Acne vulgaris: management
Notice
• Provide written information about acne—reassure that the skin is not dirty and that you
can help.
• Explain that all treatments take 3–4 months to have a maximal effect and that acne may
get a little worse before it gets better. Treatment may have to be continued for months or
even years.
• If acne is not responding to treatment (and the patient is following doctor's advice), any
different diagnosis? Is there an underlying systemic disease?
Mild acne
Start one or more topical preparations (combination more effective than monotherapy).
Explain treatment should be applied to all the skin, not just ‘spots’. Continue treatment
for at least 4 months and usually longer. topical preparations (cream, gel, or lotion) may
include:
• Antibiotics, e.g. erythromycin or clindamycin lotion.
• Benzoyl peroxide 2.5% (as effective and less irritant than higher percentage, bleaches
clothing; can combine with a topical retinoid).
• Topical retinoid (avoid in pregnancy), e.g. tretinoin, isotretinoin, or 0.1% adapalene (a
retinoid-like drug). All are irritants and may cause post-inflammatory hyperpigmentation
in dark skin. Increase contact time gradually, washing off after 30–60min at first.
Moderate acne
• Oral antibiotics for a 4-month course initially, e.g. oxytetracycline 500mg bd,
lymecycline 408mg/day, or erythromycin 500mg bd, combined with topical benzoyl
peroxide to reduce the incidence of bacterial resistance to antibiotics. Do not combine
with a topical antibiotic. Avoid tetracyclines in children aged <12 years.
• ♀: oral contraceptive with anti-androgen activity such as co- cyprindiol (takes 6 months
to have maximal effect). Avoid contraceptive pills containing norethisterone (androgenic
properties).
Severe acne or acne with a major psychosocial impact
• Refer to a specialist. the oral retinoid isotretinoin may be the best option
(0.5–1.0mg/kg/day; cumulative dose 120–150mg/kg). Isotretinoin is teratogenic. Other
adverse effects include mucosal dryness and, very rarely, depression. Contraception
essential in women of childbearing age during treatment and for 1 month after stopping
isotretinoin.
• Cysts: intralesional triamcinolone (0.1mL of 2.5–10mg/mL solution).
Scars
• Shallow scars become less obvious with time. Refer for cosmetic camouflage (see
Changing Faces, available at: https://www. changingfaces.org.uk/home).
• Surgical approaches (chemical peels, lasers, dermabrasion) may improve the
appearance of deep scars and are not indicated until acne has been controlled.