CKS Acne vulgaris - Management

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How should I diagnose acne vulgaris?
 A person with acne usually presents with a history of troublesome 'spots', most
commonly affecting the face, shoulders, back, and chest. The person is most
commonly an adolescent or young adult, but acne can occur for the first time in
later life.
 Examine all affected areas of skin (including the back and shoulders).
o The skin and hair may have an oily texture and appearance.
o Depending on the severity of the acne, there may be non-inflammatory
comedones, inflamed papules or pustules, or a mixture of both.
 Closed comedones (whiteheads) appear as raised bumps on the
skins surface, and are skin-coloured or slightly reddened.
 Open comedones (blackheads) have a characteristic black 'plug'
caused by oxidised oil and dead skin cells.
 Papules are small, round or oval, inflamed (red), raised elevations
of the skin.
 Pustules resemble papules, but have a central pocket of pus.
 Nodules are poorly demarcated swellings that are usually red and
tender. They may be fluctuant on palpation. In very severe acne,
nodules may track together and form large, deep sinuses (acne
conglobata).
 Haemorrhagic acne is caused by bleeding inflammatory lesions,
and may be very painful and distressing.
o Look for evidence of scarring and hyperpigmentation.
 Scarring may occur when acne heals, particularly when nodules
have been present. It is most commonly atrophic in nature,
leading to the formation of 'ice-pick' scars or 'pock marks'.
 Hyperpigmentation may occur after acne resolves, especially in
people with darker complexions.
 If the features are atypical of acne vulgaris, consider the possibility of a severe
form or clinical variant of acne.
 Images of acne and its clinical variants can be viewed at www.dermnet.org.nz.

[Brown and Shalita, 1998; Thiboutot, 2000; Simpson and Cunliffe, 2004; ICSI, 2006]

Clinical variants

 If acne presents with atypical features, consider the possibility of a rarer form of
acne.
o Acne conglobata is very severe acne where inflammatory lesions
predominate and run together, often accompanied by exudate or
bleeding. This form of acne may cause extensive scarring.
 o Acne fulminans is a sudden severe inflammatory reaction that
precipitates deep ulcerations and erosions, sometimes with systemic
effects (such as fever and arthralgia).
o Acne excoriée mainly affects young women and is characterized by self-
inflicted wounds. It is primarily a psychological or emotional problem.
o Acne mechanica is caused secondarily to pressure, friction, or rubbing
from clothing (such as a mask or hat).
o Acne cosmetica is caused by contact of the skin with comedogenic
products.
o Chloracne is caused by occupational exposure to halogenated
hydrocarbons. It is characterized by the presence of numerous, large
comedones.

Basis for recommendation

Recommendations for the diagnosis of acne vulgaris and its clinical variants are based
on an international guideline [ICSI, 2006] and expert opinion from narrative reviews
[Brown and Shalita, 1998; Thiboutot, 2000; Wolf, 2002; Simpson and Cunliffe, 2004].

What else might it be?

 Acne vulgaris is rarely misdiagnosed. Conditions which may mimic the signs
of acne include:
o Rosacea is the condition most commonly mistaken for acne vulgaris. It
usually occurs in older people and its main symptom is flushing and the
presence of inflammatory papules, with a central facial distribution.
However, there is an absence of comedones, nodules, or scarring. See the
CKS topic on Rosacea.
o Folliculitis and boils may present with pustular lesions similar to those
seen in acne. Swabs usually yield Staphylococcus aureus. Sycosis barbae
is persistent folliculitis of the beard area. See the CKS topic on Boils and
paronychia.
o Milia are small keratin cysts that may be confused with whiteheads.
They tend to be whiter than acne whiteheads, they do not have a central
punctum, and they are most commonly found around the eyes.
o Perioral dermatitis presents as erythema and small papules around the
mouth, nasolabial folds, and sometimes the lower eyelids. It can have
both eczematous and acneiform features, and when acneiform features
predominate it may be mistaken for acne. In these cases, the perioral
distribution gives the best clue as to its nature.
o Demodex folliculitis is caused by mites and usually occurs in older
people. It predominantly affects the face.
o Pityrosporum folliculitis is caused by a yeast-like organism. It tends to
affect younger people and predominates on the trunk.

Basis for recommendation

Information on the differential diagnosis of acne vulgaris is from expert opinion
described in narrative reviews [Healy and Simpson, 1994; Layton, 2000; Thiboutot,
2000; Wolf, 2002].

How should I investigate the cause of acne in a

woman?
 Diagnostic investigations are not necessary for the management of acne vulgaris
unless it is suspected as being secondary to an underlying cause in women.
Hyperandrogenism should be suspected if the woman has:
o Irregular periods, androgenic alopecia (hair thinning on the front of the
scalp), or excessive facial or body hair (hirsutism).
o Acne resistant to conventional treatment (including oral antibiotics), or
there is a rapid relapse after a course of oral isotretinoin.
o A sudden onset of severe acne.
 If hyperandrogenism is suspected, consider the following investigations:
o Total and free testosterone — elevated levels may indicate polycystic
ovarian syndrome (PCOS) or, rarely, ovarian cancer.
o Luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio —
may be altered in PCOS, with elevated LH.
o Serum dehydroepiandrosterone (DHEA) — elevated levels may indicate
adrenal tumour or congenital adrenal hyperplasia.
o 17-hydroxyprogesterone — elevated levels may indicate congenital
adrenal hyperplasia.
o Prolactin — may reveal hyperprolactinaemia.
o 24 hour urinary-free cortisol — elevated levels may indicated Cushing's
disease or syndrome.

Basis for recommendation

Recommendations for suspecting and investigating hyperandrogenism in women is

based on opinion from expert reviews [James, 2005; Ravenscroft, 2005].

How should I assess a person with acne?

 Ask about the problems the person has experienced with their acne. Enquire
about:
o The reasons for the person presenting, how long they have had acne, and
whether it is worsening.
o Any treatments the person has already tried (for example over-the-
counter medication).
o Possible causes or aggravating factors (for example, occupational
exposure to halogenated hydrocarbons).
 In women, consider whether the acne could be secondary to a hormonal cause.
Features of hyperandrogenism include: irregular periods; androgenic alopecia or
hirsutism; acne resistant to conventional treatment (or relapse immediately after
a course of oral isotretinoin); and premenstrual flares of acne or a sudden onset
of severe acne.
  Assess the severity of the acne. Physically, acne can be categorized as mild,
moderate, or severe, but other factors, such as the extent of acne and evidence of
scarring, should also be considered.
o Mild acne predominantly consists of non-inflammatory comedones.
o Moderate acne consists of a mixture of non-inflammatory comedones
and inflammatory papules and pustules.
o Severe acne is characterized by the presence of nodules and cysts, as
well as a preponderance of inflammatory papules and pustules.
o Scarring often indicates previous episodes of severe acne (its presence
may warrant more aggressive treatment to prevent further scarring).
o Acne conglobata and acne fulminans are severe variants that require
immediate referral.
 Ask about the psychosocial impact of the acne (such as problems at work or
school). If the psychological impact seems to be particularly severe or
disproportionate, consider using a validated quality of life scale, such as the
Cardiff Acne Disability Index (which can be downloaded from
www.dermatology.org.uk). This can be used to monitor the person's
psychological state during subsequent management.

Basis for recommendation

These recommendations are based on expert opinion from international guidelines

[ICSI, 2006; Strauss et al, 2007] and narrative reviews [Webster, 2002; Wolf, 2002;
James, 2005; Ravenscroft, 2005; Acne Working Group, 2008].

Categorizing acne severity

 There is no universal grading system for the classification of acne severity

[Strauss et al, 2007]. Grading systems have largely been developed for use in
clinical trials and rely on lesion counts, but these are generally not suitable for
clinical practice [Webster, 2002]. However, there is general consensus from
experts that it is useful to categorize acne into three severity grades in order to
guide management of the condition.

Psychosocial impact of acne

 During assessment, it is important to recognize the psychosocial impact of acne.

