Dr Kash Bhatti and Dr Bruce Pollock summarise the recently updated PCDS pathway on acne vulgaris and outline what to consider when managing the condition

Dr Kash Bhatti

Dr Kash Bhatti

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Read this article to learn more about:

  • diagnosing acne and assessing the treatment goals of patients
  • treatment options for different types of acne and preventing scarring
  • when to refer patients to secondary care.

Acne (acne vulgaris) is one of the most common presentations in primary care. No longer trivialised as a condition that only affects teenagers, acne is known to be a chronic inflammatory disorder that can have huge ramifications mentally, physically, and financially.1,2 The longer acne is left untreated, the more severe it can become, and permanent scarring may develop.1,3,4 People may try many products and treatments, which may or may not do harm, to cure their acne. It is therefore vital to provide authoritative advice when patients seek help.

GPs may not always be sure which treatment to prescribe a patient with acne, when, or for how long. The Primary Care Dermatology Society (PCDS) has updated its guidance on acne vulgaris, as well as producing a primary care treatment pathway that provides a useful reference when considering treatment for acne (see Figure 1).5,6 This article summarises the PCDS recommendations and examines how to approach the acne consultation.

The PDCS primary care treatment pathway for acne

Figure 1: PDCS acne primary care treatment pathway

Primary Care Dermatology Society. Acne vulgaris. www.pcds.org.uk/clinical-guidance/acne-vulgaris (accessed 6 October 2020).

Acne: the basics

At medical school it has generally been taught that acne occurs as a result of pilosebaceous gland dysfunction and inflammation.1,6 Ongoing research has provided further information. Acne is an inflammatory disorder of an as yet unknown cause, which principally affects the face, neck, chest, back, and sometimes the scalp. In advancing acne, the commensal Cutibacterium acnes (formerly Propionibacterium acnes) further encourages a pro-inflammatory state.7 More inflammation leads to cyst, abscess, and nodule formation. Gland destruction and scarring may occur.1 Each stage of the pathophysiology of acne is a target of acne medicines. Therefore, describing to a patient how acne occurs can help them understand different prescription choices and why treatments take time to reverse this chronic state.8

Recognising acne is generally not challenging: a constellation of signs is seen.1,6 The earliest acne lesions are comedones (see Figure 2). These are aggregates of keratin in blocked, dilated glands. They appear as ‘whiteheads’ (closed comedones: the skin surface is not broken), or ‘blackheads’ (open comedones: the skin surface is broken and exposed keratin has oxidised to a dark colour). These are non-inflammatory lesions and patients with comedonal acne predominantly have comedones. Inflammatory acne is characterised by erythematous papules and pustules (see Figure 3). In more severe acne, nodules (large, firm, woody lesions) and cysts (fluctuant swellings) will be present (nodulocystic acne)—see Figure 4. Lesions may be sore and uncomfortable. The challenge in acne is recognising the variants and knowing which treatment is suited to each type. Different types of lesions may be present all at once or appear at different times over the course of a patient’s acne.

Figure 2 Acne open and closed comedones

Figure 2: Comedones

Closed comedones (left) and open comedones (right)

Acne pustules and papules

Figure 3: Papules and pustules

An image showing examples of nodulocystic acne on the torso.

Figure 4: Nodulocystic acne

© Health Waikato Ltd. DermNet NZ

Reproduced with permission.

Acne can occur at any age,1 but most patients are in the adolescent age group. However, new-onset acne can develop in older age groups, such as in women up to the fourth decade of life.6 Acne in certain age groups, such as prepubescent children, is atypical, and may warrant investigation of endocrinological causes.1 Acne can be heightened by hyperandrogenic states, such as polycystic ovary syndrome.6

It is important to be aware of the differentials of acne. The PCDS website includes a general dermatology diagnostic table, which provides helpful guidance on recognising similar-looking conditions, such as rosacea and perioral dermatitis.9 It is appropriate to refer to dermatology to seek guidance when there is diagnostic doubt, rather than trying treatments empirically that may or may not worsen the skin and frustrate patient and practitioner alike.

