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13.6 Preparations for Acne and Rosacea

Refer to notes on the “Management of acne”. See also the Acne Dermatology Referral and Management Pathway and the Rosacea Dermatology Referral and Management Pathway.

Keratolytics

Benzoyl Peroxide 4%, 5% cream, 5%, 10% gel.  (2.5% cream is available to buy over the counter)
Dose:  Apply 1 to 2 times daily, starting with the lower strength preparations.

Topical antibiotics

Erythromycin 2% topical solution, 4% topical solution with zinc acetate.
Dose:  To be applied twice daily.

Clindamycin 1% topical solution, lotion
Dose:  To be applied twice daily. 

Topical retinoids and related preparations

Isotretinoin 0.05% gel
Dose:  Apply 1-2 times daily.

Adapalene 0.1% gel, cream
Dose:  Apply once daily at night.

Combined preparations containing a topical antibiotic with a topical retinoid are available where the combination of both is clinically indicated.

Topical brimonidine

Brimonidine is a selective alpha2-adrenoceptor agonist, which is a treatment to reduce facial redness in rosacea by cutaneous vasoconstriction. It is indicated for: patients with moderate to severe persistent facial erythema, particularly where this is causing distress; patients who are severely affected by facial erythema while a response to treatment of the rosacea is awaited; or in those who have patterns of rosacea unlikely to respond well to laser treatment. Patients should be reviewed after 1-2 months of starting topical brimonidine and only continued if benefit, with further regular reviews (4 monthly) recommended thereafter.   

 Brimonidine tartrate 0.33% gel
Dose:  Apply thinly once daily until erythema subsides (max. 1g of gel (equivalent to 5mg brimonidine tartrate) daily divided over the forehead, chin, nose, and cheeks)

Oral antibiotics

Oxytetracycline tablets 250mg
Dose:  500mg twice daily, for at least 3 months

Erythromycin e/c tablets 250mg
Dose:  500mg twice daily for at least 3 months

Doxycycline capsules 50mg, 100mg
Dose:  100mg daily for at least 3 months for patients who are unable to comply with oxytetracycline treatment.

Lymecycline capsules 408mg (= tetracycline 300mg)
Dose:  408mg daily for at least 8 weeks as an alternative to doxycycline for patients unable to comply with oxytetracycline treatment.

    Lymecycline is also used in pyoderma gangrenosum [unlicensed use ‘off-label’], in hidradenitis suppurativa [unlicensed use ‘off-label’], in severe atopic eczema [unlicensed use ‘off-label’] and in autoimmune bullous disorders [unlicensed use ‘off-label’] (See also section 13.5.3).

    Minocycline is licensed for acne, however is associated with a greater risk of lupus erythematosus-like syndrome and sometimes causes irreversible pigmentation, so is rarely used for acne. It is used in pyoderma gangrenosum [unlicensed use ‘off-label’], and in hidradenitis suppurativa [unlicensed use ‘off-label’] (typical dose range 100-400mg daily).

    Trimethoprim in a dose of 300mg twice daily may be used for acne resistant to other antibacterials [unlicensed use ‘off-label’]. Prolonged treatment with trimethoprim may depress haematopoiesis.

Other preparations

Co-cyprindiol (brands include Dianette^®) tablets (cyproterone acetate 2mg, ethinylestradiol 35micrograms)
Dose:  1 tablet  daily for 21 days starting on the first day of the menstrual cycle and repeated after a 7 day interval, usually for several months; discontinue 3-4 months after complete resolution of acne (repeat courses may be given if recurrence).  

Co-cyprindiol is no more effective than oral antibiotic therapy for acne; it should only be considered in females who also wish to benefit from its oral contraceptive action and who are willing to accept the small risk of VTE (risk greater than some other combined hormonal contraceptives).  Co-cyprindiol should only be used for licensed or appropriate dermatological indications: severe acne refractory to oral antibiotics, moderately severe hirsutism, and hidradenitis suppurativa [unlicensed use ‘off-label’]. As co-cyprindiol provides effective contraception in women who require it for treatment of androgen-sensitive conditions, use of an additional hormonal contraceptive is contra-indicated. The female symbol (♀) may be used on prescriptions for co-cyprindiol when it is also being used for contraception. See Drug Safety Update Volume 6, Issue 11, June 2013 for information on the balance of benefits and risks of co-cyprindiol.

Oral retinoid

    Isotretinoin capsules are licensed for the treatment of severe forms of acne resistant to adequate courses of standard therapy with systemic antibacterials and topical therapy. Isotretinoin may also be prescribed for hidradenitis suppurativa [unlicensed use ‘off-label’] or rosacea [unlicensed use ‘off-label’]. Isotretinoin is a retinoid and should only be prescribed by a consultant dermatologist, a secondary care Dermatology clinic or by a pharmacist according to a Patient Specific Direction. Isotretinoin is teratogenic and must not be given to women of child bearing potential unless they practise effective contraception 1 month before, during and 1 month after treatment; also after detailed continual assessment and explanation by the prescriber. Women must also be registered with a pregnancy prevention programme. Monitoring is undertaken by the Dermatology clinic.

For further information see the Isotretinoin Patient Specific Direction (Staffnet intranet link only). See also MHRA Drug Safety Update, December 2014 Isotretinoin: reminder of possible psychiatric disorders.

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