It can have a severe negative impact on the person's life. Although often the
person tends to overestimate the severity of their acne, the healthcare
professional tends to underestimate it. Estimating the physical severity of acne
alone is insufficient to guide management, as it may be appropriate to treat acne
associated with a greater psychosocial impact more aggressively, or refer the
person [Acne Working Group, 2008].


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Acne vulgaris - Management
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What information should I give about acne?
 Reassure the person about the natural course of the condition, but do not
trivialize it. Advise that:
o Acne is one of the most common disorders, affecting nearly everyone at
some point in their life.
o Acne will improve. It is primarily a skin disorder of the young, and will
usually clear up in later life without leaving significant scarring.
o Treatments are effective but take time to work (typically up to 8 weeks)
and may irritate the skin, especially at the start of treatment.
 Dispel popular myths about acne. In particular inform the person that:
o Acne is not caused by poor hygiene, and there is no evidence it is
improved by cleaning. In fact, excessive washing can aggravate acne.
o Diet has little or no effect on acne. For example, there is no evidence that
chocolate or fatty foods cause or aggravate acne. However if the person
notices that a particular food triggers flares of acne then it is reasonable
to avoid it.
o Picking at acne does not improve it, and may cause scarring.
Occasionally it may be beneficial to drain large purulent lesions, but this
should be done under medical supervision.
o Stress probably does not cause acne, although there is a correlation
between stress and acne, and unsightly lesions may cause increased
levels of stress.
o Acne is not infectious and cannot be passed on to other people. The main
bacterium involved in the inflammation, Propionibacteria acnes, is
naturally present on skin but, in acne, it colonizes follicles.
o Sunlight probably has little benefit in acne, and there is no evidence to
support active sunbathing or exposure to other sources of ultraviolet
light. Excessive sun exposure should be avoided by all people, especially
when taking drugs such as topical or oral retinoids, or oral tetracyclines.

Basis for recommendation

Providing reassurance

 The prognosis of acne is good for most people, with less than 12% of women
and 3% men being affected after 25 years of age. However, the condition should
not be trivialized, as it may last for several years and have a negative
psychological impact in some people. A balanced understanding of the disease
course and its impact on everyday life is required [Acne Working Group, 2008].

Myths about acne

  Experts believe that dispelling 'myths' is an integral component of the
management of acne [ICSI, 2006].
 Evidence on the myths about acne is based mainly on poor-quality data from
uncontrolled trials and observational studies, and expert opinion.
 There is insufficient evidence from observational studies or controlled trials to
indicate that changes in diet, use of hygiene measures, or exposure to sunlight is
beneficial in the management of acne.
 There is a consensus of expert opinion that stress does not cause acne, although
it is widely believed it can exacerbate the psychological reaction to acne [ICSI,
2006].

What self-care advice should I give to a person with

acne?
 Advise about washing and skin care. In general, it is recommended that people
with acne:
o Do not wash more than twice a day.
o Use a mild soap or cleanser and lukewarm water (as very hot or cold
water may worsen acne).
o Do not use vigorous scrubbing when washing acne-affected skin, and the
use of abrasive soaps, cleansing granules, astringents, or exfoliating
agents should be discouraged (advise use of a soft wash-cloth and fingers
instead).
o Should not attempt to 'clean' blackheads. Scrubbing or picking acne is
liable to worsen the condition.
o Ideally, should avoid excessive use of makeup and cosmetics. If they
must be used, advise that a non-comedogenic, water-based product
should be used sparingly (advise that details of cosmetic ingredients are
displayed on the product label), and that all makeup should be removed
completely at night.
o Use a fragrance-free, water-based emollient if dry skin is a problem
(several topical acne drugs dry the skin). The use of ointments or oil-rich
creams should be avoided as these can clog pores.
 Advise about non-prescription treatments.
o Benzoyl peroxide is a useful topical drug available over-the-counter.
However, there is a lack of evidence of benefit for other over-the-counter
drugs.
o Complementary and alternative medicines (for example herbal
medicines) are not usually harmful but there is a general lack of evidence
to support their use.

Basis for recommendation

Advice on hygiene measures

 Recommendations on hygiene measures are based on consensus of experts

[Webster, 2002; ICSI, 2006].

Over-the-counter (OTC) treatments

  Most OTC products are not recommended because there is a lack of evidence
from clinical trials to support their efficacy [Sharpe, 1995; Brown and Shalita,
1998; Ravenscroft, 2005; Strauss et al, 2007].
o Salicylic acid is a common ingredient in OTC acne treatments. It is a
keratolytic drug that has some anti-comedone activity, but there is a lack
of evidence from controlled trials to confirm this, and it is considered
less effective than the topical retinoids.
o Abrasives (such as aluminium oxide) and sulphur (available combined
with resorcinol, as Eskamel®) have been used historically, but lack
evidence from controlled trials. Some products containing aluminium
oxide are abrasive and can irritate inflamed skin.
o Nicotinamide (available as Nicam®) has been reported as being as
effective as topical clindamycin in open-label cohort studies [Dos et al,
2003; Sardesai and Kambli, 2003], but CKS identified no randomized
controlled trials to confirm this.
o However, there is substantial placebo-controlled trial evidence to support
the use of benzoyl peroxide in the treatment of acne.

Complementary and alternative medicine (CAM)

 There is little evidence to support the use of CAM in the treatment of acne.
o A review of CAM treatments for acne found an overall lack of good
quality evidence of beneficial effect; studies were limited in number and
most were methodologically poor or underpowered [Magin et al, 2006].
o One systematic review (search date: October 2002) found two trials that
investigated the efficacy of herbal remedies in acne [Martin and Ernst,
2003]. Both studies were small and of poor methodological quality.
 One trial compared tea tree oil with benzoyl peroxide. There was
no placebo group and the study lacked the statistical power to
show equivalence or superiority of the regimens.
 In the other trial, the herb Ocimum gratissimum (dissolved in
alcohol and added to oil) was compared with benzoyl peroxide
and placebo. However, as various concentrations were
investigated, the groups were too small to allow any firm
conclusions.

How should I treat mild acne?

 In mild acne, open and closed comedones (blackheads and whiteheads)
predominate. Although the physical severity of the condition is limited and
scarring is unlikely, the psychosocial impact may be disproportionate in some
people, which is an indication for more aggressive treatment.
 Prescribe a single topical treatment.
o Prescribe a topical retinoid (tretinoin, isotretinoin, or adapalene) or
benzoyl peroxide (especially if papules and pustules are present) as first-
line treatment.
o Prescribe a topical antibiotic or azelaic acid if both topical retinoids and
benzoyl peroxide are poorly tolerated.
o Combined treatment is rarely necessary for mild acne.
  Consider prescribing a standard combined oral contraceptive in women who
require contraception, particularly if the acne is having a negative psychosocial
impact.

Basis for recommendation

Recommendations for treatment are based on international guidelines [ICSI, 2006;

Strauss et al, 2007] and narrative reviews [Webster, 2002; James, 2005; Ravenscroft,
2005; Zaenglein and Thiboutot, 2006; Acne Working Group, 2008], and reflect
published data from randomized controlled trials (RCTs) where available, and
otherwise, expert opinion.

Topical retinoids

 Topical retinoids normalize follicular keratinization, promote drainage of

comedones, and inhibit new comedone formation. They have been used
historically mainly to treat comedones, but they are also effective at treating
inflammatory lesions (if used in the longer term) by inhibiting microcomedone
formation [Thiboutot, 2000; Wolf, 2002]. This is supported by good evidence
from placebo-controlled trials [Purdy and DeBerker, 2008].

Topical benzoyl peroxide

 Benzoyl peroxide is a potent bactericide and significantly reduces the population

of Propionibacterium acnes in the sebaceous follicle [Thiboutot, 2000]. There is
good evidence from placebo-controlled trials that benzoyl peroxide reduces both
inflammatory and non-inflammatory lesions [Purdy and DeBerker, 2008].

