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Management Of Acne

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Therapeutic Notes

Acne can be broadly classified into the following categories:

Mild: The disease consists of open and closed comedones with some superficial papules and pustules.

Moderate:  Encompasses more frequent deeper papules and pustules with mild scarring.

Severe: Comprises all of the above plus nodular abscesses and leads to more extensive scarring. 

Refer to algorithm.

1. First Choice
   Benzoyl peroxide applied once or twice daily
   Introduce gradually starting with the weakest preparation building up to the highest concentration tolerated.  Emphasise there must be some skin peeling if treatment is going to work, if problematic reduce the frequency of application to alternate days.
   or
   Isotretinoin applied once or twice daily.
   or
   Adapalene applied once daily, may be less irritant than retinoids.
   Avoid retinoids and adapalene during pregnancy.  Exposure to sunlight of areas treated with topical retinoids or adapalene should be avoided or minimised.  When exposure cannot be avoided, a sunscreen product and protective clothing should be used.
   

2. First Choice
   Erythromycin (topical) applied once daily
   or
   Erythromycin and zinc acetate applied once daily
   or
   Clindamycin 1% lotion applied once daily, is more suitable for dry skin.
   These should be prescribed concomitantly with topical benzoyl peroxide, ie topical antibiotic to be applied in the morning and topical benzoyl peroxide at night. 
   or
   Adapalene – see above.
   

3. First Choice
   Oxytetracycline 500mg twice daily for at least 3 months
   or
   Erythromycin 500mg twice daily for at least 3 months
   Tetracyclines should not be prescribed in pregnancy, to breast-feeding mothers or to children under 12.
   Oxytetracycline can be given as a twice-daily dose to aid compliance and must be given for an adequate length of time (at least 3 months).  Oxytetracycline tablets should be taken an hour before food and should not be taken with iron or antacid preparations which may reduce absorption. 
   

4. If patients taking a combined oral contraceptive (COC) are commenced on an oral antibiotic treatment, then additional contraceptive precautions should be taken for three weeks.  If this falls into the pill free period then the next pack should be started without a break.  Patients on every day pills should discard the inactive pills and continue immediately with the active pills (ie an active COC must be taken during this three-week period as well as other additional precautions).
   If the antibiotic course exceeds three weeks, resistance to this interference develops and additional precautions become unnecessary after this initial three-week period.
   If the patient has been receiving long-term oral antibiotic treatment then no precautions are necessary when the COC is introduced.
   Effectiveness of oral progestogen-only contraceptives (including the emergency hormonal contraceptive Levonelle^®) is not affected by broad spectrum antibiotics, but is reduced by enzyme inducing drugs.
   

5. Co-cyprindiol (Dianette^® ) is in general no more effective than oral antibiotic therapy, but is useful in females who also wish to receive oral contraception.  It is contra-indicated in pregnancy, so the need for careful compliance must be explained to patients before commencing.
   It reduces sebum excretion, which is under androgen control, and so can also help in idiopathic hirsutism.
   

6. Check compliance
   If not showing satisfactory response by 3 months, switch to alternative antibiotic such as doxycycline 100mg daily for at least 3 months or lymecycline 408mg daily for at least 8 weeks, then assess response.  Doxycycline and lymecycline may be taken with food, and this may help to reduce the incidence of nausea.   Avoid excess sun exposure when taking doxycycline (dose-dependant, but idiosyncratic, phototoxic reaction).  Minocycline 100mg daily for 3 months is a third line option of oral antibiotic for acne (non-formulary), as if continued beyond this time, monitoring for hepatotoxicity (LFTs), pigmentation and for SLE (serum antinuclear antibodies) is required.  If these develop, or if pre-existing SLE worsens, it must be discontinued.
   

7. Oral isotretinoin side effects include teratogenicity, hyperlipidaemia, dryness and irritation of skin and mucous membranes.

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