Assessing the patient

Consultation and communication are at the heart of general practice and acne should be managed like any other chronic disorder. In addition to details such as when the acne started, how bad it gets (‘is today a good day, typical, or at its worst?’), what makes it worse, and so on, it is vital to know what the patient thinks of their acne, their beliefs, what concerns them, and what help they are seeking. No two patients are alike and the extent of disease does not always tally with its impact on the patient. Find out which treatments patients have already tried, for how long, and why they stopped using them or felt they did not work. What is their definition of success, and what are their goals for treatment? Do they seek to improve the appearance of acne, to prevent scars or, especially in patients with skin of colour, to improve marks (post-inflammatory hyperpigmentation—see Figure 5)? This information is fundamental to tailoring a management plan. 

Figure 5: Hyperpigmentation resulting from acne

An image showing hyperpigmentation of the skin following acne

Figure 5: Hyperpigmentation resulting from acne

Primary Care Dermatology Society. Acne vulgariswww.pcds.org.uk/clinical-guidance/acne-vulgaris (accessed 6 October 2020).

Reproduced with kind permission from the Primary Care Dermatology Society and Professor Bill Cunliffe.

Management options

The aims of treatment are to improve the lesion count, severity, risk of scarring, and impact of acne on quality of life.1,2 In most people, acne resolves without complication. However, for some patients, lesions may resolve as hyperpigmented macules, atrophic scars, or spontaneous keloids and hypertrophic scars.1 The risk of scarring cannot be predicted from patient to patient. Although scarring is more likely with more severe acne, even with mild acne, scars may develop.1,3

The guidance presents options for treating acne by morphological stage. The recommended treatment options for different types of acne are summarised in Table 1.

Type of acneRecommended treatment

Comedonal

  • In general, topical therapy is recommended.

Papulopustular

  • Combination treatment with a topical agent and a topical antibiotic or
  • Combination treatment with a topical (non-antibiotic) agent and an oral antibiotic is recommended.

Nodulocystic

  • An oral antibiotic with a topical (non-antibiotic) agent is recommended alongside referral to secondary care.

Any type of acne that is resulting in scarring

  • Institute treatment and concomitantly refer to secondary care.

With such a myriad of choices available, it is helpful for clinicians to become familiar with a few agents. A practical option is to prescribe a topical retinoid as a single agent or in combination with benzoyl peroxide first line, because retinoids target multiple steps along the pathophysiologic pathway.1,3,10,11 Retinoids are beneficial in reducing gland dysfunction, inflammation, scarring, and hyperpigmentation, and can be used for all skin types. Irritation can occur with any topical agent, but is more likely with topical retinoids, especially in drier skin.6 Different practitioners may suggest alternative ways to combat this, but common practice is to start with a pea-sized or smaller amount of retinoid and spread it thinly over the face, avoiding sensitive areas around the eyes, nasolabial folds, and lips where the skin is thinner. The patient may start by applying treatment once or twice a week, gradually increasing frequency to daily use. To further reduce irritation, retinoids may be applied for short periods, such as for 30–60 minutes, then washed off. The time that the treatment is left on the skin can then be gradually increased. Frequent application of a gentle, non-greasy, non-acnegenic moisturiser may be helpful.

Signs of irritation such as erythema, dryness, skin peeling, photosensitivity, and, occasionally, acne, may flare initially then start to improve.8,10 These signs may be viewed as a positive indicator that the treatment is working, but patients should be warned that it can take several weeks to see improvements. If side-effects occur and persist, treatment should be slowed down until an acceptable regimen is achieved; then treatment can be titrated back up to regular use over a period, rather than abandoned.

