Acne Pathway
ND CCG
Acne Pathway
Version number
Date approved – do we need a process to approve them before
they are issued?
0.1
Status
Owner
Review date
Draft
Dr Louise Moss
August 2015
Version date
Document history
Version
0.1
0.2
0.3
0.4
Date
30 Apr 13
22 May 13
11 June 13
22 August 13
Updated: 22 August 2013
Details
Draft version produced for review by the group
Updated draft after review GP dermatology group
Updated draft after review by Guidelines Group
Updated after review by JAPC
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Acne Pathway
ND CCG
Aim/outline
Acne vulgaris is a very common condition which can cause significant physical and psychological
morbidity

About 15% of the adolescent population have sufficient problems to seek treatment. This is an
age when self-esteem is very important.

Although in most patients acne clears up by the early 20s, more severe acne tends to last longer
and a group of patients have persistent acne lasting up to the age of 30 - 40 years

Acne may scar – most of the time this is preventable by using the correct treatment given in a
timely fashion

Acne makes up a significant proportion of referrals to hospital dermatology clinics-14% of the
rashes referred to the community GPwSI service in 2009.
Given the large numbers of patients who suffer from acne, it is important that these should be managed
effectively in the community in the majority of cases. Early effective treatment for all with the condition will
prevent scarring and promote self-esteem. Hospital referral should be reserved for those patients
requiring hospital only drugs to control their disease.
The aim of this pathway is to enable GPs to manage acne more effectively within the community
and to improve the appropriateness of their dermatology referrals to secondary care. It is hoped
this may lead to reduced referral rates.
Guideline Developed by, and Contacts for Advice:
Primary care
Dr Louise Moss
Moss Valley Medical Practice
01246 439101
louise.moss@nhs.net
Dr Liz Riches
Chatsworth Road Medical Practice
01246 568065
liz.riches@nhs.net
Secondary Care
Dr Colver
Chesterfield Royal Hospital
All patients diagnosed with acne vulgaris in the community.
Who?

Diagnosis
Take a good skin history.
- How long have they had acne?
- Family history?
- What previous treatments have they tried? What sort of response have
they had? Were there side effects? Are they compliant? Have there been
gaps in treatment?
- How does their acne affect them?
- Are there any aggravating features? E.g. use of anabolic steroids, oilbased cosmetics, topical/oral steroids, lithium, ciclosporin, oral iodides in
Updated: 22 August 2013
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Acne Pathway
ND CCG
homeopathic remedies.

Look carefully at their skin and try to grade the acne so you will be
able to assess whether there is improvement when they come for
review.
- Is it mild, moderate or severe?
- Comedonal (black & white-heads) or inflammatory (papules, pustules and
nodules present) or a mixture?
- Is there any scarring present? Type -‘ice-pick’/ keloid?

Investigation?
- In those women with features of polycystic ovarian syndrome e.g.
oligomenorrhoea, hirsuitism consider doing a testosterone level to exclude
a male virilising tumour.
Use a patient information leaflet and talk patient through why you are
using each treatment.
Talk about the need to treat as many of the major aetiological features as
possible and which treatment works for each:A. androgen induced excess sebum production (1st line option COC/
2nd line option co-cyprindiol 2000/35)
B. comedone formation (topical retinoid e.g. adapalene)
C. inflammation (benzoyl peroxide e.g. Acnecide gel or Quinoderm
cream)
D. infection- colonisation with P. acnes (antibiotics – topical or oral)

Management


Mild comedonal acne - start with topical retinoid e.g. adapalene
(Differin) cream or gel is the formulary choice.
Apply at night – wash off after 1.5 hours initially to reduce side effects.
Warn patient that they may suffer from irritant dermatitis. To reduce the
effect of this use a water based moisturiser and consider washing off after
a shorter length of time/using alternate days to start with and gradually
build up treatment. Reinforce the importance of this treatment for
comedones and that there is no better alternative.
Topical retinoids are contra-indicated in pregnancy; women of child-bearing
age must use effective contraception (oral progesterone-only
contraceptives not considered effective). Note other warnings and cautions
in the BNF including avoid UV light exposure or use appropriate sunscreen
or protective clothing.

