Printed on: September 9th, 2024

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Acne

Acne

In 2021, NICE released guidance on the management of acne vulgaris. Here, we review its advice, alongside some useful resources from the 2018 UK Primary Care Dermatology Society guidance, a 2018 NEJM Clinical Practice article and a 2024 DTB review (NICE 2021 NG178, NEJM 2018;379:1343, PCDS 2018 acne vulgaris, DTB 2024;62:6).

This article was last updated in April 2024.

The DTB tell us why acne matters (DTB 2024;62:6):

• It is very common, affecting over 90% of teenagers and persisting into their 20s in 40–60% of patients.
• It leads to scarring in 20% of the population.
• It can cause significant distress, decreased self-confidence and increased rates of depression and suicidal thoughts (interestingly, this occurs most frequently in women and people identifying as non-white).

Ask about duration, type and distribution of lesions.

Remember:

• Acne has four contributory factors:
  • Inflammation.
  • Proliferation of Propionibacterium acnes.
  • Comedones (black heads and white heads) due to abnormal keratin proliferation.
  • Androgen-driven sebum production.

Consider medications which might be causing or exacerbating acne: phenytoin, lithium, steroids (including illicit anabolic steroid use) and progestogen-only contraceptives.

Acne may also be triggered by sweating, occlusive clothing and greasy topical products such as ointments.

Smoking: a dose-dependent relationship between smoking and acne severity has been demonstrated (J Invest Dermatol. 2006;126(8):1749).

Diet: NICE did not find sufficient evidence to comment on diet. A systematic review suggested that a high-dairy diet and those with ‘high glycaemic loads’ may be associated with more severe acne (NEJM 2018;379:1343, PCDS 2018).

Few patients will need blood tests. However, there are some features that might warrant further investigations:

• If there are features suggestive of PCOS or other endocrinopathy.
• In sudden-onset acne: consider gonadal tumours as a cause.
• Acne with systemic features such as fever arthralgia and myalgia.

Ask about psychosocial impact. Adolescents with acne have higher levels of depression and anxiety, similar to other chronic diseases.

• All therapies for acne work on ‘tomorrow’s’ skin; improvement takes 3–6 weeks minimum, and may take 3–6m for maximal effect to be seen.
• There have been very few head-to-head trials of acne treatments, and most studies have been small.
• The primary aim of treatment is to prevent or minimise scarring.

NICE suggests (wait for it!) counting the number of lesions! The Primary Care Dermatology Society (PCDS) takes a slightly more pragmatic view. Both suggest classifying the disease as mild–moderate or moderate–severe. This distinction matters because it affects treatment choices. We have summarised both approaches here:

NICE reminds us to provide information to patients and caregivers on:

• Causes of acne (NICE does not outline any specific causes to mention but we have included a few in our introduction above).
• Treatment options, including over-the-counter treatments.
• Pros and cons of treatments:
  • Side-effects, including skin irritation.
  • Implications of treatment on pregnancy and conception.
• Importance of treatment adherence.
• Delayed onset of treatment benefits.
• Impact of acne, including psychological impact.
• Relapses after treatment: when and how to seek advice.
• Diet: NICE found no clear evidence to support any specific diet.

• Avoid comedogenic make-up and moisturisers.
• Remove make-up daily.
• Avoid persistent picking at spots as this may cause scarring.
• Use a non-alkaline synthetic detergent face wash twice daily.
• Synthetic detergent facewashes are cleansers formulated to be closer to the usual pH of skin than traditional soap. They do not produce a lather, and are less of an irritant to inflamed skin. They are widely available on supermarket shelves.

When reviewing after 12 weeks, determine how successful the treatment has been and consider the following management options:

NICE suggests referral if:

• Diagnosis uncertain.
• Not responding to treatment.
• Severe nodulo-cystic acne.
• Persistent scarring or pigmentation.
• Associated mental or physical health problems (refer to relevant team).

Treatments that NICE recommends are considered in secondary care:

• Oral isotretinoin (see below for more information).
• Oral corticosteroids: may be used in acne fulminans or if severe flare occurs after starting oral isotretinoin.
• Intralesional corticosteroids: off-label triamcinolone into severe inflammatory lesions under consultant-led care only.
• Photodynamic therapy.
• Scarring may be managed with CO₂ laser treatments or glycolic peels.

NICE suggests we should use combination (dual) agents for most. There are two situations where we might not do this:

• In mild disease where people are buying OTC preparations that are working for them (e.g. OTC benzoyl peroxide).
• Topical azelaic acid when used in combination with oral antibiotics.
• To reduce the risk of relapse in those who have recurrent relapses, if dual therapy is not tolerated (see ‘resolved’ in the section on ‘Management after 12w’ (above).

Oral isotretinoin can only be prescribed under expert supervision (so not in most primary care settings).

NICE recommendations around prescribing:

• In people >12y, for severe acne resistant to first-line treatments.
• Assess mental health before starting and refer to mental health services if appropriate.
• Monitor for signs of depression during treatment.
• Follow MHRA Pregnancy Prevention Programme (see below).
• Continue until a cumulative dose of 120–150mg/kg is reached OR if there has been good response and no new acne lesions for 4–8 weeks, whichever is the sooner.