Antibiotics used for acne include tetracyclines, macrolides, and trimethoprim. Usually, first-line antibiotic choices are lymecycline (408 mg once daily) or doxycycline (100 mg once daily). Trimethoprim (200–300 mg twice daily) is reserved for second- or third-line treatment; its use is off-label and patients should be warned of the risk of drug rashes and, rarely, severe reactions such as Stevens–Johnson syndrome/toxic epidermal necrolysis. Courses of treatment should be for 12 weeks. Acne should then be reviewed, although in some cases benefits may take 24 weeks to be seen. The decision to extend antibiotic treatment beyond 12 weeks needs to be carefully considered because of antimicrobial resistance. Oral antibiotics should always be used with non-antibiotic topicals to reduce microbial resistance.1,4,11,12 Combining topical and oral antibiotics does not improve acne any further, but does increase bacterial resistance. At review, a reduction in acne lesions and improvement should be assessed. Topical therapy should be continued as maintenance therapy.3 Antibiotic courses can be repeated every few months if the skin persistently flares.

When should patients be referred?

The PCDS guidance summarises the situations that warrant immediate referral:5,6

  • acne that is causing severe psychological distress
  • acne that is uncontrolled and leading to scarring
  • advanced acne (nodulocystic acne)
  • when there is diagnostic uncertainty
  • acne that has not responded to multiple therapeutic interventions or to two adequate courses of antibiotics (12 weeks each).

Once scarring starts to develop, there is a greater chance that further scars will result.3,4 If scarring continues to develop after any length of treatment, then this is an indication to refer. Reluctance to change the course of treatment or refer a patient will increase medicolegal risk if progressive scarring occurs.

When considering antibiotic options, there is no value in trialling different tetracyclines: treatment failure with any tetracycline means the next antibiotic or agent should be of a different class. For patients who have started developing scars despite initial treatment it may be prudent to prescribe a different treatment at the same time as referring them to dermatology. This may reduce or prevent further scarring while they wait for their appointment.

It is helpful to prepare patients about what they can expect in secondary care. Oral isotretinoin is indicated for acne that is severe, occurs with scarring, or is not responding to appropriate initial management.13 It is the best treatment for trying to control acne and induce remission. It is usually prescribed until the skin is clear of lesions, which may take several months.3 Patients are usually discharged with advice to continue topical treatments as maintenance. If their acne flares, usual management following the PCDS guidance should be recommenced. Some patients may need multiple courses of isotretinoin.

Patients should be aware of the side-effects they may experience when taking isotretinoin (see Box 1). The British Association of Dermatologists (BAD) has produced a patient leaflet on isotretinoin, which provides details of most of these.14 Women should be aware that isotretinoin is teratogenic and they should therefore be established on a reliable form of contraception before treatment commences.13 A negative pregnancy test is mandatory before treatment, regular testing is performed during the treatment course, and women should not try to conceive for at least a month after treatment.

Box 1: Side-effects of isotretinoin14

  • Common:
    • dryness of the skin, lips, and eyes
      • dryness can turn into eczema and require additional treatment
      • if the inside of the nose is very dry, nosebleeds can occur
      • dry, cracked skin is more susceptible to infection and takes longer to heal
    • increased photosensitivity
    • aching of muscles and joints after exercise
    • temporary hair thinning
    • increased levels of fats in the blood
    • rarely (<1 in 10,000 people), disturbances of vision, particularly night vision
  • Rare:
    • in 1 in 1000 to 1 in 10,000 people, changes in mood or behaviour; less commonly, these can include thoughts of self-harm and suicide
    • in <1 in 10,000 people, increased pressure in the brain, leading to severe headache, nausea, vomiting, and blurred vision
    • sexual side-effects, such as erectile dysfunction, vaginal dryness, and decreased libido
    • inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis—although it is unclear whether isotretinoin causes inflammatory bowel diseases, treatment should be ceased immediately if a patient develops bloody diarrhoea.

Other considerations

The role of diet is a matter of ongoing debate and, so far, there are no firm conclusions as to its effects on acne. Certainly, a balanced healthy diet is advocated. Some patients may be aware of certain foodstuffs that exacerbate their acne, in which case, avoidance or reduction may be suitable.1,6

