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Management of relapse of acne vulgaris

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Relapse

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

another 12-week course of the same treatment, or
an alternative 12-week treatment (see table)

If acne relapses after an adequate response to oral isotretinoin and is currently mild to moderate, offer an appropriate treatment option (see table)

If acne relapses after an adequate response to oral isotretinoin and is currently moderate to severe, offer either:

a 12-week course of an appropriate treatment option (see table), or
re-referral, if the person is no longer under the care of the consultant dermatologist-led team

If acne relapses after a second course of oral isotretinoin and is currently moderate to severe, further care should be decided by the consultant dermatologist-led team. If the person is no longer under the care of the consultant dermatologist-led team, offer re-referral

Treatment choices for mild to moderate and moderate to severe acne vulgaris

Acne severity	Treatment	Advantages	Disadvantages
Any severity	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening	topical does not contain antibiotics	not for use during pregnancy use with caution during breastfeeding can cause skin irritation, photosensitivity, and bleaching of hair and fabrics
Any severity	Fixed combination of topical tretinoin with topical clindamycin, applied once daily in the evening	topical	not for use during pregnancy or breastfeeding can cause skin irritation, and photosensitivity
Mild to moderate	Fixed combination of topical benzoyl peroxide with topical clindamycin, applied once daily in the evening	topical can be used with caution during pregnancy and breastfeeding	can cause skin irritation , photosensitivity, and bleaching of hair and fabrics
Moderate to severe	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening, plus either oral lymecycline or oral doxycycline taken once daily	oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is a Medicines and Healthcare products Regulatory Agency (MHRA) requirement for subsequent oral isotretinoin (see the MHRA alert on isotretinoin for severe acne: uses and effects)	not for use in pregnancy, during breastfeeding, or under the age of 12 topical adapalene and topical benzoyl peroxide can cause skin irritation, photosensitivity, and bleaching of hair and fabrics oral antibiotics may cause systemic side effects and antimicrobial resistance oral tetracyclines can cause photosensitivity
Moderate to severe	Topical azelaic acid applied twice daily, plus either oral lymecycline or oral doxycycline taken once daily	oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin (see the MHRA alert on isotretinoin for severe acne: uses and effects)	not for use in pregnancy, during breastfeeding, or under the age of 12 oral antibiotics may cause systemic side effects and resistance oral tetracyclines can cause photosensitivity

Reference:

National Institute for Health and Care Excellence. Acne vulgaris: management. Dec 2023 [internet publication]

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