Introduction

  • Virtually every adolescent has a few ‘spots’, however, about 15% of the adolescent population have sufficient problems to seek treatment. In most patients, but not all, the acne clears up by the late teens or early 20s
  • More severe acne tends to last longer. A group of patients have persistent acne lasting up to the age of 30 to 40 years, and sometimes beyond. Patients with persistent acne often have a family history of persistent acne. Acne may scar—most of the time this is preventable by using the correct treatment given in a timely fashion

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 and/or less frequent application. 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
  • Benzoyl peroxide 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. Erythromycin is second line (first line in pregnancy) due to high bacterial resistance. Trimethoprim is an option, but uncommonly used in primary care
  • Oral contraceptives: unopposed progesterones (including long-acting reversible contraceptives) can make acne worse. Second and third generation combined oral contraceptives are generally preferred. Co-cyprindiol 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. Combination products improve adherence

Overview of combination products for the treatment of acne

Generic name Advantages Disadvantages
0.1% adapalene with 2.5% benzoyl peroxide No issue with antibiotic resistance Anticomedonal Irritation can be a problem
1% clindamycin with 0.025% tretinoin Broad spectrum of action Anticomedonal Rapid onset of action on imflammatory lesions Two strengths available
1% clindamycin with 3% benzoyl peroxide Antibiotic resistance may limit the duration of treatment No action on comedones

Primary care treatment pathway of acne

 

Maintenance

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 glycaemic index 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:

References

Full guidelines available from… 2nd Floor, Titan Court, 3 Bishop Square, Hatfield, UK, AL10 9NA (Tel—01707 226024) www.pcds.org.uk Primary Care Dermatology Society. Acne—primary care treatment pathway. November 2015