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Acne Vulgaris

NICE Clinical Guideline [NG198] Acne vulgaris: management. Last Updated: Dec 2023. NICE CKS Acne Vulgaris. Last Updated: Nov 2023.

Background Information

Acne: blockage and inflammation of the pilosebaceous unit (hair follicle + hair shaft + sebaceous gland)

2 main presentations:
  • Comedones: non-inflammed follicular plugs
  • Papules and pustules: inflammatory acne lesions

Processes involved in pathogenesis:
  • Proliferation of Cutibacterium acnes
  • Androgen-induced seborrhoea 
  • Altered follicular keratinocyte proliferation

Main risk factors:
  • Family history 
  • State of high androgen
    • Puberty
    • Polycystic ovarian syndrome
    • Other conditions associated with hyperandrogenism

Affected site:
  • Face (99%)
  • Back (60%)
  • Chest (15%)

Clinical features:
  • Comedones
    • Open comedones (blackheads): dark open portion of sebaceous material
    • Closed comedones (white heads): closed small round lesions with white material (sebum and shed keratin)
 
  • Inflammatory acne: occurs when follicle burst and release irritants, red +/- painful
    • Papular / pustular acne: <5mm, arise from comedones
    • Nodulocystic acne: >5mm commonly affect neck and back
    • Acne conglobata: severe form of nodulocystic acne with interconnecting sinus and abscess
    • Acne fulminans: rare severe form characterised by painful ulcerative skin lesions and systemic upset
 
  • Seborrhoea - common
  • Scarring
  • Pigmentation 

 

Factors that distinguish acne vulgaris from acne rosacea:

  • Scarring is only present in acne vulgaris
  • Comedones are only present in acne vulgaris

2 main severities outlined by NICE:
 
Severity Criteria (≥1 features)
Mild to moderate
  • Any number of comedones
  • <35 inflammatory lesions
  • <3 nodules
Moderate to severe
  • ≥35 inflammatory lesions
  • ≥3 nodules
 

Guidelines

Refer to secondary care if any of the following:
  • Acne fulminans - same day referral 
  • Acne conglobata 
  • Nodulo-cystic acne
  • Uncertain diagnosis

Consider referral if any of the following:
  • Mild to moderate acne not responded to 2 courses of treatment
  • Moderate to severe acne not responded to oral antibiotics
  • Acne with scarring
  • Acne associated with psychological distress / mental health disorder
  • Acne with persistent pigmentary changes

Offer skin care advice:
  • Non-alkaline (pH neutral / slightly acidic) synthetic detergent cleansing product BD
  • Remove make-up at the end of the day
  • Avoid oil-based and comedogenic skin care products and sunscreens
  • Avoid picking and scratching acne lesions (↑ risk of scarring)

NICE says there is not enough evidence to support specific diets for acne.

Remembering the exact treatment options for acne can be confusing and challenging. However, remembering the DONT's and contraindications, it will ease you in MCQ exams. 

 

NICE states NOT to offer:
  • Antibiotic monotherapy (topical / oral) 
  • Combination of topical and oral antibiotic 

Pregnancy contraindications:
  • Any form of retinoids (topical / oral)
  • Tetracycline 

Medications safe for pregnancy:
  • Erythromycin 
  • Topical clindamycin
  • Topical benzoyl peroxide

Offer 12-week course of dual therapy from a choice of below:
 
Severity Choice of Therapy
Any 
  • Fixed combination topical adapalene + topical benzoyl peroxide 
  • Fixed combination topical tretinoin + topical clindamycin

**Adapalene and tretinoin are retinoids
Mild to moderate
  • Options from 1st row
  • Fixed combination topical benzoyl peroxide + topical clindamycin
Moderate to severe
  • Options from 1st row
  • Options with oral antibiotic:
    • Oral tetracycline (doxycycline / lymecycline) + fixed combination topical benzoyl peroxide + topical adapalene 
    • Oral tetracycline (doxycycline / lymecycline) + topical azelaic acid

**Alternative to tetracycline: trimethoprim / macrolide 

NICE also recommends to consider COCP + topical agents as an alternative to systemic antibiotics in women

 

Oral antibiotics are only indicated in moderate to severe acne, make sure to combine it with topical therapy (non-antibiotic!).

Topical benzoyl peroxide monotherapy

Standard dose: 0.5-1 mg/kg until total cumulative dose of 120-150 mg/kg (but consider discontinuing sooner if adequate response and now acne lesions for 4-8 weeks)
  • Only to be considered in >12 y/o with severe form of acne that is resistant to adequate courses of standard therapy with topical therapy and systemic antibiotic 

Important safety information from MHRA:
  • Teratogenic
  • Assess prior initiating and counsel patients about:
    • Mental health side effects
    • Sexual function side effects
  • 2 independent prescribers need to agree the initiation of isotretinoin in patients under 18 years

  • Photodynamic therapy 
  • Intralesional triamcinolone acetonide (corticosteroid) for severe inflammatory cysts

Offer review first line therapy at 12 weeks.

If there is inadequate response to 12 week course of 1st line therapy:
  • Mild to moderate: offer alternative option from above
  • Moderate to severe:
    • No antibiotic used → offer option with oral antibiotic
    • Antibiotic used already → consider referral

Encourage appropriate skin care and consider maintenance therapy only in those with history of frequent relapse:
  • 1st line: fixed combination topical benzoyl peroxide + topical adapalene
  • 2nd line: monotherapy topical adapalene / azelaic acid / benzoyl peroxide
  
 

In short, only offer topical non-antibiotic therapy in maintenance therapy, if indicated.

If scarring persists 1 year after acne cleared → refer to specialist to consider:
  • CO2 laser treatment 
  • Glycolic acid peel

References

Author: Adams Lau
Reviewer: 
Last Edited: 20/03/25