Up to 70% of women experience premenstrual acne flares.1 A combined hormonal contraceptive (CHC) may help reduce acne in some women.1,3,15,16 Note that the converse is true of purely progestogenic contraceptives, which can exacerbate acne.1,15 The same rule of risks versus benefits applies when prescribing contraceptives, especially when considering the risk of venous thromboembolism (VTE). Co-cyprindiol is a CHC that is licensed for use in treating recalcitrant moderate-to-severe acne in the setting of acne related to androgen sensitivity. Much angst exists around the use of co-cyprindiol: the risk of VTE is thought to be similar to that of third- and fourth-generation CHCs (containing desogestrel and gestodene, or drospirenone).17 The absolute risk of VTE incidence per annum in 10,000 women is 2 for non-pregnant non-users of CHC, 5–7 for women using a levonorgestrel-containing product, and 9–12 for women using products that contain gestodene, desogestrel, or drospirenone, and co-cyprindiol (according to the summaries of product characteristics).17,18 These risks are lower than the risk of VTE in pregnancy.12,19

Acne generally takes 3–6 months to improve with CHCs.12 Like other forms of treatment, CHCs can be combined with topical agents or oral antibiotics (except for rifampicin, which reduces contraceptive efficacy) to maximise benefit. CHCs should be continued until at least 3 months after control is achieved.20 Maintenance topical treatment should be continued to prevent flares; in the authors’ view, this should be for 6–12 months, in the absence of specific guidance.

GPs may be asked by secondary care to consider appropriate contraception for women who have been prescribed treatments such as isotretinoin.

Finally, patients should be signposted to the BAD acne support website, which gives excellent advice about skincare.21

How can scars be managed?

The guidance does not discuss scarring, for which treatment largely lies in the private sector. Patients may ask for advice, however, so it is useful to have some awareness of the management options.

First, it is imperative that patients understand that the best way to treat scarring is by preventing it in the first place. Adhering to treatment is essential, as is using the most appropriate treatment. Over-cleansing the skin, scratching, and picking lesions may cause inflammation and scarring.1,11

Second, it is important to clarify what patients mean by scarring. Some patients, particularly patients with skin of colour, may consider red or brown marks (post-inflammatory hyperpigmentation) to be scarring. They can be reassured that these marks will resolve in time. Topical retinoids and azelaic acid may be used to hasten their improvement. Private treatments, such as chemical peels, may improve pigmentation, but patients should be warned to seek authoritative guidance and be aware that some methods may cause further post-inflammatory hyperpigmentation.22 Papules, pustules, and nodules can be confused with scars, and these will improve with optimal treatment. Atrophic scars are more troublesome and their management is generally beyond the scope of the NHS. Hypertrophic and keloid scars may be treated, depending on the CCG, with intralesional steroid injections, topical silicone gels and sheets, or other modalities; patients may need to be referred for these. Treatments can be disappointing, however, and scars may improve only to recur in the future.1

Summary

Acne can have long-term sequelae. Timely and optimised management can help control the condition, reduce the risk of scarring, and improve the patient’s mental health. It helps clinicians to know some facts about acne and spend time with patients to talk through the aims and objectives of treatment. Align their agenda to yours: set review periods and agree on endpoints for treatment. Time and dedication are needed to control the disease rather than elicit a dramatic cure. Warn patients early about the risks of treatment so that nothing comes as a surprise; be receptive and re-assess when side-effects limit treatment tolerability. Finally, if the desired responses are not achieved, consider referral to secondary care, especially if scarring is developing.

Dr Kash Bhatti

GP and GP Trainer, GPwER Dermatology, Leeds

Executive committee member, Primary Care Dermatology Society

Dr Bruce Pollock

Consultant Dermatologist, Mid Yorks NHS Hospital Trust, Wakefield

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Review the current care pathways for the management of acne in your area
  • Refine formulary guidance and choice of medications to reflect the guidance featured in this article and other guidance
  • Consider producing an app or webpage to support patients with acne, with links to BAD patient leaflets:
    • publicise this resource to GPs and other primary care providers, e.g. pharmacists, so they can make it available to patients at their premises or via websites
  • Ensure there are clear definitions of who is responsible for the monitoring of oral retinoid treatment, with shared-care agreements in place if there is an expectation that primary care will be involved in this.

