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Referral criteria from primary care - acne vulgaris

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Referral to specialist care

Urgently refer people with acne fulminans on the same day to the on-call hospital dermatology team, to be assessed within 24 hours

Refer people to a consultant dermatologist-led team if any of the following apply:

there is diagnostic uncertainty about their acne
they have acne conglobata
they have nodulo-cystic acne

Consider referring people to a consultant dermatologist-led team if they have:

mild to moderate acne that has not responded to 2 completed courses of treatment (see table below)
moderate to severe acne which has not responded to previous treatment that contains an oral antibiotic (see table below)
acne with scarring
acne with persistent pigmentary changes

Consider referring people to a consultant dermatologist-led team if their acne of any severity, or acne-related scarring, is causing or contributing to persistent psychological distress or a mental health disorder.

Consider referral to mental health services if a person with acne experiences significant psychological distress or a mental health disorder, including those with a current or past history of:

suicidal ideation or self-harm
a severe depressive or anxiety disorder
body dysmorphic disorder

When considering referral, take into account the person's potential treatment options (for example, oral isotretinoin)

Consider condition-specific management or referral to a specialist (for example a reproductive endocrinologist), if a medical disorder or medication (including self-administered anabolic steroids) is likely to be contributing to a person's acne.

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]

Acne vulgaris

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Referral criteria from primary care - acne vulgaris

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