NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is mild acne.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Benzoyl peroxide and azelaic acid

Benzoyl peroxide 5%

• Gel (£7.07 = 30g)

Indications

• Mild to moderate acne

Dose

• Apply 1–2 times daily preferably after washing with soap and water, start treatment with lower-strength preparations.
• If skin irritation occurs, reduce frequency or suspend use until irritation subsides and re-introduce at reduced frequency.

Notes

1. Avoid excessive exposure to sunlight.
2. May bleach fabrics and hair.

Duac Once Daily

(Benzoyl peroxide 5% plus clindamycin 1%)

• Gel (£13.14 = 30g)

Indications

• Moderate acne
• Unresponsive mild acne

Dose

• Apply once daily in the evening

Notes

1. Treatment with Duac Once Daily Gel should not exceed more than 12 weeks of continuous use.

Azelaic acid

• Gel 15% (£7.48 = 30g)
• Cream 20% (£4.49 = 30g)

Indications

• Mild to moderate acne
• May be useful for post inflammatory hyperpigmentation associated with acne
• Mild papulopustular rosacea (gel – first line indication)

Dose

• Apply twice daily. In cases of sensitive skin, once daily for first week (cream) or once daily until irritation ceases (gel)
• Finacea gel – discontinue if no improvement after 1 month for acne or 2 months for rosacea.

Topical retinoids and related preparations for acne

Patients should be advised:

• Redness and skin peeling may occur initially, but usually settles with time
• Exposure to UV light (including sunlight, solariums) should be avoided; if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used (even on a bright but cloudy day).
• To allow peeling (e.g. from benzoyl peroxide) to subside before using a topical retinoid
• Alternating a preparation that causes peeling with a topical retinoid may give rise to contact dermatitis (reduce frequency of retinoid application)
• Use of retinoids with abrasive cleaners, comedogenic or astringent cosmetics should be avoided.
• To avoid accumulation in the angles of the nose
• Use with caution in sensitive areas such as the neck

MHRA Drug Safety Update (June 2019): Teratogenic risk and risk of neuropsychiatric reactions with topical retinoids

• Systemic exposure is thought to be negligible following application of topical retinoids (topical adapalene, alitretinoin, isotretinoin, tazarotene, and tretinoin) during pregnancy.
• However, since risk cannot be excluded, use of topical retinoids is contraindicated during pregnancy as a precaution.
• Women and girls should be advised not to use topical retinoids if they are planning a pregnancy and to use effective contraception to minimise the risk of accidental exposure in pregnancy if they are of childbearing potential.
• For topical retinoids (adapalene, alitretinoin, isotretinoin, tazarotene, and tretinoin), the review concluded that data show systemic exposure is negligible following topical application and is unlikely to be associated with an increased risk of neuropsychiatric disorders (see EMA Public Assessment Report)
• See also resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation

Topical retinoids should be avoided in severe acne involving large areas.

Several months of treatment may be needed to achieve an optimal response and the treatment should be continued until no new lesions develop.

Adapalene

• Cream 0.1% (£16.43 = 45g)
• Gel 0.1% (£16.43 = 45g)

Indications

• Mild acne

Dose

• Apply thinly once daily in the evening

Treclin

(Tretinoin 0.025% plus clindamycin 1%)

• Gel (£11.94 = 30g)

Indications

• Moderate acne

Dose

• Apply once daily (thinly) at bedtime

Notes

1. Treatment with Treclin should not exceed 12 weeks of continuous use without careful evaluation. It should be noted that therapeutic improvement may not be observed for several weeks after starting treatment.
2. Treclin gel is indicated for the topical treatment of acne vulgaris when comedones, papules and pustules are present in patients 12 years or older.
3. The routine commissioning of Clindamycin 1%/Tretinoin 0.025% w/w gel (Treclin) is accepted in Devon for the treatment of moderate acne vulgaris in adults and children aged 12 years and older for treatment courses of up to 12 weeks (see Commissioning Policy for more details)

Epiduo

(Adapalene 0.1% plus benzoyl peroxide 2.5%)

• Gel (£19.53 = 45g)

Indications

• Moderate acne
• Unresponsive mild acne

Dose

• Apply thinly once daily in the evening

Notes

1. May bleach clothing and hair