STP=sustainability and transformation partnership; ICS=integrated care system; BAD=British Association of Dermatologists

References

  1. Layton A, Eady E, Zouboulis C. Acne. In: Griffiths C, Barker J, Bleiker T et al, editors. Rook’s Textbook of Dermatology. 9th ed. Chichester: John Wiley & Sons, 2016: 1–64.
  2. Samuels D, Rosenthal R, Lin R et al. Acne vulgaris and risk of depression and anxiety: a meta-analytic review. J Am Acad Dermatol 2020; 83 (2): 532–541.
  3. Thiboutot D, Dréno B, Abanmi A et al. Practical management of acne for clinicians: an international consensus from the Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2018; 78 (2 Suppl 1): S1–S23.e1.
  4. Layton A. Top ten list of clinical pearls in the treatment of acne vulgaris. Dermatol Clin 2016; 34 (2): 147–157.
  5. Bewley T, Bower C, Kownacki S et al. Acne—primary care treatment pathway. PCDS, 2019. Available at: www.pcds.org.uk/ee/images/uploads/general/Acne_Treatment_2019-final-web.pdf
  6. Primary Care Dermatology Society. Acne: acne vulgaris. www.pcds.org.uk/clinical-guidance/acne-vulgaris (accessed 9 September 2020).
  7. Harper J. Acne vulgaris: what’s new in our 40th year. J Am Acad Dermatol 2020; 82 (2): 526–527.
  8. Hepburn N. Talking to patients about acne. Dermatology in Practice 2020; 26 (1): 20–23.
  9. Primary Care Dermatology Society. The Cunliffe (TP) General Dermatology Diagnostic Table. www.pcds.org.uk/p/general-dermatology-table (accessed 30 September 2020).
  10. Marson J, Baldwin H. An overview of acne therapy, part 1: topical therapy, oral antibiotics, laser and light therapy, and dietary interventions. Dermatol Clin 2019; 37 (2): 183–193.
  11. Romano M, Dellavelle R. Acne vulgaris. In: Williams H, Bigby M, Herxheimer A et al, editors. Evidence-based dermatology. 3rd ed. Chichester: John Wiley & Sons, 2014: 87–105.
  12. Marson J, Baldwin H. An overview of acne therapy, part 2: hormonal therapy and isotretinoin. Dermatol Clin 2019; 37 (2): 195–203.
  13. British National Formulary. Isotretinoin. bnf.nice.org.uk/drug/isotretinoin.html#pregnancy (accessed 9 September 2020).
  14. British Association of Dermatologists. Isotretinoin. London: BAD, 2019. Available at: www.bad.org.uk/shared/get-file.ashx?id=2314&itemtype=document
  15. Requena C, Llombart B. Oral contraceptives in dermatology. Actas Dermosifiliogr 2020; 111 (5): 351–356.
  16. Arowojolu A, Gallo M, Lopez L, Grimes D. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev 2012; (6): CD004425.
  17. Bayer plc. Dianettesummary of product characteristics. August 2020. www.medicines.org.uk/emc/product/1122/smpc
  18. Medicines and Healthcare products Regulatory Agency. Combined hormonal contraceptives and venous thromboembolism: review confirms risk is small. MHRA, 2014. www.gov.uk/drug-safety-update/combined-hormonal-contraceptives-and-venous-thromboembolism-review-confirms-risk-is-small (accessed 9 September 2020).
  19. Faculty of Sexual and Reprodutive Healthcare. FSRH CEU Statement: strengthening of warnings about use of Dianette and other brands of co-cyprindiol. London: FSRH, 2013. Available at: www.fsrh.org/standards-and-guidance/documents/cec-ceu-statement-dianette-jun-2013/
  20. NICE. Acne vulgaris. Clinical Knowledge Summary. Available at: cks.nice.org.uk/topics/acne-vulgaris/ (accessed 9 September 2020).
  21. BAD. Acne support. www.acnesupport.org.uk/ (accessed 9 September 2020).
  22. Petit A, Diallo M. Common skin conditions and ethnicity. In: Dadzie O, Petit A, Alexis A, editors. Ethnic dermatology: principles and practice. Chichester: John Wiley & Sons, 2013: 19–62.