acetonide. See NICE's information on prescribing medicines for more information.

For people with polycystic ovary syndrome and acne:

• treat their acne using a first-line treatment option (see recommendation 1.5.1 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).