ACNE
Explain the diagnosis and provide patient information
Discuss treatment aims.
Advise
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🚫 over cleaning (dryness and irritation). Not caused by poor hygiene and BD washing with a gentle soap and fragrance-free cleanser
If cosmetics are used, non-comedogenic preparations with pH close to the skin ✅
🚫 picking and squeezing spots which may increase the risk of scarring.
Tx effective but take time to work (usually up to 8 weeks) and may irritate the skin, especially at the start
healthy diet. ✅
MILD-MODERATE
Single TOPICAL treatment
Topical RETINOID +/- benzyl peroxide.
AZELAIC ACID [20%]
e.g. adapalene
retinoids 🚫pregnancy and breastfeeding
Topical ANTIBIOTIC + ALWAYS WITH benzoyl peroxide ( ❌ bacterial resistance)
e.g. clindamycin 1%
Topical BP + topical erythromycin ✅ pregnancy if treatment felt to be necessary.
OR
OR
Application
Creams / lotions may be preferable for people with dry or sensitive skin. Less greasy gels may be preferable for people with oily skin.
Concentration or application frequency of topical treatments may need to be reduced or lowered if skin irritation occurs.
frequency of application can be gradually increased from once or twice a week to OD if tolerated.
MODERATE - NOT RESPONDING TO TOPICAL
consider ADDING an ORAL tetracycline (for max 3/12).
ie lymecycline or doxycycline
always coprescribe with a TOPICAL retinoid OR benzoyl peroxide - ❌ antibiotic resistance
Macrolides (erythromycin) generally 🚫 due to high levels of P. acnes resistance but can be used if tetracyclines are CI (e.g. pregnancy)
---Change to an alternative abx if no improvement after 3 months, the person is unable to tolerate SE or acne worsens
NO RESPONSE to TWO different courses, or if starting to SCAR
REFER to DERM ? isotretinoin 👥
COCPs (if not CI) + topical agents = alternative to po antibiotics
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progesterone only pills or progestin implants with androgenic activity may exacerbate acne, --- third and fourth generation COCPs are generally preferred.
Co-cyprindiol (Dianette®) or other ethinylestradiol/cyproterone acetate containing products can be considered in moderate to severe acne where other tx have failed but require careful discussion of the risks and benefits with the patient.
Use should be discontinued 3 months after acne controlled and Rx guided by UK MEC for Contraceptive Use and the SPC for the individual product.
Refer
Refer, with urgency depending on the clinical situation if:
severe variant of acne i.e. acne conglobata or acne fulminans IMMEDIATE REFERRAL
Severe acne + visible scarring or risk of scarring/ significant hyperpigmentation — primary care tx should be initiated
Multiple failed tx
Significant psychological distress (regardless of severity)
Diagnostic uncertainty.
? underlying endocrinological cause for the acne (PCOS) that needs assessment
During COVID - cannot give initial treatment in the practice so if any signs of severe attack then admit. If moderate can I give initial tx??