A guide to prescribing acne treatment in primary care.
Mild acne –Benzoyl peroxide 2.5 % or 5 % once or twice a day Benzoyl peroxide – cheapest option- works quickly and can be as effective as topicl retinoids branded examples include Acnecide gel 5 % Azelaic acid 20 % BD Topical erythromycin 2-4 % bd or clindamycin 1 % BD Topical retinoid Tretinoin 0.01 % or 0.025 % once or twice a day Adapalene 0.1 % nocte Isotretnoin 0.05 % BD Topical retinoids – warn that it may irritate the skin -can be started slowly for eg once or twice a week and then increased gradually to every day. You cal also advie to consider ↑ ing the application time gradually for e.g start with 15-30 mins and increase gradually to overnight.
Mild to moderate acne-Use of combination treatment for e.g Benzoyl peroxode + an antibiotic like erythromycin or clindamycin Benzoyl peroxide + clindamycin ( Duac® ) Benzoyl peroxide + a topical retinoid for e.g adapalene 0.1 % ( Epiduo® gel ) Topical retinoid + a topical antibiotic for e.g Tretnoin 0.025 % + clindamycin 1 % ( Treclin® ) . Topical erythromycin ( Zineryt® ) ↑ ing resistance ) Consider using topical antibiotic in combination with BPO or a retinoid rather than in isolation
Severe acne –More extensive lesions or unresponsive to topical therapy or truncal disease where topical application is difficult Systemic treatment + topical retinoid / BPO Discontinue topical antibiotic Oral antibiotic for atleast 3 months choose from the following commonly used preparations ○ Doxycyline 50-100 mg od ○ Lymecylcine 409 mg od ○ Oxytetracycline 500 mg bd ○ Erythromycin 500 mg bd In female patient an OCP can be used in combination with topical treatment or systemic antibiotics Dianette® is licensed for severe acne but increases the risk of VTE- the risk is 1.5 to 2 times higher than for COCs with levonorgestrel and may be similar to the risk with contraceptives containing gestodene , desogestrel or drospirenone. Yasmin is also considered to be a good choice but POPs worsen acne.
Topical retinoids and tetracyclines including oral formulations are contra-indicated in pregnancy. Females of child bearing age must use effective contraception ( oral progestogen-only contraceptives not considred effective ) BNF
References Swindon CCG & Wiltshire Acne Prescribing Guidelines – Clinical Management in Primary Care Cambridgeshire and Peterborough Clinical Commissioning Group Acne Pathway Coventry and Rugby Clinical Commissioning Group Acne Vulgaris