Acne

Prescribing Notes:

• Mild to moderate acne includes people who have 1 or more of:
  • any number of non-inflammatory lesions (comedones)
  • up to 34 inflammatory lesions (with or without non-inflammatory lesions)
  • up to 2 nodules.
• Topical treatment takes at least 30 days to become effective.
• Adapalene + Benzoyl peroxide (Epiduo) – not for use during pregnancy, use with caution during breastfeeding. Can cause skin irritation, photosensitivity, and bleaching of hair and fabrics.
• The higher strength EpiDuo gel (adapalene 0.3% and benzoyl peroxide 2.5% gel) is recommended in the treatment of moderate acne that is mostly inflammatory in nature, when comedones and numerous papules and pustules are present e.g. on the entire face.
• Clindamycin + Tretinoin (Treclin) – not for use during pregnancy or breastfeeding. Can cause skin irritation and photosensitivity.
• Benzoyl peroxide + Clindamycin (Duac Once Daily) – can be used with caution during pregnancy and breastfeeding. Can cause skin irritation, photosensitivity, and bleaching of hair and fabrics.
• The choice of treatment depends on whether the acne is predominantly inflammatory or comedonal and its severity.
• Topical retinoids are recommended for comedonal acne; they may initially cause redness and peeling of the skin but this settles with time. Build up frequency and duration of application over 2-3 weeks, this may reduce redness. Several months of treatment may be needed to achieve an optimal response and the treatment should be continued until no new lesions develop.
• Exposure to sunlight of areas treated with retinoids should be avoided or minimised. Topical retinoids are best applied at night.
• Adapalene is less irritant than other topical retinoids.
• Trifarotene (Aklief) is approved for the cutaneous treatment of acne vulgaris of the face and/or the trunk in patients from 12 years of age and older, when many comedones, papules and pustules are present.
• Topical retinoids should be avoided in severe acne involving large areas.
• Tetracyclines and retinoids (systemic or topical) must be avoided in pregnancy.  Females of childbearing age must use effective contraception (oral progestogen-only contraceptives not considered effective) when using topical retinoids and related drugs including: adapalene, trifarotene, Epiduo gel and Treclin gel.
• Gel or cream is dependent on patient preference, typically gel is the preferred formulation for patients with acne. If the patient finds the gel formulation drying they may find the cream formulation more acceptable.

Prescribing Notes:

• Moderate to severe acne this includes people who have either or both of:
  • 35 or more inflammatory lesions (with or without non-inflammatory lesions)
  • 3 or more nodules.
• Adapalene + Benzoyl peroxide (Epiduo) – not for use during pregnancy, use with caution during breastfeeding. Can cause skin irritation, photosensitivity, and bleaching of hair and fabrics.
• The higher strength EpiDuo gel (adapalene 0.3% and benzoyl peroxide 2.5% gel) is recommended in the treatment of moderate acne that is mostly inflammatory in nature, when comedones and numerous papules and pustules are present e.g. on the entire face.
• Azelaic acid – not for use in pregnancy, during breastfeeding, or under the age of 12.
• People who cannot tolerate or have contraindications to oral lymecycline or oral doxycycline, consider replacing these medicines with oral erythromycin.
• Oral antibiotics may cause systemic side effects and antimicrobial resistance.
• Oral antibiotic duration is initially 12 weeks, then review. If acne has completely cleared consider stopping the antibiotic but continuing the topical treatment. If 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.
• Assess response to oral antibiotics at three months. If poor response, change to alternative oral antibiotic but continue for six months minimum.
• Oral tetracyclines can cause photosensitivity.
• Systemic antibacterial treatment is useful for inflammatory acne if topical treatment is not adequately effective. Systemic antibacterial treatment should always be accompanied with a topical treatment. If combination adapalene and benzoyl peroxide or azelaic acid is not tolerated alternative topical options include adapalene, trifarotene or benzoyl peroxide.
• Trifarotene (Aklief) is approved for the cutaneous treatment of acne vulgaris of the face and/or the trunk in patients from 12 years of age and older, when many comedones, papules and pustules are present.
• Tetracyclines and retinoids (systemic or topical) must be avoided in pregnancy. Females of childbearing age must use effective contraception (oral progestogen-only contraceptives not considered effective) when using topical retinoids and related drugs including: adapalene, trifarotene, Epiduo gel and Treclin gel.
• Switch to an alternative antibiotic if no response after 6 months.
• Antibiotics should not be co-prescribed by the systemic and topical route.
• For details on co-cyprindiol in relation to contraception and alternative combined oral contraceptive pill options see the Contraception recommendations in the Obstetrics, gynaecology, and urinary-tract disorders chapter of the formulary.
• The progesterone only contraceptive pill or progestin implants with androgenic activity should be avoided in females with acne.
• Co-cyprindiol is a treatment for moderate to severe acne where other treatments have failed and only in those patients may it also be used as an oral contraceptive. Co-cyprindiol should be withdrawn 3-4 cycles after the treated condition has completely resolved. If ongoing contraception is required, substitution with another combined oral contraceptive is likely to maintain the improvement.
• Co-cyprindiol is no more effective than an oral broad-spectrum antibacterial.
• Co-cyprindiol should not be used solely for contraception due to a higher risk of venous thromboembolism than low-dose combined oral contraceptives. The risk of VTE is rare but this remains an important side effect. Healthcare professionals should be vigilant for signs of DVT or PE in patients prescribed co-cyprindiol.
• Gel or cream is dependent on patient preference, typically gel is the preferred formulation for patients with acne. If the patient finds the gel formulation drying they may find the cream formulation more acceptable.

