Rebecca Penzer-Hick outlines the recommendations from NICE Guideline 198 on acne vulgaris, and explains how treatment differs according to severity of disease

PENZER-HICK, Rebecca

Rebecca Penzer-Hick

Read this article to learn more about: 

  • skin care advice for all levels of acne severity
  • first-line treatments, and a stepwise approach to the management of acne
  • when to refer patients with acne to a dermatologist-led team.

Read this article online at: GinP.co.uk/456383.article

Acne is a common chronic inflammatory skin condition that affects up to 95% of teenagers in the Western world but can persist into adult life.1 NICE has recently published NICE Guideline (NG) 198, Acne vulgaris: management,2 which considers many aspects of this complex condition. This article will focus on the management of acne in primary care using topical and oral therapies.

Disease severity

The treatment recommendations of NG198 are based on disease severity. NICE categorises acne into mild-to-moderate or moderate-to-severe disease; descriptions for these severities of acne can be found in Box 1.2

Box 1: Acne severity categories used for the purposes of the NICE guideline2

Mild to moderate acne

Acne severity varies along a continuum. For mild to moderate acne, this includes people who have 1 or more of:

  • any number of non-inflammatory lesions (comedones)
  • up to 34 inflammatory lesions (with or without non-inflammatory lesions)
  • up to 2 nodules.

Moderate to severe acne

Acne severity varies along a continuum. For moderate to severe acne, this includes people who have either or both of:

  • 35 or more inflammatory lesions (with or without non-inflammatory lesions)
  • 3 or more nodules. 

© NICE 2021. Acne vulgaris: management. NICE Guideline 198. NICE, 2021. Available at: www.nice.org.uk/ng198

All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/ uk-open-content-licence for further details.

Skin care

Skin care advice should be given to all patients with acne, regardless of disease severity.2 People with acne should be advised to use a nonalkaline (skin pH neutral or slightly acidic) synthetic detergent (syndet) cleaning product twice daily on acne-prone skin.2 Syndets are synthetic surfactants that are widely available in liquid or solid form. Patients with acne who use skin care products (for example, moisturisers) and sunscreens should also be advised to avoid oil-based and comedogenic preparations.2 Similarly, people with acne who use make-up should avoid oil-based and comedogenic products, and remove make-up at the end of the day.2 Although NICE states that no relevant evidence was identified on the use of skin care products such as oil-based and noncomedogenic preparations or make-up, the consensus among the guideline development committee was that acne is typified by excessively oily skin and the blocking of skin pores; therefore, oil-based and comedogenic products may make acne vulgaris worse.2

Treatment options

First-line options

Disease severity varies along a continuum;2 therefore, in the mild-to-moderate category, there will be a range of symptom severities. Treatment selection should take into account the person’s preferences, and should take place after a discussion of the advantages and disadvantages of each option.2 NICE recommends that fixed-combination topical products should form the first line of treatment (see Table 1).2 People with acne should be offered a 12-week course of an appropriate first-line treatment option.2 The first-line treatment should then be reviewed at 12 weeks to assess whether their acne has improved, whether they have experienced any side effects, and whether treatment should continue.2

Table 1: Treatment choices for mild to moderate and moderate to severe acne vulgaris2
Acne severityTreatmentAdvantagesDisadvantages

Any severity

Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening

 

  • Topical
  • Does not contain antibiotics

 

 

  • Not for use during pregnancy
  • Use with caution during breastfeeding (see recommendation 1.5.8)
  • Can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics

 

Any severity

Fixed combination of topical tretinoin with topical clindamycin, applied once daily in the evening

 

  • Topical

 

  • Not for use during pregnancy or breastfeeding (see recommendation 1.5.8)
  • Can cause skin irritation (see recommendation 1.5.7), and photosensitivity

 

Mild to moderate

Fixed combination of topical benzoyl peroxide with topical clindamycin, applied once daily in the evening

 

  • Topical
  • Can be used with caution during pregnancy and breastfeeding

 

 

  • Can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics

 

Moderate to severe

 

Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening, plus either oral lymecycline or oral doxycycline taken once daily

 

  • Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back)
  • Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is a Medicines and Healthcare products Regulatory Agency (MHRA) requirement for subsequent oral isotretinoin (see recommendation 1.5.8 and the MHRA alert on isotretinoin for severe acne: uses and effects)[A]

 

  • Not for use in pregnancy, during breastfeeding (see recommendation 1.5.8), or under the age of 12
  • Topical adapalene and topical benzoyl peroxide can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics
  • Oral antibiotics may cause systemic side effects and antimicrobial resistance
  • Oral tetracyclines can cause photosensitivity

 

 

Moderate to severe

 

Topical azelaic acid applied twice daily, plus either oral lymecycline or oral doxycycline taken once daily

  • Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back)
  • Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin (see recommendation 1.5.8 and the MHRA alert on isotretinoin for severe acne: uses and effects)[A]

 

  • Not for use in pregnancy, during breastfeeding (see recommendation 1.5.8), or under the age of 12
  • Oral antibiotics may cause systemic side effects and resistance
  • Oral tetracyclines can cause photosensitivity

 

[A] Medicines and Healthcare products Regulatory Agency. Isotretinoin for severe acne: uses and effects.www.gov.uk/government/publications/isotretinoin-for-severe-acne-uses-and-effects/isotretinoin-for-severe-acne-uses-and-effects

© NICE 2021. Acne vulgaris: management. NICE Guideline 198. NICE, 2021. Available at: www.nice.org.uk/ng198

All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/ uk-open-content-licence for further details.