Topical antibiotics

 Topical antibiotics reduce colonization of sebaceous follicles by P. acnes and

may also have an anti-inflammatory effect. Most evidence from placebo-
controlled trials has addressed the effectiveness of topical antibiotics at reducing
inflammatory acne lesions, and most experts believe they are of limited use for
the treatment of mild acne [Dreno, 2004; ICSI, 2006].

Azelaic acid

 Azelaic acid is a second-line option that should be considered for mild acne if
other treatments are unsuitable [Acne Working Group, 2008]. There is a lack of
trial evidence to support the use of azelaic acid in comparison with data
available for other topical treatments, and the clinical effect of azelaic acid has
been reported to be disappointing by some experts [Brown and Shalita, 1998;
James, 2005].

Combined oral contraceptives (COCs)

 COCs are recommended as a first-line adjunctive treatment for women who

have acne [ICSI, 2006; Strauss et al, 2007]. There is good evidence from
 placebo-controlled trials that COCs are effective in reducing lesion count, acne
severity, and the woman's perception of the condition [Arowojolu et al, 2007].

How should I follow up a person with acne?

 Arrange follow up after about 6 weeks, and review the effectiveness and
tolerability of treatment, as well as compliance with regimens.
 Advise the person to return sooner if the acne deteriorates significantly despite
treatment.

Basis for recommendation

Recommendations for following up people with acne are based on international [ICSI,
2006] and national [Acne Working Group, 2008] guidelines.

 There is evidence from a randomized controlled trial involving both topical

drugs and oral antibiotics that it may take about 6 weeks for an adequate
response, although the maximal response may take up to 3 months [Ozolins et
al, 2005].
 Therefore, it is reasonable to assess response to treatment after a period of about
6 weeks, and continue treatment if the drug has had a positive effect. If it has
not, it is reasonable to try other strategies (such as increasing treatment strength,
switching treatments, or adding on treatments).

What should I do if mild acne fails to respond to

treatment?
 Check adherence to treatment.
 If adherence is poor, this may be because the treatment is poorly tolerated.
Consider:
o Reducing the strength of treatment (for example, reducing from 5% to
2.5% benzoyl peroxide).
o Switching to an alternative topical drug that causes less irritation (for
example a topical antibiotic or azelaic acid).
o Using a different formulation of drug (for example a cream instead of a
drug with an alcoholic base).
 If adherence is adequate, consider:
o Increasing the drug strength and/or frequency of application.
o Combining different topical products (if not already doing so). Benzoyl
peroxide combined with erythromycin or clindamycin is particularly
effective against both non-inflammatory and inflammatory acne.

Basis for recommendation

These are pragmatic recommendations that are in line with expert opinion from
international [ICSI, 2006] and national [Acne Working Group, 2008] guidelines.

When should I refer a person with mild acne?

  People who have severe psychosocial problems, including a morbid fear of
deformity (body dysmorphic disorder), or people who have suicidal ideation,
should be referred soonto psychiatry.
 Refer for a routine appointment:
o To endocrinology or gynaecology, those women suspected of having an
underlying endocrinological cause of acne (such as polycystic ovary
syndrome) that needs assessment.
o To dermatology, people with features that make the diagnosis uncertain.

Basis for recommendation

Referral criteria for acne vulgaris are based on Referral advice: A guide to appropriate
referral from general to specialist services, published by the National Institute for
Health and Clinical Excellence (NICE). For people requiring referral 'immediately' or
'soon', NICE specify that 'Health authorities, trusts, and primary care organizations
should work to local definitions of maximum waiting times in each of these categories.
The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks
to be appropriate for the urgent category' [NICE, 2001].

Prescriptions
Benzoyl peroxide (gel)

Age from 12 years onwards

Benzoyl peroxide 2.5% aqueous gel
PanOxyl Aquagel 2.5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.76
OTC cost: £3.10
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% aqueous gel
PanOxyl Aquagel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.92
OTC cost: £3.38
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% aqueous gel
PanOxyl Aquagel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £2.07
OTC cost: £3.65
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% alcoholic gel
Panoxyl Acnegel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.51
OTC cost: £2.66
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% alcoholic gel
Panoxyl Acnegel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.69
OTC cost: £2.98
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.

Benzoyl peroxide (cream and wash)

Age from 12 years onwards

Benzoyl peroxide 4% cream
Benzoyl peroxide 4% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £3.30
OTC cost: £5.82
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% cream
Benzoyl peroxide 5% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.89
OTC cost: £3.33
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% wash
Benzoyl peroxide 10% wash
Apply to the affected area once a day.
Supply 150 ml.
Age: from 12 years onwards
NHS cost: £4.00
OTC cost: £7.05
Licensed use: yes
Patient information: Wet the affected area with water and wash thoroughly with the
Wash. Rinse well with warm water, then rinse with cold water, and pat dry with a clean
towel. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands
after use. This product may bleach clothing, hair, towels and bed linen.

Topical retinoids (tretinoin, isotretinoin, adapalene)

Age from 12 years onwards

Adapalene 0.1% cream
Adapalene 0.1% cream
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Adapalene 0.1% gel
Adapalene 0.1% gel
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Isotretinoin 0.05% gel
Isotretinoin 0.05% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £6.18
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Tretinoin 0.025% gel
Tretinoin 0.025% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Tretinoin 0.01% gel
Tretinoin 0.01% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.

Topical antibiotics (clindamycin, erythromycin, erythromycin/zinc)

Age from 12 years onwards

Clindamycin 1% gel
Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £8.66
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Clindamycin 1% aqueous lotion
Clindamycin 1% aqueous lotion
Apply thinly to the affected area(s) twice a day.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.47
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Erythromycin 2% alcoholic solution
Erythromycin 2% solution
Apply thinly to the affected area(s) twice a day, after washing.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.00
Licensed use: yes
Erythromycin 4% gel
Erythromycin 4% gel
Apply thinly to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £4.97
Licensed use: yes
Erythromycin 4% + zinc acetate 1.2% solution
Erythromycin 40mg/ml / Zinc acetate 12mg/ml lotion
Apply to the affected area(s) twice a day.
Supply 30 ml.
Age: from 12 years onwards
NHS cost: £7.71
Licensed use: yes

Azelaic acid (gel and cream)

Age from 12 years onwards

Azelaic acid 20% cream
Azelaic acid 20% cream
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £3.74
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes.
Age from 18 years onwards
Azelaic acid 15% gel (facial acne)
Azelaic acid 15% gel
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 18 years onwards
NHS cost: £7.48
Licensed use: yes
Patient information: Wash the affected area(s) with water and pat dry before use. Avoid
contact with the eyes, mouth and other mucous membranes.

Combination products (BPO/antibiotic, topical retinoid/antibiotic)

Age from 12 years onwards

Benzoyl peroxide 5% + clindamycin 1% gel
Benzoyl peroxide 5% / Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 25 grams.
Age: from 12 years onwards
NHS cost: £9.95
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Tretinoin 0.025% + erythromycin 4% alcoholic solution
Erythromycin 4% / Tretinoin 0.025% solution
Apply thinly to the affected area(s) once or twice a day.
Supply 25 ml.
Age: from 12 years onwards
NHS cost: £7.05
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Isotretinoin 0.05% + erythromycin 2% gel
Erythromycin 2% / Isotretinoin 0.05% gel
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £7.78
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.

Anti-androgen and oestrogen (co-cyprindiol)

Age from 14 to 50 years

Cyproterone acetate 2mg + ethinylestradiol 35micrograms
Co-cyprindiol 2000microgram/35microgram tablets
Take one tablet once a day for 21 days. Start the next packet after a 7-day break. See
package insert for full instructions.
Supply 63 tablets.
Age: from 14 years to 50 years
NHS cost: £3.92
Licensed use: yes
Patient information: Take the pill at the same time each day. If you forget one or more
pills or experience diarrhoea or vomiting and are unsure what to do, seek the advice of a
health professional.

