PDCS Acne primary care treatment pathway v2

PCDS Acne primary care treatment pathway. Download a PDF of this visual summary

Practical advice

  • 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 (tea time to bed time) or less frequent application (two or three times a week). 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
  • BPO 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. No tetracycline should be used in the under 12. Erythromycin is second line (first line in pregnancy and in children) due to high bacterial resistance. Trimethoprim is an option, but uncommonly used in primary care
  • Oral contraceptives: unopposed progesterones (including LARCS) can make acne worse. Second and third generation combined oral contraceptives are generally preferred. Co-cyprindiol (Dianette) 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 (ref: NICE CKS). Combination products improve adherence
Overview of combination products for the treatment of acne
 Advantages Disadvantages
  • no issue with antibiotic resistance 
  • anticomedonal
  • irritation can be a problem 
  • broad spectrum of action
  • anticomedonal
  • antibiotic resistance may limit the duration of treatment 
  • rapid onset of action on inflammatory lesions
  • two strengths available
  • no action on comedones


  • 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 GI 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:

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Full guideline:

Primary Care Dermatology Society, PO Box 789, Rickmansworth, WD3 0NU (Tel—0333 939 0126)


Primary Care Dermatology Society. Acne—primary care treatment pathway. October 2019.

Published date: October 2019.