The following recommendations are largely based on NICE Clinical Guideline (NG198) Acne vulgaris: management (2021, last updated 2023) and NICE CKS (Last revised November 2023).

Acne is a chronic skin condition in which blockage or inflammation of the hair follicles and accompanying sebaceous glands occurs. It principally affects the face (99% of cases), back (60% of cases) and chest (15% of cases). Acne affects most adolescents and two-thirds of adults. It causes a major psychological health burden that is linked with the chronicity and severity of the disease.

Self-care advice

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 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.

Advice for people with acne:

• Use a non-alkaline (skin pH neutral or slightly acidic) synthetic detergent cleansing product twice daily on acne-prone skin.
• Avoid skin care products (e.g. moisturisers), make-up and sunscreens that are oil-based or likely to block skin pores.
• Remove make-up at the end of the day.
• Persistent picking or scratching of acne lesions increases the risk of scarring.

Hormonal contraception

If a person receiving treatment for acne wishes to use hormonal contraception, consider using the combined oral contraceptive pill in preference to the progestogen-only pill. Oral progesterone-only contraceptives or progestin implants with androgenic activity may exacerbate acne, ethinylestradiol with desogestrel, ethinylestradiol with norgestimate, or ethinylestradiol with drospirenone are generally preferred.

See section 7.3.1 Combined hormonal contraceptives (CHC)

For people with polycystic ovary syndrome and acne:

• treat their acne using a first-line treatment option (see below)
• if first-line treatment is not effective, consider adding co-cyprindiol or an alternative combined oral contraceptive pill to their treatment.
• for those using co-cyprindiol, review at 6 months and discuss continuation or alternative treatment options.

See section 13.6.2 Oral preparations for acne

Severity

There is no universally agreed grading system for acne, but it is often categorised by lesion type and severity into:

• Mild acne — predominantly non-inflamed lesions (open and closed comedones) with few inflammatory lesions.
• Moderate acne — more widespread with an increased number of inflammatory papules and pustules.
• Severe acne — widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present.

Within this guidance, treatment recommendations are based on the following descriptions use by NICE:

Mild to moderate acne includes people who have one or more of:

• any number of non-inflammatory lesions (comedones)
• up to 34 inflammatory lesions (with or without non-inflammatory lesions)
• up to 2 nodules.

Moderate to severe acne includes people who have either or both of:

• 35 or more inflammatory lesions (with or without non-inflammatory lesions)
• 3 or more nodules.

Treatment in adults and children over 12 years

Treatment of acne should be commenced as early as possible to prevent scarring. Patients should be counselled that treatments are effective, but an improvement might not be seen for at least a couple of months, and products may cause irritation to the skin at the start of treatment.

To reduce the risk of skin irritation associated with topical treatments, such as benzoyl peroxide or retinoids, start with alternate-day or short-contact application (for example washing off after an hour). If tolerated, progress to using a standard application.

Stress to patients the importance of good compliance. Treatment should not be used for longer than necessary.

Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy.

Offer people with acne a 12-week course of one of the following first-line treatment options, taking account of the severity of their acne and the person's preferences, and after a discussion of the advantages and disadvantages of each option (see here):

Mild to moderate acne:

Benzoyl peroxide plus clindamycin

• Benzoyl peroxide 3% / clindamycin 1% gel
• Benzoyl peroxide 5% / clindamycin 1% gel
• Applied once daily in the evening for 12 weeks

Epiduo (Adapalene plus benzoyl peroxide)

• Adapalene 0.1% / benzoyl peroxide 2.5% gel
• Adapalene 0.3% / benzoyl peroxide 2.5% gel
• Applied once daily in the evening for 12 weeks

Treclin (Clindamycin plus tretinoin)

• Clindamycin 1% / tretinoin 0.025% gel
• Applied once daily in the evening for 12 weeks

Please see section: 13.6.1 Topical preparations for acne

Moderate to severe acne:

Epiduo or Treclin (as above)