Acne vulgaris - Management

View full scenario
How should I treat moderate acne?
 In moderate acne, inflammatory lesions (papules and pustules) predominate. The
acne may be widespread, there may be a risk of scarring, and there may be
 considerable psychosocial morbidity, all of which are indications for aggressive
treatment.
 Treatment options are a single topical drug, a combination of topical drugs, or
oral antibiotics.
o Consider a single topical drug in people with limited acne which is
unlikely to scar.
 Prescribe benzoyl peroxide or a topical retinoid first-line as they
are most effective against inflammatory acne. However, topical
retinoids are also effective, and azelaic acid may is an option if
other drugs are poorly tolerated.
o Combined treatment should be considered in all people with moderate
acne.
 Benzoyl peroxide combined with a topical antibiotic is the usual
preferred regimen, as it is proven to be effective and may limit
the development of bacterial resistance.
 Other options include a topical retinoid combined with benzoyl
peroxide (but this may be poorly tolerated) or a topical retinoid
combined with a topical antibiotic (but this may promote
bacterial resistance).
o Consider prescribing an oral antibiotic (tetracycline, oxytetracycline,
doxycycline, lymecycline, or erythromycin) if topical treatment cannot
be tolerated, if there is moderate acne on the back or shoulders (where it
may be particularly extensive or difficult to reach), or if there is a
significant risk of scarring or substantial pigment change.
 Consider prescribing a standard combined oral contraceptive in women who
require contraception. Standard combined oral contraceptives or co-cyprindiol
(Dianette®) are options.

Basis for recommendation

Recommendations for treatment are based on international guidelines [ICSI, 2006;

Strauss et al, 2007] and narrative reviews [Webster, 2002; James, 2005; Ravenscroft,
2005; Zaenglein and Thiboutot, 2006; Acne Working Group, 2008], and reflect
published data from randomized controlled trials (RCTs) where available, and
otherwise, expert opinion.

Topical benzoyl peroxide

 Benzoyl peroxide is a potent bactericide and significantly reduces the population

of Propionibacterium acnes in the sebaceous follicle [Thiboutot, 2000]. There is
good evidence from placebo-controlled trials that show benzoyl peroxide
reduces both inflammatory and non-inflammatory lesions [Purdy and DeBerker,
2008].

Topical retinoids

 Topical retinoids normalize follicular keratinization, promote drainage of

comedones, and inhibit new comedone formation. Although they have been used
historically mainly to treat comedones, they are also effective at treating
inflammatory lesions (if used in the longer term) by inhibiting microcomedone
 formation [Thiboutot, 2000; Wolf, 2002]. This is supported by good evidence
from placebo-controlled trials [Purdy and DeBerker, 2008].

Topical antibiotics

 Topical antibiotics reduce colonization of sebaceous follicles by P. acnes and

may also have an anti-inflammatory effect. There is evidence for effectiveness
from placebo-controlled trials [Purdy and DeBerker, 2008], and they are
probably most useful against papules and pustules which are not impractically
widespread [ICSI, 2006].

Azelaic acid

 Azelaic acid is a second-line option that should be considered if other treatments

are unsuitable [Acne Working Group, 2008]. There is limited evidence from two
small placebo-controlled trials that azelaic acid is effective in the treatment of
acne, but clinical experience with its use has been reported to be disappointing
[Brown and Shalita, 1998; James, 2005]. However, azelaic acid may cause less
adverse effects than benzol peroxide or topical retinoids [Ravenscroft, 2005].

Combining topical treatments

 Combining topical treatments is recommended by experts for most people with

moderate acne [Acne Working Group, 2008].
o Benzoyl peroxide combined with a topical antibiotic is usually the
preferred choice, as it is an effective and well-tolerated regimen. The
efficacy of this combination has been shown by evidence from three
large RCTs, and the addition of benzoyl peroxide to a topical antibiotic
has been shown to prevent the development of bacterial resistance
[Strauss et al, 2007].
o A topical retinoid combined with a topical antibiotic is a useful option in
people who cannot tolerate benzoyl peroxide. In theory this combination
should demonstrate synergy, with both inflammatory and non-
inflammatory lesions being directly treated, although limited evidence
from an RCT suggests this combination is not as effective as benzoyl
peroxide combined with a topical antibiotic, and there are concerns that
bacterial resistance could develop.
o Benzoyl peroxide combined with a topical retinoid has been reported as
being a 'very effective' treatment [Thiboutot, 2000], although CKS
identified no good-quality RCTs to support this. This combination may
cause an unacceptable rate of adverse effects.
o CKS identified no information on when it may be appropriate to combine
azelaic acid with another topical treatment.

Oral antibiotics

 Oral antibiotics are universally recommended by experts for the treatment of

severe acne, or extensive acne that would be difficult to treat with a topical drug
[Dreno et al, 2004; ICSI, 2006; Strauss et al, 2007].
 o Oral tetracyclines are recommended first-line. There is good evidence
from placebo-controlled trials that tetracycline is effective at reducing
lesion counts and severity. Although there is a lack of placebo-controlled
trials to verify the efficacy of the other standard tetracyclines, there is
evidence from comparative trials that there is likely to be a class effect.
o Oral erythromycin should be reserved for use when tetracyclines are
contraindicated.
 There is a lack of evidence from placebo-controlled trials to
verify the efficacy of erythromycin, although evidence from
comparative trials indicate it is probably as effective as
tetracyclines.
 However, there is evidence from observational and controlled
studies that there are particular problems with the development of
bacterial resistance to erythromycin.
 Minocycline is increasingly not recommended for the treatment of acne vulgaris
as other tetracyclines are regarded as being as effective, and less expensive with
better safety profiles [DTB, 2006; DTB, 2009].

Combined oral contraceptives (COCs)

 COCs are recommended as a first-line adjunctive treatment for women who

have acne [ICSI, 2006; Strauss et al, 2007]. There is good evidence from
placebo-controlled trials that COCs are effective in reducing lesion count, acne
severity, and the woman's perception of the condition [Arowojolu et al, 2007].

What information should I give about acne?

 Reassure the person about the natural course of the condition, but do not
trivialize it. Advise that:
o Acne is one of the most common disorders, affecting nearly everyone at
some point in their life.
o Acne will improve. It is primarily a skin disorder of the young, and will
usually clear up in later life without leaving significant scarring.
o Treatments are effective but take time to work (typically up to 8 weeks)
and may irritate the skin, especially at the start of treatment.
 Dispel popular myths about acne. In particular inform the person that:
o Acne is not caused by poor hygiene, and there is no evidence it is
improved by cleaning. In fact, excessive washing can aggravate acne.
o Diet has little or no effect on acne. For example, there is no evidence that
chocolate or fatty foods cause or aggravate acne. However if the person
notices that a particular food triggers flares of acne then it is reasonable
to avoid it.
o Picking at acne does not improve it, and may cause scarring.
Occasionally it may be beneficial to drain large purulent lesions, but this
should be done under medical supervision.
o Stress probably does not cause acne, although there is a correlation
between stress and acne, and unsightly lesions may cause increased
levels of stress.
 o Acne is not infectious and cannot be passed on to other people. The main
bacterium involved in the inflammation, Propionibacteria acnes, is
naturally present on skin but, in acne, it colonizes follicles.
o Sunlight probably has little benefit in acne, and there is no evidence to
support active sunbathing or exposure to other sources of ultraviolet
light. Excessive sun exposure should be avoided by all people, especially
when taking drugs such as topical or oral retinoids, or oral tetracyclines.

Basis for recommendation

Providing reassurance

 The prognosis of acne is good for most people, with less than 12% of women
and 3% men being affected after 25 years of age. However, the condition should
not be trivialized, as it may last for several years and have a negative
psychological impact in some people. A balanced understanding of the disease
course and its impact on everyday life is required [Acne Working Group, 2008].

Myths about acne

 Experts believe that dispelling 'myths' is an integral component of the

management of acne [ICSI, 2006].
 Evidence on the myths about acne is based mainly on poor-quality data from
uncontrolled trials and observational studies, and expert opinion.
 There is insufficient evidence from observational studies or controlled trials to
indicate that changes in diet, use of hygiene measures, or exposure to sunlight is
beneficial in the management of acne.
 There is a consensus of expert opinion that stress does not cause acne, although
it is widely believed it can exacerbate the psychological reaction to acne [ICSI,
2006].

