Acne—primary care treatment pathway
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- Virtually every adolescent has a few 'spots', however, about 15% of the adolescent population have sufficient problems to seek treatment. In most patients, but not all, the acne clears up by the late teens or early 20s
- More severe acne tends to last longer. A group of patients have persistent acne lasting up to the age of 30 to 40 years, and sometimes beyond. Patients with persistent acne often have a family history of persistent acne. Acne may scar—most of the time this is preventable by using the correct treatment given in a timely fashion
- Topical retinoids should be used for all grades of acne. Adapalene is better tolerated than other topical retinoids
- The irritant reaction with topical retinoids and benzoyl peroxide (BPO) can be ameliorated by gradual introduction e.g. by short contact initially and/or less frequent application. Concurrent use with light non-comedogenic emollients may be useful
- Azelaic acid may be beneficial in patients with darker skin where acne can lead to hyperpigmentation
- Benzoyl peroxide can cause bleaching of fabric
- Oral antibiotics should not be used as sole treatment. They should be prescribed with a topical retinoid and/or a BPO. Tetracyclines are first line and all show similar efficacy. Lymecycline and doxycycline are likely to have better adherence due to their once daily dosage. Minocycline should not normally be used in view of higher risks. Erythromycin is second line (first line in pregnancy) due to high bacterial resistance. Trimethoprim is an option, but uncommonly used in primary care
- Oral contraceptives: unopposed progesterones (including long-acting reversible contraceptives) can make acne worse. Second and third generation combined oral contraceptives are generally preferred. Co-cyprindiol is used in moderate to severe acne where other treatments have failed and discontinued three months after the acne has been controlled
- Combination products: combining topical treatments is recommended for most people with moderate acne. Combination products improve adherence
|Epiduo||No issue with antibiotic resistance
|Irritation can be a problem|
|Treclin||Broad spectrum of action
|Antibiotic resistance may limit the duration of treatment|
|Duac||Rapid onset of action on imflammatory lesions Two strengths available||No action on comedones|
Primary care treatment pathway of acne
- As acne is a chronic condition it is advisable to use a topical retinoid for long term maintenance. This may mean years. Occasional flares may require revisiting previously successful treatments
Top tips and myth busting
- Acne is not caused by a poor diet. However, the role of diet in acne remains controversial and a healthy diet is positively encouraged. There is some evidence that a high glycaemic index diet can exacerbate acne
- Poor hygiene is not a contributing factor to acne and aggressive washing is to be discouraged. Patients with acne should be encouraged to wash no more than twice a day using gentle, fragrance free cleanser and dissuaded from picking and squeezing spots (pustules)
- Non comedogenic make up and emollients are recommended
- Acne is not infectious
- Further information for healthcare professionals and patients can be found at:
|Now Test and Reflect: view our multiple choice questions|
full guidelines available from...
Primary Care Dermatology Society, PO Box 789, Rickmansworth, WD3 0NU (Tel—0333 939 0126)
Primary Care Dermatology Society. Acne—primary care treatment pathway.
First included: December 2015.
Read the Guidelines in Practice article Early and aggressive treatment is key to managing acne for more information on the implementing the PCDS Acne—primary care treatment pathway