OR topical treatment plus oral antibiotic for 12 weeks:

Epiduo once daily OR Azelaic acid (15% gel or 20% cream) twice daily, PLUS either

• Lymecycline 408mg once daily, OR
• Doxycycline 100mg once daily
• If lymecycline and doxycycline are contraindicated or not tolerated, consider trimethoprim 300mg twice daily (off-label), or erythromycin 500mg twice daily, or oxytetracycline 500mg twice daily.
• NICE CKS suggests that combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women. If so, ethinylestradiol with desogestrel, ethinylestradiol with norgestimate, or ethinylestradiol with drospirenone (all off label for acne) are generally preferred.

Please see section: 13.6.1 Topical preparations for acne, 5.1.3 Tetracyclines, 5.1.8 Sulfonamides and trimethoprim, 5.1.5 Macrolides, and 7.3.1 Combined hormonal contraceptives (CHC)

Alternative treatment options (for acne of any severity):

If the first-line treatments above are contraindicated, or the person wishes to avoid using a topical retinoid, or an antibiotic (topical or oral):

Benzoyl peroxide 5% gel

• Applied once or twice daily for 12 weeks
• See section 13.6.1 Topical preparations for acne

Review:

Review treatment at 12 weeks.

Acne completely cleared or is improving

In people whose initial treatment did not include an oral antibiotic, consider no further treatment / self-care only, or maintenance therapy (see below).

In people whose initial treatment included an oral antibiotic:

• If acne has completely cleared, consider stopping the antibiotic but continuing the topical treatment (or alternative maintenance therapy below).
• if acne has improved but not completely cleared consider continuing the oral antibiotic, alongside the topical treatment, for up to 12 more weeks.
  • Only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances. Review at 3-monthly intervals and stop the antibiotic as soon as possible.

Inadequate Response

If acne fails to respond adequately to a 12-week course of a first-line treatment option and at review the severity is:

• Mild to moderate:
• Following one 12-week treatment course, offer another treatment option (see above).
• Following two different 12-week treatment courses, consider referral.
• Moderate to severe and the treatment:
• Did not include an oral antibiotic, offer another treatment option that includes an oral antibiotic (see above).
• Included an oral antibiotic, consider referral.

Relapse

If acne responds adequately to a course of an appropriate first-line treatment but then relapses, consider either:

• another 12‑week course of the same treatment, or
• an alternative 12‑week treatment (above).

Maintenance

After completion of treatment (above), maintenance treatment is not always necessary.

Consider maintenance treatment in people with a history of frequent relapse after treatment.

Review maintenance treatments after 12 weeks to decide if they should continue.

Epiduo (Adapalene plus benzoyl peroxide)

• Adapalene 0.1% / benzoyl peroxide 2.5% gel
• Adapalene 0.3% / benzoyl peroxide 2.5% gel
• Applied once daily in the evening
• See section 13.6.1 Topical preparations for acne

Alternative maintenance options:

If Epiduo is not tolerated or is contraindicated, consider topical monotherapy:

Adapalene 0.1% cream or 0.1% gel

• Applied once daily in the evening

Azelaic acid 15% gel or 20% cream

• Applied twice daily

Benzoyl peroxide 5% gel

• Applied once or twice daily

Trifarotene 50micrograms/g cream

• Applied once daily in the evening

Please see section 13.6.1 Topical preparations for acne

Referral

Refer all people with severe acne.

Consider referring people if they have:

• mild to moderate acne that has not responded to 2 completed courses of treatment.
• moderate to severe acne which has not responded to previous treatment that contains an oral antibiotic.
• acne that is leading to scarring.
• acne with persistent pigmentary changes.

Consider referral to mental health services if a person with acne experiences significant psychological distress or a mental health disorder.

Patients presenting with acne with a suspected endocrinological cause should be referred to an endocrinologist rather than a dermatologist.

Clinical Referral Guidelines (CRGs):

• Eastern locality Acne Vulgaris CRG