What self-care advice should I give to a person with

acne?
 Advise about washing and skin care. In general, it is recommended that people
with acne:
o Do not wash more than twice a day.
o Use a mild soap or cleanser and lukewarm water (as very hot or cold
water may worsen acne).
o Do not use vigorous scrubbing when washing acne-affected skin, and the
use of abrasive soaps, cleansing granules, astringents, or exfoliating
agents should be discouraged (advise use of a soft wash-cloth and fingers
instead).
o Should not attempt to 'clean' blackheads. Scrubbing or picking acne is
liable to worsen the condition.
o Ideally, should avoid excessive use of makeup and cosmetics. If they
must be used, advise that a non-comedogenic, water-based product
should be used sparingly (advise that details of cosmetic ingredients are
 displayed on the product label), and that all makeup should be removed
completely at night.
o Use a fragrance-free, water-based emollient if dry skin is a problem
(several topical acne drugs dry the skin). The use of ointments or oil-rich
creams should be avoided as these can clog pores.
 Advise about non-prescription treatments.
o Benzoyl peroxide is a useful topical drug available over-the-counter.
However, there is a lack of evidence of benefit for other over-the-counter
drugs.
o Complementary and alternative medicines (for example herbal
medicines) are not usually harmful but there is a general lack of evidence
to support their use.

Basis for recommendation

Advice on hygiene measures

 Recommendations on hygiene measures are based on consensus of experts

[Webster, 2002; ICSI, 2006].

Over-the-counter (OTC) treatments

 Most OTC products are not recommended because there is a lack of evidence
from clinical trials to support their efficacy [Sharpe, 1995; Brown and Shalita,
1998; Ravenscroft, 2005; Strauss et al, 2007].
o Salicylic acid is a common ingredient in OTC acne treatments. It is a
keratolytic drug that has some anti-comedone activity, but there is a lack
of evidence from controlled trials to confirm this, and it is considered
less effective than the topical retinoids.
o Abrasives (such as aluminium oxide) and sulphur (available combined
with resorcinol, as Eskamel®) have been used historically, but lack
evidence from controlled trials. Some products containing aluminium
oxide are abrasive and can irritate inflamed skin.
o Nicotinamide (available as Nicam®) has been reported as being as
effective as topical clindamycin in open-label cohort studies [Dos et al,
2003; Sardesai and Kambli, 2003], but CKS identified no randomized
controlled trials to confirm this.
o However, there is substantial placebo-controlled trial evidence to support
the use of benzoyl peroxide in the treatment of acne.

Complementary and alternative medicine (CAM)

 There is little evidence to support the use of CAM in the treatment of acne.
o A review of CAM treatments for acne found an overall lack of good
quality evidence of beneficial effect; studies were limited in number and
most were methodologically poor or underpowered [Magin et al, 2006].
o One systematic review (search date: October 2002) found two trials that
investigated the efficacy of herbal remedies in acne [Martin and Ernst,
2003]. Both studies were small and of poor methodological quality.
  One trial compared tea tree oil with benzoyl peroxide. There was
no placebo group and the study lacked the statistical power to
show equivalence or superiority of the regimens.
 In the other trial, the herb Ocimum gratissimum (dissolved in
alcohol and added to oil) was compared with benzoyl peroxide
and placebo. However, as various concentrations were
investigated, the groups were too small to allow any firm
conclusions.

How should I follow up a person with acne?

 Arrange follow up after about 6 weeks, and review the effectiveness and
tolerability of treatment, as well as compliance with regimens.
 Advise the person to return sooner if the acne deteriorates significantly despite
treatment.

Basis for recommendation

Recommendations for following up people with acne are based on international [ICSI,
2006] and national [Acne Working Group, 2008] guidelines.

 There is evidence from a randomized controlled trial involving both topical

drugs and oral antibiotics that it may take about 6 weeks for an adequate
response, although the maximal response may take up to 3 months [Ozolins et
al, 2005].
 Therefore, it is reasonable to assess response to treatment after a period of about
6 weeks, and continue treatment if the drug has had a positive effect. If it has
not, it is reasonable to try other strategies (such as increasing treatment strength,
switching treatments, or adding on treatments).

What should I do if moderate acne fails to respond to

treatment?
For people using topical treatments:

 Check adherence to treatment.

o If adherence is poor, this may be because the treatment was poorly
tolerated. Consider:
 Reducing the strength (for example, reducing from 5% to 2.5%
benzoyl peroxide).
 Switching to an alternative topical drug that causes less irritation
(for example a topical antibiotic or azelaic acid).
 Using a different formulation of drug (for example a cream
instead of a drug with an alcoholic base).
o If adherence is adequate, consider:
 Increasing the drug strength and/or frequency of application.
 Combining different topical products (if not already doing so).
Benzoyl peroxide combined with erythromycin or clindamycin is
 particularly effective against both non-inflammatory and
inflammatory acne.
 Starting an oral antibiotic.

For people taking an oral antibiotic:

 If the person has not responded adequately, bear in mind that it can take up to
3 months for a full response to occur.
o Check adherence to treatment.
o If there has been some response, continue treatment and consider adding
topical benzoyl peroxide or a topical retinoid (if the person is not already
using these), or prescribe both of these.
o If there has been no response, consider seeking specialist advice or
referral.

Basis for recommendation

These are pragmatic recommendations that are in line with expert opinion from
international [ICSI, 2006] and national [Acne Working Group, 2008] guidelines.

When should I refer a person with moderate acne

 People who have severe psychosocial problems, including a morbid fear of
deformity (body dysmorphic disorder), or people who have suicidal ideation,
should be referred soon to psychiatry.
 Refer for a routine dermatology appointment:
o People who are developing scarring, or are at risk of developing it,
despite primary care interventions.
o People who have moderate acne that has failed to respond adequately to
treatment. Treatment should generally include several courses of both
topical and oral drugs over a period of at least 6 months, and treatment
failure should be judged on the person's perception of their condition.
o People with features that make the diagnosis uncertain.
 Refer routinely to endocrinology or gynaecology, those women suspected of
having an underlying endocrinological cause of acne (such as polycystic ovary
syndrome) that needs assessment.

Basis for recommendation

Referral criteria for acne vulgaris are based on Referral advice: A guide to appropriate
referral from general to specialist services, published by the National Institute for
Health and Clinical Excellence (NICE). For people requiring referral 'immediately' or
'soon', NICE specify that 'Health authorities, trusts, and primary care organizations
should work to local definitions of maximum waiting times in each of these categories.
The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks
to be appropriate for the urgent category' [NICE, 2001].

Prescriptions
Benzoyl peroxide (gel)

Age from 12 years onwards

Benzoyl peroxide 2.5% aqueous gel
PanOxyl Aquagel 2.5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.76
OTC cost: £3.10
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% aqueous gel
PanOxyl Aquagel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.92
OTC cost: £3.38
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% aqueous gel
PanOxyl Aquagel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £2.07
OTC cost: £3.65
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% alcoholic gel
Panoxyl Acnegel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.51
OTC cost: £2.66
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% alcoholic gel
Panoxyl Acnegel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.69
OTC cost: £2.98
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.

Benzoyl peroxide (cream and wash)

Age from 12 years onwards

Benzoyl peroxide 4% cream
Benzoyl peroxide 4% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £3.30
OTC cost: £5.82
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% cream
Benzoyl peroxide 5% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.89
OTC cost: £3.33
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% wash
Benzoyl peroxide 10% wash
Apply to the affected area once a day.
Supply 150 ml.
Age: from 12 years onwards
NHS cost: £4.00
OTC cost: £7.05
Licensed use: yes
Patient information: Wet the affected area with water and wash thoroughly with the
Wash. Rinse well with warm water, then rinse with cold water, and pat dry with a clean
towel. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands
after use. This product may bleach clothing, hair, towels and bed linen.

