Severe acne

Moderate-severe in patients aged 12 years or older:

• if response to topical preparations alone is inadequate consider adding an oral antibiotic, a tetracycline, such as lymecycline or doxycycline (for a maximum of 3 months)
• to reduce the risk of antibiotic resistance developing - always co-prescribe a topical retinoid (if not contraindicated) e.g. adapalene, or benzoyl peroxide
  • the evidence for additional benefit in using antibiotics for more than three months is minimal; also prolonged use of antibiotics increase the likelihood of P.acnes resistance
• an oral tetracycline is the first-line choice. Their adverse-effects should be taken into consideration when prescribing (1)
  • doxycyline and lymecycline are taken once a day, and can be taken with food. Tetracycline and oxytetracycline are taken twice a day on an empty stomach. All these drugs should be swallowed whole with plenty of fluids
    • lymecycline: a single 408mg capsule once a day, or,
    • doxycyline: a single 50mg capsule once a day
      
      
• macrolide antibiotics e.g. erythromycin should be considered in people who can't tolerate the tetracyclines
  • macrolide antibiotics should though be avoided if possible due to high levels of P. acnes resistance
  • erythromycin however may be considered to treat acne in pregnancy

Review after 6 weeks to assess the treatment effect and compliance. Should continue treatment for a maximum of 3 months before stopping. If there is a flare up restarting oral therapy should be considered.

• referral to a dermatologist is an option, with a view to using isotretinoin to treat severe acne
  
  
• reasons for referral to a dermatologist regarding acne treatment include:
  • nodulocystic acne, scarring, pigmentation, poor treatment response, unpleasant side effects from current treatment regime, late onset acne (2)
  • failure to respond to two different courses of antibiotics
  • diagnostic uncertainty
  • if there is significant psychological distress is associated with acne - this is regardless of severity primary care based acne therapies should be initiated
    • whilst awaiting specialist review then
  • There is diagnostic uncertainty.

Examples of other treatments that may be initiated by a specialist (2)

• alternative antibiotics
  • trimethoprim
    • highly effective in the treatment of acne
    • may cause an allergic rash in 5 per cent of patients
  • occasionally prescribe may use other antibiotics, such as clindamycin and clarithromycin
• also dermatologist may use anti-inflammatory agents such as dapsone

If required antibiotic courses can be repeated if flare ups in the future.

Factors to take into account at review

• Review first-line treatment at 12 weeks and:
  • assess whether the person's acne has improved, and whether they have any side effects
  • in people whose treatment includes an oral antibiotic, if their acne has completely cleared consider stopping the antibiotic but continuing the topical treatment
  • in people whose treatment includes an oral antibiotic, if their 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
• be aware that the use of antibiotic treatments is associated with a risk of antimicrobial resistance
• if a person's acne has cleared, consider maintenance options (see linked item)
• 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: offer another option from the table of treatment choices (see table below)
  • moderate to severe: and the treatment did not include an oral antibiotic: offer another option which includes an oral antibiotic from the table of treatment choices (see table below)
  • moderate to severe, and the treatment included an oral antibiotic: consider referral to a consultant-led dermatology team
• If mild to moderate acne fails to respond adequately to 2 different 12-week courses of treatment options, consider referral to a consultant dermatologist-led team.

For details regarding use of isotretinoin then see linked item.

Other specialist therapies available for severe acne include (4):

• Physical treatments
  • consider photodynamic therapy for people aged 18 and over with moderate to severe acne if other treatments are ineffective, not tolerated or contraindicated
• use of intralesional corticosteroids
  • consider treating severe inflammatory cysts with intralesional injection of triamcinolone acetonide (0.1 ml of triamcinolone acetonide per cm of cyst diameter, at 0.6 mg/ml diluted in 0.9% sodium chloride). This should be done by a member of a consultant dermatologist-led team
  • in June 2021 this was an off-label use for triamcinolone acetonide

The summary of product characteristics should be consulted before prescribing any of the drugs mentioned

Notes:

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

Reference:

• 1. Clinical Knowledge Summaries.Acne Vulgaris(accessed 9/8/21)
• 2. MeReC Bulletin (1999);10 (8): 29-32.
• 3. Prescriber (2006); 14 (22):44-55.
• 4. NICE (May 2023). Acne vulgaris: management