Mild inflammatory acne (papular/pustular) - use both a topical antiinflammatory agent (benzoyl peroxide) e.g. Quinoderm cream / Acnecide
5% gel and an antibacterial one e.g. clindamycin (Dalacin T topical solution
or lotion). If there are comedones add a topical retinoid as well. Consider
using combination products e.g. Duac Once Daily gel (clindamycin &
benzoyl peroxide) or Epiduo gel (adapalene & benzoyl peroxide 2.5%)
although these tend to be more expensive.

Moderate acne - combine systemic & topical treatment
- Quinoderm / Acnecide cream in the morning
- Topical adapalene at night e.g. Differin cream or gel
- Oral antibiotics
First-line – use a tetracycline (contra-indicated in under 12 years,
pregnancy and breast feeding)
Doxycycline 100mg daily
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ND CCG
(formulary choice – can be taken with food, warn re. possible sun
sensitivity)
Lymecycline 408mg daily - an alternative if photosensitive with doxycycline
(Note - Minocycline is not recommended due to greater risk of lupus
erythematosus-like syndrome, and can cause irreversible pigmentation)
Second-line – erythromycin 500mg twice daily (NB European acne
guidelines - increasing problem of microbial resistance to erythromycin so
in general reserve for cases where tetracyclines not tolerated or are
contraindicated e.g. pregnancy & breastfeeding)
Third-line – trimethoprim 300mg twice daily for acne resistant to other
antibacterials (unlicensed indication) - CARE may depress haematopoiesis
if used for long periods BNF states that it should generally be initiated by
specialists.
Do not use oral and topical antibiotics together- this may cause bacterial
resistance
 Moderately severe acne in women- consider adding co-cyprindiol
2000/35 (if no contra-indications). Once sustained improvement (3 months)
consider changing to an oestrogenic COC e.g. Gedarel 30/150 to prevent
rebound.

Monitoring
Patient info
Referral
criteria
Acne in pregnancy – Benzoyl peroxide, topical and oral erythromycin are
all considered safe if treatment considered appropriate.
Severe acne- as for moderate acne but consider early referral for oral
isotretinoin if large nodulocystic lesions, scarring or no rapid response to
treatment.
Review after two months. Tell your patient that if their treatment is working
well they can expect 50% improvement at this point, no more.
If there is little improvement assess compliance.
If no better consider doubling the dose of doxycycline to twice daily (note this is
above the BNF recommended dose for acne, patients may also get increased
side effects) and reviewing after a further two months. If no better after four
months swap to a second-line antibiotic.
Remember to reinforce use of topical benzoyl peroxide and adapalene.
Antibiotic monotherapy is poor management and will only partially treat the
acne process!
In order to minimise the development of antibiotic resistance –
Always use benzoyl peroxide alongside oral antibiotics – even intermittent
treatment can help prevent this developing.
Stop systemic antibiotics after sustained improvement (3 months) and continue
topical treatment.
There are good patient acne information leaflets at
www.bad.org.uk and www.pcds.org.uk
The acne information leaflet used at CRHFT is in appendix A.
If you are considering referring for oral isotretinoin you can give them a copy of
the leaflet in appendix B. If they wouldn’t consider taking this then you may
save a referral.
 Severe acne - refer early for oral isotretinoin if large nodulocystic lesions,
scarring or no rapid response to treatment
 Moderately severe acne which has not responded to 2 x 4 month courses
of different antibiotics PLUS topical treatment, especially if starting to scar.
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Acne Pathway
ND CCG
Refer only
Routine
Clinic
information
Additional
Information
Appendices
 Patients with severe psychological symptoms.
Those requiring oral isotretinoin. Do FBC, fasting lipid profile and liver function
tests first. If they are female make sure they are on contraception (even if they
are not sexually active) as otherwise their treatment will be delayed until they
start this and will need an additional hospital appointment.
First Outpatient appointment = £119
Follow up appointment = £67
If a referral is required book against the following on the Choose and Book system:
Speciality : Dermatology
Clinic Type: Not otherwise specified
www.bad.org.uk- patient information leaflet
www.pcds.org.uk/clinical-guidance-and-guidelines
Appendix A- CNDRH Acne leaflet
Appendix B- Oral isotretinoin leaflet
Appendix C- Leeds acne grading scale
Updated: 22 August 2013
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