Topical retinoids (tretinoin, isotretinoin, adapalene)

Age from 12 years onwards

Adapalene 0.1% cream
Adapalene 0.1% cream
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Adapalene 0.1% gel
Adapalene 0.1% gel
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Isotretinoin 0.05% gel
Isotretinoin 0.05% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £6.18
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Tretinoin 0.025% gel
Tretinoin 0.025% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Tretinoin 0.01% gel
Tretinoin 0.01% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Topical antibiotics (clindamycin, erythromycin, erythromycin/zinc)

Age from 12 years onwards

Clindamycin 1% gel
Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £8.66
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Clindamycin 1% aqueous lotion
Clindamycin 1% aqueous lotion
Apply thinly to the affected area(s) twice a day.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.47
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Erythromycin 2% alcoholic solution
Erythromycin 2% solution
Apply thinly to the affected area(s) twice a day, after washing.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.00
Licensed use: yes
Erythromycin 4% gel
Erythromycin 4% gel
Apply thinly to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £4.97
Licensed use: yes
Erythromycin 4% + zinc acetate 1.2% solution
Erythromycin 40mg/ml / Zinc acetate 12mg/ml lotion
Apply to the affected area(s) twice a day.
Supply 30 ml.
Age: from 12 years onwards
NHS cost: £7.71
Licensed use: yes

Azelaic acid (gel and cream)

Age from 12 years onwards

Azelaic acid 20% cream
Azelaic acid 20% cream
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £3.74
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes.
Age from 18 years onwards
Azelaic acid 15% gel (facial acne)
Azelaic acid 15% gel
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 18 years onwards
NHS cost: £7.48
Licensed use: yes
Patient information: Wash the affected area(s) with water and pat dry before use. Avoid
contact with the eyes, mouth and other mucous membranes.

Combination products (BPO/antibiotic, topical retinoid/antibiotic)

Age from 12 years onwards

Benzoyl peroxide 5% + clindamycin 1% gel
Benzoyl peroxide 5% / Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 25 grams.
Age: from 12 years onwards
NHS cost: £9.95
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Tretinoin 0.025% + erythromycin 4% alcoholic solution
Erythromycin 4% / Tretinoin 0.025% solution
Apply thinly to the affected area(s) once or twice a day.
Supply 25 ml.
Age: from 12 years onwards
NHS cost: £7.05
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Isotretinoin 0.05% + erythromycin 2% gel
Erythromycin 2% / Isotretinoin 0.05% gel
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £7.78
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.

Oral antibiotics ('standard tetracyclines' and erythromycin)

Age from 12 years onwards
Tetracycline tablets: 500mg twice a day
Tetracycline 250mg tablets
Take two tablets twice a day.
Supply 112 tablets.
Age: from 12 years onwards
NHS cost: £36.36
Licensed use: yes
Patient information: Swallow these tablets whole with plenty of fluid while sitting or
standing.
Oxytetracycline tablets: 500mg twice a day
Oxytetracycline 250mg tablets
Take two tablets twice a day.
Supply 112 tablets.
Age: from 12 years onwards
NHS cost: £4.32
Licensed use: yes
Patient information: Swallow these tablets whole with plenty of fluid while sitting or
standing.
Doxycycline capsules: 50mg once a day
Doxycycline 50mg capsules
Take one capsule once a day.
Supply 28 capsules.
Age: from 12 years onwards
NHS cost: £1.76
Licensed use: yes
Patient information: Swallow these capsules whole with plenty of fluid while sitting or
standing.
Lymecycline capsules: 408mg once a day
Lymecycline 408mg capsules
Take one capsule once a day.
Supply 28 capsules.
Age: from 12 years onwards
NHS cost: £7.77
Licensed use: yes
Patient information: Swallow these capsules whole with plenty of fluid while sitting or
standing.
Erythromycin e/c tablets: 500mg twice a day
Erythromycin 250mg gastro-resistant tablets
Take two tablets twice a day.
Supply 112 tablets.
Age: from 12 years onwards
NHS cost: £7.12
Licensed use: yes

Anti-androgen and oestrogen (co-cyprindiol)

Age from 14 to 50 years

Cyproterone acetate 2mg + ethinylestradiol 35micrograms
Co-cyprindiol 2000microgram/35microgram tablets
Take one tablet once a day for 21 days. Start the next packet after a 7-day break. See
package insert for full instructions.
Supply 63 tablets.
Age: from 14 years to 50 years
NHS cost: £3.92
Licensed use: yes
Patient information: Take the pill at the same time each day. If you forget one or more
pills or experience diarrhoea or vomiting and are unsure what to do, seek the advice of a
health professional.

Acne vulgaris - Management

View full scenario
How should I treat severe acne?
 In severe acne, there are nodules and cysts (nodulocystic acne), as well as a
preponderance of inflammatory papules and pustules. There is a high risk of
scarring (or scarring may already be evident), and there is likely to be
considerable psychosocial morbidity.
 Refer all people with severe acne for specialist assessment and treatment (for
example with oral isotretinoin), and consider prescribing an oral antibiotic in
combination with a topical drug whilst waiting for an appointment.
o Oral tetracycline, oxytetracycline, doxycycline, or lymecycline are first-
line options. Erythromycin is an alternative if tetracyclines are poorly
tolerated or contraindicated (such as in pregnancy). Minocycline is not
recommended.
o Benzoyl peroxide or a topical retinoid are recommended as adjunctive
treatment for most people. Azelaic acid is an alternative, but avoid the
use of topical antibiotics with oral antibiotics.
 Consider prescribing a combined oral contraceptive in women who require
contraception. Standard combined oral contraceptives or co-cyprindiol
(Dianette®) are options.

Basis for recommendation

Recommendations for treatment are based on international guidelines [ICSI, 2006;

Strauss et al, 2007] and narrative reviews [Webster, 2002; James, 2005; Ravenscroft,
2005; Zaenglein and Thiboutot, 2006; Acne Working Group, 2008], and reflect
published data from randomized controlled trials (RCTs) where available, and
otherwise, expert opinion.

Referral

 Referral of all people with severe acne vulgaris is consistent with Referral
advice: A guide to appropriate referral from general to specialist services,
published by the National Institute for Health and Clinical Excellence (NICE)
 [NICE, 2001]. This is recommended in order to alleviate pain and psychological
distress, and to prevent or limit scarring.

Oral antibiotics

 Oral antibiotics are universally recommended by experts for the treatment of

severe acne, or extensive acne that would be difficult to treat with a topical drug
[Dreno et al, 2004; ICSI, 2006; Strauss et al, 2007].
o Oral tetracyclines are recommended first-line. There is good evidence
from placebo-controlled trials that tetracycline is effective at reducing
lesion counts and severity. Although there is a lack of placebo-controlled
trials to verify the efficacy of the other standard tetracyclines, there is
evidence from comparative trials that there is likely to be a class effect.
o Oral erythromycin should be reserved for use when tetracyclines are
contraindicated.
 There is a lack of evidence from placebo-controlled trials to
verify the efficacy of erythromycin, although evidence from
comparative trials indicate it is probably as effective as
tetracyclines.
 However, there is evidence from observational and controlled
studies that there are particular problems with the development of
bacterial resistance to erythromycin.
 Minocycline is increasingly not recommended for the treatment of acne vulgaris
as other tetracyclines are regarded as being as effective, and less expensive with
a better safety profile [DTB, 2006; DTB, 2009].

Combining oral and topical drugs

 There is little evidence from RCTs to confirm the effectiveness of combining

oral and topical treatment, but expert consensus supports this practice [Dreno et
al, 2004].
o Combining an oral antibiotic with a topical retinoid targets both
inflammatory and non-inflammatory lesions, and inhibits the formation
of microcomedones (the precursors of acne).
o For long-term use (such as over 3 months), addition of benzoyl peroxide
should be considered, to prevent the development of bacterial resistance
[Ozolins et al, 2005].
o Oral and topical antibiotics should never be combined (as this increases
the risk of antibiotic resistance without giving additional benefit) [Dreno
et al, 2004].