• Dapsone is not included in NICE, European or PCDS guidelines, and is not licensed for acne in the UK.
• A common first-line agent in US guidelines (5% gel used as a twice-daily application).
• Oral dapsone is associated with risks of haemolytic anaemia, and should be prescribed by specialists.

A UK-based, double-blind RCT has found spironolactone beneficial in treating acne in young women (BMJ 2023;381:e074349).

400 women aged ≥18y with facial acne judged by clinicians severe enough to fit the NICE criteria for oral antibiotics were allocated to receive spironolactone or placebo. They continued any other acne treatments they were already using such as topical gels or hormonal pills.

Women were excluded if they had been using oral retinoids in the previous 6 months, if they had any plans for pregnancy in the next 6 months, or if they had contraindications to spironolactone use such as raised potassium or reduced eGFR.

Spironolactone was prescribed at a dose of 50mg daily for 6 weeks, then increased to 100mg daily.

• At 12 weeks, there was a small but statistically significant improvement in quality-of-life scores for the women using spironolactone.
• At 24 weeks, there was improvement in quality of life and self-reported severity of acne.
• NNT to improve self-reported severity of acne at 24 weeks was 5.
• Minimal adverse reactions were reported.

In an associated editorial in the BMJ, the authors postulate that offering spironolactone to young women with acne might reduce antibiotic treatment, and could also provide an alternative where the maximum recommended 6-month course of antibiotics is complete but acne persists (BMJ 2023;381:p1114).

The author of the BMJ editorial suggests a regimen of 50mg for 2 weeks, then 100mg, i.e. stepping-up sooner than in the trial, speculating that women might gain benefit more rapidly.

• Not licensed for this indication or recommended in UK guidelines.
• Cannot be used in men due to risk of gynaecomastia.
• Spironolactone cannot be used in pregnancy. The authors advise giving contraceptive counselling similar to when prescribing oral tetracyclines: for effective contraception to be in place during use and for 4 weeks after stopping treatment.
• Renal function monitoring: renal function and potassium checks are needed prior to starting treatment in all. Ongoing monitoring is only required if women are >45y of age or have other relevant comorbidities.
  • For women ≤45y and without other medications or medical history that might affect renal function, spironolactone use was associated with very low risk of renal problems; ongoing monitoring was therefore not advised.
• Menstrual disturbance: this trial does not comment on the risk of menstrual disturbance on spironolactone, but a previous study showed menstrual irregularity only occurred at higher doses of around 200mg per day (Am. J Clin Dermatol 2017;18(2):169).

NICE says we can consider adding combined oral contraception in women with PCOS if first-line treatment fails. However, the DTB suggests we could consider ‘off-label’ use of the COCP to treat acne in any woman.

The COCP is inferior to oral antibiotics at 3 months, but equivalent to antibiotics at reducing acne at 6 months (DTB 2024;62:6).

NO! Evidence on varying effectiveness of different progestogens may have been overplayed in the past. A Cochrane review agreed and identified no differences in efficacy between different COCP preparations, including cyproterone acetate (Dianette) (Cochrane 2012;7:CD004425). Be mindful of safety concerns for cyproterone acetate (see below), and remember that progestogen-based contraceptives may make skin worse.

The DTB reminds us (DTB 2013;51:48):

• There is no role for minocycline in the treatment of acne.
• Other tetracyclines are equally effective and do not carry the same risks of SLE, autoimmune hepatitis and slate-grey skin pigmentation.

NICE did not think so. However, many people with acne and their families ask about this. A recent JAMA review considered this issue and stated the following (JAMA 2021;326(20):2055):

• Overall, there is little high-quality evidence about the impact of particular foods on acne.
• The ‘most compelling’ evidence suggests that high-glycaemic-load diets may exacerbate acne.
• A number of observational studies have indicated an association (not causation) between consumption of dairy products, particularly low-fat milk, and exacerbation of acne. A meta-analysis of these observational studies showed an OR 1.16 of acne in milk drinkers consuming ≥2 cups per day.

There have been no RCTs of dairy exclusion and impact on skin, despite the fact this would be relatively easy to do! For this reason, no standard clinical guidelines in the UK or USA offer specific recommendations on diet.

	Acne Provide information and support, including skin care advice and advice on treatments and management of relapses. Use topical treatments for mild to moderate acne, and consider referring if no response after trials of 2 agents. Consider topical treatments + oral antibiotics in widespread moderate to severe acne, or acne with scarring. Beware of antimicrobial resistance with oral antibiotics – use for 12w maximum duration and always alongside topical treatments. Refer severe scarring acne and moderate acne that is treatment-resistant for consideration of oral retinoid treatment. Check LFT and lipid profile while waiting for appointment, and, if possible, give information on the risks and benefits at the point of referral. The COCP reduces sebum production and is an effective acne treatment for women with hormonal acne. There is no evidence that any particular COCP (including Dianette) is more effective – start with the one with the lowest VTE risk!
	Do you still have any patients on minocycline? This could be a nice, quick safety audit for your PDP.
	Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Acne Support British Skin Foundation - acne British Association of Dermatologists - patient information leaflet on isotretinoin Videos YouTube – What is the Best Way to Treat Acne? (the DTB recommends this patient information video by Dr Mike Evans)