Acne vulgaris, affecting primarily young individuals, is a common skin condition characterized by lesions on the face, chest, and back. Treatment aims to alleviate severity, prevent recurrence, and minimize scarring, considering individual preferences and disease characteristics. Standardizing treatment protocols is essential due to variability in clinical practice, with antibiotic therapy requiring adherence to antimicrobial guidance and policies to mitigate resistance risks. Thus, the National Institute for Health and Care Excellence (NICE) has updated guidelines for acne vulgaris, ensuring that individuals receive the best possible care and support.

 

Information and support for people with acne vulgaris

Provide individuals with acne clear and tailored information covering: possible causes, treatment options (including over-the-counter remedies), benefits and drawbacks of treatments, acne's potential impact, adherence importance, and managing relapses. Include parents or carers in discussions for support when needed, especially for those with cognitive impairment.

 

Skincare advice

Recommend acne-affected people to use a non-alkaline synthetic detergent cleansing product twice daily and to avoid oil-based or comedogenic skincare products, including moisturizers, sunscreens, and makeup. Additionally, emphasize the importance of removing makeup at day end and discourage constant scratching or picking of acne lesions to reduce scarring risk.

 

Diet

Inform individuals that there is insufficient evidence to endorse specific diets for alleviating acne.

 

Referral to specialist care

Promptly refer those dealing with acne fulminans to the hospital dermatology team for examination within twenty-four hours. Refer to a nationally accredited general practitioner with an extended role or a consultant dermatologist-led team for diagnostic ambiguity, severe acne types, scarring, or stubborn pigmentary changes. Consider referral for psychological distress or mental health disorders, especially for those battling suicidal ideation or severe depressive/anxiety disorders. Additionally, consider condition-specific management or referral to specialists if medical ailments or medications are contributing to acne.

 

Managing acne vulgaris

(a) First-line therapeutic options

Offer individuals with acne a 12-week course of first-line treatment options, considering severity and preferences, such as fixed combinations of topical agents like adapalene with benzoyl peroxide or tretinoin with clindamycin, tailored to their needs. Topical benzoyl peroxide monotherapy can be deemed as an alternative if contraindications exist or if individuals prefer to avoid certain medications. For moderate to severe acne intolerant to or contraindicated for oral antibiotics, take into account alternative oral options like trimethoprim or macrolides in combination treatments.

(b) Factors to take into account during consultations

Acknowledge that acne, regardless of severity, can trigger psychological distress and mental health issues. Emphasize the importance of completing the treatment course, highlighting that positive effects may take 6 to 8 weeks to manifest.

(c) Factors to consider when selecting a treatment option

Consider acne severity and duration, which magnify scarring risk. Begin topical treatments cautiously to minimize skin irritation. Discuss contraception and evade the utilization of oral or topical antibiotics alone for acne relief. If oral isotretinoin is a potential future option, exhaust standard therapies first.

(d) Factors to contemplate at review

At 12 weeks, assess treatment effectiveness and side effects. Consider discontinuing oral antibiotics if acne clears completely, or if continuing for partial improvement. Limit antibiotic use to exceptional cases beyond 6 months due to resistance risk. Explore maintenance options for cleared acne and offer alternatives or refer for non-responsive cases.

(e) Oral isotretinoin use

Following the Medicines and Healthcare products Regulatory Agency (MHRA) guidance for protective actions, consider oral isotretinoin for severe acne resistant to standard therapy, such as nodulo-cystic or acne at risk of scarring. Inform individuals fully about potential risks and benefits, including mental health effects, and involve them in decision-making. Emphasize the importance of contraception due to teratogenicity and prescribe isotretinoin at a standard daily dose of 0.5 to 1 mg/kg, adjusting if necessary for adverse effects. Monitor mental health regularly during treatment and advise seeking medical help if concerns arise.

(f) Incorporating oral corticosteroids along with oral isotretinoin

Consider incorporating a course of oral prednisolone if an acne flare (acute considerable deterioration) happens following initiating oral isotretinoin. Additionally, when commencing oral isotretinoin for acne fulminans, contemplate the addition of oral prednisolone for acne flare prophylaxis.

(g) Physical therapies

Contemplate photodynamic therapy for adults suffering from moderate to severe acne if other therapies are contraindicated, not tolerated, or inefficient.

(h) Usage of intralesional corticosteroids

Consider tackling severe inflammatory cysts using intralesional injection of triamcinolone acetonide. This procedure must be executed by a member of a consultant dermatologist-led team or nationally accredited general practitioners with extended roles working within a mutually agreed pathway.

(i) Therapeutic options for polycystic ovary syndrome (PCOS) sufferers

For those with PCOS and acne, initial treatment must encompass first-line options. If these are ineffective, consider supplementing with ethinylestradiol with cyproterone acetate (co-cyprindiol) or another combined oral contraceptive pill. Review co-cyprindiol use at six months. Also, discuss continuation or substitute therapeutic options. Additionally, consider referral to a specialist, such as a reproductive endocrinologist, for those struggling with PCOS and additional features of hyperandrogenism.

 

Relapse

If acne relapses after an initial successful treatment, options include repeating the same treatment or trying an alternative for another 12-week course. For cases where acne relapses after responding well to oral isotretinoin and is mild to moderate, offer appropriate treatment options. If it relapses and is moderate to severe, provide either another 12-week course of treatment or re-referral to a dermatologist-led team for further management.

 

Maintenance

After completing acne treatment, maintenance may not always be obligatory, but it's advised for individuals with a history of frequent relapse. For maintenance, topical adapalene and benzoyl peroxide (fixed combination) is suggested. Alternatives incorporate adapalene, azelaic acid, or benzoyl peroxide monotherapy if the combination isn't well-tolerated. Reviewing maintenance treatments after 12 weeks aids to ascertain ongoing necessity.

 

Management of acne-related scarring

Individuals with acne-related scarring must be addressed with tailored information considering their concerns. This encompasses comprehending the causes of scarring, managing ongoing acne to prevent further scarring, exploring therapeutic options for existing scars, discussing potential changes in scar appearance over time, and addressing any psychological distress. For severe and persistent scarring lasting a year post-acne clearance, referral to a dermatologist-led team is suggested, where treatments such as CO2 laser or glycolic acid peel may be taken into consideration.