Combined oral contraceptives (COCs)

 COCs are recommended as a first-line adjunctive treatment for women who

have acne [ICSI, 2006; Strauss et al, 2007]. There is good evidence from
placebo-controlled trials that COCs are effective in reducing lesion count, acne
severity, and the woman's perception of the condition [Arowojolu et al, 2007].
 Co-cyprindiol is licensed for 'severe acne, refractory to prolonged oral antibiotic
therapy; or moderately severe hirsutism' [ABPI Medicines Compendium,
2008a]. However, some experts suggest it may be appropriate to use it in
 suitable women before antibiotics are tried, and this is commonly done in
practice.

What should I do if severe acne fails to respond to

treatment?
 If the acne deteriorates whilst waiting for referral, seek advice or an urgent
appointment. Otherwise, whilst waiting for referral:
o Bear in mind the full response to an oral antibiotic may take up to
3 months to develop.
o If there has been some response, check compliance, continue treatment,
and consider adding topical benzoyl peroxide or a topical retinoid (if the
person is not already using these), or prescribe both of these.

Basis for recommendation

These are pragmatic recommendations that are in line with expert opinion from
international [ICSI, 2006] and national [Acne Working Group, 2008] guidelines.

When should I refer a person with severe acne?

 Refer urgently (within 2 weeks) if the person has a severe variant of acne with
systemic symptoms (such as acne fulminans).
 Refer (soon) all other people with severe acne including people with:
o Painful, deep, nodules or cysts (nodulocystic acne).
o Severe psychosocial problems, including a morbid fear of deformity
(body dysmorphic disorder), or people who have suicidal ideation.

Basis for recommendation

Referral criteria for acne vulgaris are based on Referral advice: A guide to appropriate
referral from general to specialist services, published by the National Institute for
Health and Clinical Excellence (NICE). For people requiring referral 'immediately' or
'soon', NICE specify that 'Health authorities, trusts, and primary care organizations
should work to local definitions of maximum waiting times in each of these categories.
The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks
to be appropriate for the urgent category' [NICE, 2001].

Treatment options that are available in secondary care include:

Oral isotretinoin

 Oral isotretinoin is an effective option in secondary care [MHRA, 2008]. It must

not be initiated in primary care, except under the care of a dermatology
specialist. The manufacturer's Summary of Product Characteristics states that
isotretinoin 'should only be prescribed by, or under the supervision of,
physicians who have expertise in the use of systemic retinoids for the treatment
 of severe acne, and a full understanding of the risks of isotretinoin therapy and
of the monitoring requirements' [ABPI Medicines Compendium, 2008b].
o Oral isotretinoin is an extremely effective treatment for acne. It is used
for severe acne conditions such as nodulocystic acne, acne conglobata,
scarring, or persistent acne that does not respond adequately to standard
treatment or is causing significant psychological problems [Wolf, 2002].
o It is associated with potentially serious adverse effects, including
teratogenicity. However, research has shown that concerns about links
between isotretinoin and depression or suicide are not established [Chia
et al, 2005; Magin et al, 2005b].

Laser treatment

 Laser treatment is sometimes used in the treatment of acne in secondary care.

Lasers primarily work by targeting Propionibacterium acnes in the sebaceous
glands. However, at present the evidence for laser therapy is limited and more
trials are needed to evaluate its effectiveness [Jordan et al, 2000; Bhardwaj et al,
2005; Hamilton et al, 2009].
o Laser treatment may also be indicated for post-acne scarring.
o Lasers are expensive and their availability is limited.

Surgical treatment

 Various surgical and medical techniques may be used for the treatment of very
severe acne in secondary care [Brown and Shalita, 1998].
o Purulent nodules can be incised and drained of pus.
o Comedones can be cauterized. Alternatively, comedone extraction is a
technique in which entire comedones are removed. Usually this is done
following several weeks of topical treatment.
o Large, tender nodules can be treated with an intralesional injection of a
corticosteroid such as triamcinolone. This rapidly reduces inflammation
and reduces lesion size.
 Surgical treatment of scarring is more problematic. If there is extensive
superficial scarring, dermabrasion may be performed by a plastic surgeon to
improve the appearance of the skin [Sharpe, 1995], although this procedure is
now less common.

What information should I give about acne?

 Reassure the person about the natural course of the condition, but do not
trivialize it. Advise that:
o Acne is one of the most common disorders, affecting nearly everyone at
some point in their life.
o Acne will improve. It is primarily a skin disorder of the young, and will
usually clear up in later life without leaving significant scarring.
o Treatments are effective but take time to work (typically up to 8 weeks)
and may irritate the skin, especially at the start of treatment.
 Dispel popular myths about acne. In particular inform the person that:
 o Acne is not caused by poor hygiene, and there is no evidence it is
improved by cleaning. In fact, excessive washing can aggravate acne.
o Diet has little or no effect on acne. For example, there is no evidence that
chocolate or fatty foods cause or aggravate acne. However if the person
notices that a particular food triggers flares of acne then it is reasonable
to avoid it.
o Picking at acne does not improve it, and may cause scarring.
Occasionally it may be beneficial to drain large purulent lesions, but this
should be done under medical supervision.
o Stress probably does not cause acne, although there is a correlation
between stress and acne, and unsightly lesions may cause increased
levels of stress.
o Acne is not infectious and cannot be passed on to other people. The main
bacterium involved in the inflammation, Propionibacteria acnes, is
naturally present on skin but, in acne, it colonizes follicles.
o Sunlight probably has little benefit in acne, and there is no evidence to
support active sunbathing or exposure to other sources of ultraviolet
light. Excessive sun exposure should be avoided by all people, especially
when taking drugs such as topical or oral retinoids, or oral tetracyclines.

Basis for recommendation

Providing reassurance

 The prognosis of acne is good for most people, with less than 12% of women
and 3% men being affected after 25 years of age. However, the condition should
not be trivialized, as it may last for several years and have a negative
psychological impact in some people. A balanced understanding of the disease
course and its impact on everyday life is required [Acne Working Group, 2008].

Myths about acne

 Experts believe that dispelling 'myths' is an integral component of the

management of acne [ICSI, 2006].
 Evidence on the myths about acne is based mainly on poor-quality data from
uncontrolled trials and observational studies, and expert opinion.
 There is insufficient evidence from observational studies or controlled trials to
indicate that changes in diet, use of hygiene measures, or exposure to sunlight is
beneficial in the management of acne.
 There is a consensus of expert opinion that stress does not cause acne, although
it is widely believed it can exacerbate the psychological reaction to acne [ICSI,
2006].

What self-care advice should I give to a person with

acne?
 Advise about washing and skin care. In general, it is recommended that people
with acne:
o Do not wash more than twice a day.
 o Use a mild soap or cleanser and lukewarm water (as very hot or cold
water may worsen acne).
o Do not use vigorous scrubbing when washing acne-affected skin, and the
use of abrasive soaps, cleansing granules, astringents, or exfoliating
agents should be discouraged (advise use of a soft wash-cloth and fingers
instead).
o Should not attempt to 'clean' blackheads. Scrubbing or picking acne is
liable to worsen the condition.
o Ideally, should avoid excessive use of makeup and cosmetics. If they
must be used, advise that a non-comedogenic, water-based product
should be used sparingly (advise that details of cosmetic ingredients are
displayed on the product label), and that all makeup should be removed
completely at night.
o Use a fragrance-free, water-based emollient if dry skin is a problem
(several topical acne drugs dry the skin). The use of ointments or oil-rich
creams should be avoided as these can clog pores.
 Advise about non-prescription treatments.
o Benzoyl peroxide is a useful topical drug available over-the-counter.
However, there is a lack of evidence of benefit for other over-the-counter
drugs.
o Complementary and alternative medicines (for example herbal
medicines) are not usually harmful but there is a general lack of evidence
to support their use.

