Community management of Acne

1. ACNE MANAGEMENT IN THE
COMMUNITY
BY
Dr U.B.Buhari
GPwER
FRCGP
MHA

2. Mainly open & closed
comedones
Topical retinoid (e.g.
Adapalene®)
Mixture of comedones &
inflammatory lesions
Topical benzoyl peroxide
(e.g. Acnecide®)
Review at 12 weeks. If in remissions, consider stopping. If poor
response; switch retinoid to benzoyl peroxide, or benzoyl
peroxide to retinoid and review after 12 weeks.
Topical benzoyl
peroxide/retinoid
combination (e.g. Epiduo®)
Combination preparation:
Topical benzoyl
peroxide/antibiotic (e.g.
Duac*) or retinoid /antibiotic
(e.g. Aknemycin
Plus®/Treclin) or benzoyl
peroxide/retinoid (e.g.
Epiduo®)
Review at 12 weeks. If in remission use topical benzoyl peroxide
or retinoid as maintenance treatment. If poor response, manage
as moderate acne
Topical benzoyl peroxide/retinoid combination (e.g. Epiduo®)
PLUS
Oral antibiotic (e.g. oxytetracycline)
Review at 8 weeks. If in remission, stop antibiotic at 12 weeks,
and continue topical treatment as maintenance.
If unsatisfactory response, switch oral antibiotic (e.g.
lymecycline) for 12 weeks and continue topical treatment.
If in remission, stop antibiotic and advice to continue topical
treatment as maintenance.
If response unsatisfactory, Consider routine referral to
Dermatology for further modality of treatment.
Urgent referral to
Community Acne clinic using
the proforma provided for
further treatment e.g. oral
isotretinoin. In the interim,
prescribe topical benzoyl
peroxide (e.g. Acnecide®)
and oral antibiotic (e.g.
oxytetracycline/Lymecycline).
Community Dermatology
Mayflower Healthcare
Alliance, 2019.
Use algorithm in conjunction with guidance notes. Always check compliance in patients with inadequate response to treatment. For females
requiring contraception, consider using combined contraceptive pill (Gedarel/Yasmin/Dianette).
Management of acne in the community
SEVREREMILD MODERATE
+

3. Guidance Notes
• Topical Retinoids are contraindicated in pregnancy and breastfeeding.
• Topical benzoyl peroxide and topical erythromycin are considered safe in
pregnancy.
• Topical antibiotics should always be prescribed in combination with benzoyl
peroxide – prevent bacterial resistance.
• Reduce frequency of topical applications initially if skin irritation occurs.
Gradually increase from once/twice a week to daily if tolerated.
• Refer for Isotretinoin therapy, if there is no response to two different courses of
antibiotics or if scarring occurs.
• Oral POC or Progestin implants may exacerbate acne.
• Co-cyprindiol (Dianette) or other ethinylestradiol/cyproterone acetate containing
products may be considered in moderate to severe acne where other treatments
have failed. Discuss risks and benefit with the patient.

4. Guidance Notes cont
• Topical retinoids should be used for all grades of acne.
• Azelaic acid may be beneficial in patients with darker skin where acne can cause
hyperpigmentation.
• Oral antibiotics should not be used as sole treatment.
• Oral Erythromycin is first line in pregnancy.
• Combination products improve adherence.
• Avoid use of topical antibiotics with oral antibiotics.
• Doxycycline may cause more photosensitivity than Lymecycline.
• Isotretinoin is not suitable for GP prescribing.

5. ISOTRETINOIN THERAPY
• Effective in resistant and severe cases.
• Can only be prescribed and will be monitored by Consultant led community
service/secondary care.
• Side effects include teratogenicity, hyperlipidaemia, dryness and irritation of
skin and mucous membranes, mood changes, etc.
• Women of child bearing potential need to be on effective contraception ONE
month before, during and ONE month after treatment;
• Usually registered with a pregnancy prevention programme.
• Dapsone – Can be helpful in resistant and severe cases, and in those who
cannot take isotretinoin.

6. Referral for Isotretinoin therapy
• Severe nodulo-cystic acne.
• Scarring/keloids
• Moderate acne that has failed to respond to two courses of 12 weeks oral
treatment with topical therapy.
• Severe variant of acne e.g Acne fulminans (need very urgent referral).
• Severe social or psychological problems secondary to acne (also Psych input).
Oral Isotretinoin –typically 0.5-1mg/kg/day x 4-6months. Cummulative dose 120-150mg/kg

7. Practical Advice
• Avoid over cleaning the skin –may cause dryness and irritation.
• Use non-comedogenic preparation make-up, cleansers and /or emollients.
• Avoid picking and squeezing spots which may increase the risk of scarring.
• Inform patient that treatment is effective but takes time to work ¬ up to 8 weeks.
• To maintain a healthy diet.
• Emphasize the importance of maintenance therapy.
• Benzoyl peroxide can bleach clothing but not skin.
• Use of non-comedogenic sunscreens may prevent tetracycline photosensitivity.

8. The formulary is simply a
guideline.
Ultimately, clinicians should
prescribe what is felt best for
patients.