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2256 pages added, reviewed or updated during the last month (last updated: 20/4/2021)

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severe acne

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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
      • whilst awaiting specialist review then
      • primary care based acne therapies should be initiated
    • 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.

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


Last edited 02/2020 and last reviewed 02/2020