Basis for recommendation

Advice on hygiene measures

 Recommendations on hygiene measures are based on consensus of experts

[Webster, 2002; ICSI, 2006].

Over-the-counter (OTC) treatments

 Most OTC products are not recommended because there is a lack of evidence
from clinical trials to support their efficacy [Sharpe, 1995; Brown and Shalita,
1998; Ravenscroft, 2005; Strauss et al, 2007].
o Salicylic acid is a common ingredient in OTC acne treatments. It is a
keratolytic drug that has some anti-comedone activity, but there is a lack
of evidence from controlled trials to confirm this, and it is considered
less effective than the topical retinoids.
o Abrasives (such as aluminium oxide) and sulphur (available combined
with resorcinol, as Eskamel®) have been used historically, but lack
evidence from controlled trials. Some products containing aluminium
oxide are abrasive and can irritate inflamed skin.
o Nicotinamide (available as Nicam®) has been reported as being as
effective as topical clindamycin in open-label cohort studies [Dos et al,
2003; Sardesai and Kambli, 2003], but CKS identified no randomized
controlled trials to confirm this.
o However, there is substantial placebo-controlled trial evidence to support
the use of benzoyl peroxide in the treatment of acne.
Complementary and alternative medicine (CAM)

 There is little evidence to support the use of CAM in the treatment of acne.
o A review of CAM treatments for acne found an overall lack of good
quality evidence of beneficial effect; studies were limited in number and
most were methodologically poor or underpowered [Magin et al, 2006].
o One systematic review (search date: October 2002) found two trials that
investigated the efficacy of herbal remedies in acne [Martin and Ernst,
2003]. Both studies were small and of poor methodological quality.
 One trial compared tea tree oil with benzoyl peroxide. There was
no placebo group and the study lacked the statistical power to
show equivalence or superiority of the regimens.
 In the other trial, the herb Ocimum gratissimum (dissolved in
alcohol and added to oil) was compared with benzoyl peroxide
and placebo. However, as various concentrations were
investigated, the groups were too small to allow any firm
conclusions.

Prescriptions
Benzoyl peroxide (gel)

Age from 12 years onwards

Benzoyl peroxide 2.5% aqueous gel
PanOxyl Aquagel 2.5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.76
OTC cost: £3.10
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% aqueous gel
PanOxyl Aquagel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.92
OTC cost: £3.38
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% aqueous gel
PanOxyl Aquagel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £2.07
OTC cost: £3.65
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% alcoholic gel
Panoxyl Acnegel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.51
OTC cost: £2.66
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% alcoholic gel
Panoxyl Acnegel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.69
OTC cost: £2.98
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.

Benzoyl peroxide (cream and wash)

Age from 12 years onwards

Benzoyl peroxide 4% cream
Benzoyl peroxide 4% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £3.30
OTC cost: £5.82
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% cream
Benzoyl peroxide 5% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.89
OTC cost: £3.33
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% wash
Benzoyl peroxide 10% wash
Apply to the affected area once a day.
Supply 150 ml.
Age: from 12 years onwards
NHS cost: £4.00
OTC cost: £7.05
Licensed use: yes
Patient information: Wet the affected area with water and wash thoroughly with the
Wash. Rinse well with warm water, then rinse with cold water, and pat dry with a clean
towel. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands
after use. This product may bleach clothing, hair, towels and bed linen.

Topical retinoids (tretinoin, isotretinoin, adapalene)

Age from 12 years onwards

Adapalene 0.1% cream
Adapalene 0.1% cream
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Adapalene 0.1% gel
Adapalene 0.1% gel
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Isotretinoin 0.05% gel
Isotretinoin 0.05% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £6.18
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Tretinoin 0.025% gel
Tretinoin 0.025% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Tretinoin 0.01% gel
Tretinoin 0.01% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.

Topical antibiotics (clindamycin, erythromycin, erythromycin/zinc)

Age from 12 years onwards

Clindamycin 1% gel
Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £8.66
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Clindamycin 1% aqueous lotion
Clindamycin 1% aqueous lotion
Apply thinly to the affected area(s) twice a day.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.47
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Erythromycin 2% alcoholic solution
Erythromycin 2% solution
Apply thinly to the affected area(s) twice a day, after washing.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.00
Licensed use: yes
Erythromycin 4% gel
Erythromycin 4% gel
Apply thinly to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £4.97
Licensed use: yes
Erythromycin 4% + zinc acetate 1.2% solution
Erythromycin 40mg/ml / Zinc acetate 12mg/ml lotion
Apply to the affected area(s) twice a day.
Supply 30 ml.
Age: from 12 years onwards
NHS cost: £7.71
Licensed use: yes

Azelaic acid (gel and cream)

Age from 12 years onwards

Azelaic acid 20% cream
Azelaic acid 20% cream
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £3.74
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes.
Age from 18 years onwards
Azelaic acid 15% gel (facial acne)
Azelaic acid 15% gel
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 18 years onwards
NHS cost: £7.48
Licensed use: yes
Patient information: Wash the affected area(s) with water and pat dry before use. Avoid
contact with the eyes, mouth and other mucous membranes.

Combination products (BPO/antibiotic, topical retinoid/antibiotic)

Age from 12 years onwards

Benzoyl peroxide 5% + clindamycin 1% gel
Benzoyl peroxide 5% / Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 25 grams.
Age: from 12 years onwards
NHS cost: £9.95
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash
hands after use. This product may bleach clothing, hair, towels and bed linen.
Tretinoin 0.025% + erythromycin 4% alcoholic solution
Erythromycin 4% / Tretinoin 0.025% solution
Apply thinly to the affected area(s) once or twice a day.
Supply 25 ml.
Age: from 12 years onwards
NHS cost: £7.05
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.
Isotretinoin 0.05% + erythromycin 2% gel
Erythromycin 2% / Isotretinoin 0.05% gel
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £7.78
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry
before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid
excessive exposure to sunlight.

Oral antibiotics ('standard tetracyclines' and erythromycin)

Age from 12 years onwards

Tetracycline tablets: 500mg twice a day
Tetracycline 250mg tablets
Take two tablets twice a day.
Supply 112 tablets.
Age: from 12 years onwards
NHS cost: £36.36
Licensed use: yes
Patient information: Swallow these tablets whole with plenty of fluid while sitting or
standing.
Oxytetracycline tablets: 500mg twice a day
Oxytetracycline 250mg tablets
Take two tablets twice a day.
Supply 112 tablets.
Age: from 12 years onwards
NHS cost: £4.32
Licensed use: yes
Patient information: Swallow these tablets whole with plenty of fluid while sitting or
standing.
Doxycycline capsules: 50mg once a day
Doxycycline 50mg capsules
Take one capsule once a day.
Supply 28 capsules.
Age: from 12 years onwards
NHS cost: £1.76
Licensed use: yes
Patient information: Swallow these capsules whole with plenty of fluid while sitting or
standing.
Lymecycline capsules: 408mg once a day
Lymecycline 408mg capsules
Take one capsule once a day.
Supply 28 capsules.
Age: from 12 years onwards
NHS cost: £7.77
Licensed use: yes
Patient information: Swallow these capsules whole with plenty of fluid while sitting or
standing.
Erythromycin e/c tablets: 500mg twice a day
Erythromycin 250mg gastro-resistant tablets
Take two tablets twice a day.
Supply 112 tablets.
Age: from 12 years onwards
NHS cost: £7.12
Licensed use: yes

Anti-androgen and oestrogen (co-cyprindiol)

Age from 14 to 50 years

Cyproterone acetate 2mg + ethinylestradiol 35micrograms
Co-cyprindiol 2000microgram/35microgram tablets
Take one tablet once a day for 21 days. Start the next packet after a 7-day break. See
package insert for full instructions.
Supply 63 tablets.
Age: from 14 years to 50 years
NHS cost: £3.92
Licensed use: yes
Patient information: Take the pill at the same time each day. If you forget one or more
pills or experience diarrhoea or vomiting and are unsure what to do, seek the advice of a
health professional.