Prescribing Notes:

• Treatment failure of severe acne with oral antibiotics indicates referral to a consultant dermatologist for consideration of treatment with oral isotretinoin. Oral isotretinoin (Roaccutane) is a toxic and teratogenic drug. Isotretinoin should be prescribed only by, or under the supervision of, a consultant dermatologist and be dispensed by a hospital-based pharmacy. Prescribers include medical and non-medical prescribers with competence to prescribe retinoids for the treatment of severe acne. Prescription of systemic isotretinoin for women is only possible if adequate contraception is undertaken (Pregnancy prevention programme). See MHRA Drug Safety Update and manufacturer’s risk minimisation materials on the electronic medicines compendium for oral isotretinoin preparations.
• Isotretinoin is a black triangle medicine and all suspected adverse reactions, including any sexual and psychiatric adverse reactions, should be reported via the Yellow Card scheme. For further advice, see MHRA Drug Safety Update.

Prescribing Notes:

• The choice of therapy in children less than 12 years depends on age, severity and whether the acne is predominantly inflammatory or comedonal. Refer to the BNF for children for guidance on neonatal and infantile acne.
• Mild to moderate acne includes people who have 1 or more of:
  
  • any number of non-inflammatory lesions (comedones)
  • up to 34 inflammatory lesions (with or without non-inflammatory lesions)
  • up to 2 nodules.
• Topical treatment takes at least 4-6 weeks to become effective. Review topical treatment after 3 months.
• Topical retinoids are recommended for comedonal acne; they may initially cause redness of the skin. Build up frequency and duration of application over 2-3 weeks, this may reduce redness.
• Exposure to sunlight of areas treated with retinoids should be avoided or minimised. Topical retinoids are best applied at night.
• Adapalene is less irritant than other topical retinoids.
• Patient information leaflets can be accessed from the British Association of Dermatologists.
• As females are reaching puberty it is important to note that females of childbearing age must use effective contraception when using topical retinoids and related drugs including: adapalene, isotretinoin, tretinoin, Epiduo gel and Aknemycin Plus solution.
• Topical antibiotics are as effective as oral antibiotics but encourage resistance and are more expensive.
• Antibacterial resistance of Propionibacterium acnes is increasing, for information on prescribing considerations and how to avoid development of resistance see BNFc guidance on topical antibacterials for acne.
• Avoid using different topical and systemic antibacterials concurrently to reduce the likelihood or resistance developing.
• Topical combination products are available and may enhance compliance.
• Adapalene + Benzoyl peroxide (Epiduo) – not for use during pregnancy, use with caution during breastfeeding. Can cause skin irritation, photosensitivity, and bleaching of hair and fabrics.
• For steroid related acne see Rosacea pathway.

Prescribing Notes:

• The choice of therapy in children less than 12 years depends on age, severity and whether the acne is predominantly inflammatory or comedonal. Refer to the BNF for children for guidance on neonatal and infantile acne.
• Moderate to severe acne this includes people who have either or both of:
  
  • 35 or more inflammatory lesions (with or without non-inflammatory lesions)
  • 3 or more nodules
• Adapalene + Benzoyl peroxide (Epiduo) can cause skin irritation, photosensitivity, and bleaching of hair and fabrics.
• Oral clarithromycin may be considered as an alternative to oral erythromycin.
• Oral antibiotics may cause systemic side-effects and antimicrobial resistance.
• Review response to oral antibiotic therapy at 3 months. If acne has completely cleared, consider stopping the antibiotic but continuing the topical treatment. If 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.
• Assess response to oral antibiotics at 3 months. If poor response switch to an alternative oral antibiotic but continue for six months minimum.
• Systemic antibacterial treatment is useful for inflammatory acne if topical treatment is not adequately effective. Systemic antibacterial treatment should always be accompanied with a topical treatment. If combination adapalene and benzoyl peroxide is not tolerated or not suitable for the age of the child alternative topical options include adapalene, or benzoyl peroxide.
• Avoid using different topical and systemic antibacterials concurrently to reduce the likelihood of resistance developing.
• Patient information leaflets can be accessed from the British Association of Dermatologists.
• As females are reaching puberty it is important to note that females of childbearing age must use effective contraception when using topical retinoids and related drugs including: adapalene, isotretinoin, tretinoin, Epiduo gel and Aknemycin Plus solution.
• For steroid related acne see Rosacea pathway.

Prescribing Notes:

• Treatment failure of severe acne with oral antibiotics indicates referral to a consultant dermatologist for consideration of treatment with oral isotretinoin. Oral isotretinoin (Roaccutane) is a toxic and teratogenic drug. Isotretinoin should be prescribed only by, or under the supervision of, a consultant dermatologist and be dispensed by a hospital-based pharmacy. Prescribers include medical and non-medical prescribers with competence to prescribe retinoids for the treatment of severe acne. Prescription of systemic isotretinoin for women is only possible if adequate contraception is undertaken (Pregnancy prevention programme). See MHRA Drug Safety Update and manufacturer’s risk minimisation materials on the electronic medicines compendium for oral isotretinoin preparations.
• Isotretinoin is a black triangle medicine and all suspected adverse reactions, including any sexual and psychiatric adverse reactions, should be reported via the Yellow Card scheme. For further advice, see MHRA Drug Safety Update.

Prescribing Notes:

• Topical treatment takes at least 30 days to become effective.
• May bleach clothing.
• Wash with mild soap and lukewarm water, no more than twice a day.
• May cause dry skin. If necessary use a water-based moisturiser. A moisturiser containing paraffin products may cause blocked pores.

Examples of Counselling Points
Benzoyl peroxide may bleach clothing.

When to advise patient to contact GP
Acne in the very young.
Severe acne.
Acne causing scarring.
Failed medication (no improvement in 2 months).
Suspected drug-induced acne.