NICE recommends that the importance of completing the course of treatment should be discussed with patients because positive effects can take 6–8 weeks to become noticeable.2 To enhance adherence to treatment, individuals should be given advice on how to use products, some of which can be irritant and, in the case of benzoyl peroxide, can bleach both hair and fabrics (see Table 1).2 In order to reduce the risk of skin irritation associated with topical treatments such as benzoyl peroxide or retinoids, patients should be advised to adopt a stepwise approach to treatment, starting with alternate-day application or short-contact application (applying products for a short period of time and then washing them off).2 As the product is tolerated, application should return to standard use.2

Furthermore, patients should be warned that retinoid-containing products will make the skin more sensitive to ultraviolet radiation, and precautions should be taken to avoid exposure to the sun (for example, by using sunscreen or protective clothing).3 Because retinoids are contraindicated in pregnancy, women of child-bearing potential should be counselled on the importance of effective contraception while using products that contain topical retinoids.2 In patients who are unable to tolerate combined products, or for whom these products are contraindicated, or who wish to avoid using a topical retinoid, NICE recommends that topical benzoyl peroxide monotherapy should be considered.2

At the 12-week review, patients who have responded well to first-line therapy may be able to discontinue treatment, but continued appropriate skin care should be encouraged.2 If further maintenance therapy is indicated (for instance, in patients with a history of frequent relapse after treatment), a fixed combination of adapalene and topical benzoyl peroxide should be considered as maintenance treatment.2 If the treatment is not tolerated or if a component of the combination is contraindicated, then topical monotherapy with adapalene, azelaic acid, or benzoyl peroxide can be considered.2 If mild-to-moderate acne fails to respond to two different 12-week courses of treatment, referral to a dermatologist-led team should be considered.2

If acne fails to respond adequately to a 12-week course of a first-line treatment option and at review the severity is:2

  • mild to moderate—offer another option from the table of treatment choices (see Table 1)
  • moderate to severe, and the treatment did not include an oral antibiotic—offer another option which includes an oral antibiotic from the table of treatment choices (see Table 1)
  • moderate to severe, and the treatment included an oral antibiotic—consider referral to a consultant dermatologist-led team.

Oral antibiotics

The addition of oral antibiotics is reserved for patients with moderate-to-severe disease (see Table 1).2 Antibiotic stewardship needs to be at the heart of antibiotic prescribing and, as a starting point, oral antibiotics should never be prescribed as monotherapy.2 They must always be prescribed in conjunction with a topical product; in the first instance, this should be fixed-combination topical adapalene and topical benzoyl peroxide, or topical azelaic acid.2 No topical product (monotherapy or combined) that contains an antibiotic should be prescribed alongside an oral antibiotic.2

The NICE-recommended first-line oral antibiotic choice is oral lymecycline (408 mg) or oral doxycycline (100 mg), to be taken once daily (see Table 1).2 Should the patient be unable to tolerate or have contraindications for one of the above tetracylines, consider switching them to oral trimethoprim or an oral macrolide (such as erythromycin) as part of a combination treatment.2 This course should be prescribed for 12 weeks.2

At the 12-week review, the options are dependent on response to treatment. In the event of complete clearance (or clearance that is satisfactory to the patient), consider stopping the oral antibiotic.2 However, maintenance therapy with topical therapies may be continued. If there has been a positive response to treatment but complete clearance hasn’t been achieved, a further 12 weeks of oral antibiotics can be prescribed alongside the topical treatment.2 Only under exceptional circumstances should treatments containing antibiotics (either oral or topical) be continued for longer than 6 months.2 In this situation, reviews should be conducted every 3 months, and the antibiotic discontinued as soon possible.2 If moderate-to-severe acne is not responding to antibiotic treatment (in combination with a topical agent) at 12 weeks, referral to a consultant dermatologist-led team should be considered.2

Scarring

Scarring can occur at any level of disease severity, but is more common as disease severity worsens and with a longer duration of acne.2 Timely and effective treatments are critical to reducing the likelihood of scarring. This should be taken into account when choosing treatment regimens, and when making decisions about referral to a dermatologist-led service.2 Scratching and picking can increase the risk of scarring, and advice about avoiding this should be given alongside general skin care information.2 The presence of scarring and/or persistent pigmentary changes are additional reasons for consideration of a referral to a dermatologist-led team.2 NICE has now recommended that, if acne-related scarring is severe and persists after active acne has been clear for 1 year, a referral to a dermatologist-led team with expertise in scar management should be made.2

Oral contraceptive pill for women

There was insufficient evidence to recommend the use of an oral contraceptive pill for mild-to-moderate acne. However, if a woman with acne wishes to use hormonal contraception, consider prescribing the combined oral contraceptive pill in preference to the progestogen-only pill.2

Psychological distress

Acne of any severity can cause psychological distress and mental health disorders.2 Referral to a dermatologist-led team should be considered if the presence of acne of any severity, or acne-related scarring, is contributing to persistent psychological distress or a mental health disorder.2

As a highly visible and sometimes painful condition, acne can impact mental wellbeing, and this should be taken into consideration when planning care. The guideline states that referral to mental health services should be considered if there is significant psychological distress or a mental health disorder. In recommendation 1.4.5 of NG198, specific consideration is given to a current or past history of:2

  • suicidal ideation or self-harm
  • a severe depressive or anxiety-related disorder
  • body dysmorphic disorder.

Summary

Acne treatments should be chosen based on an assessment of disease severity, which is measured by determining the type and number of lesions. As the response to treatment of acne can be slow, treatment cycles should be based on 12-week review periods.2 Treatments for mild disease will focus on topical products, ideally one of the fixed-combination products. Oral antibiotics can be added in for moderate-to-severe disease, but should be used judiciously, with careful consideration of antibiotic stewardship. Oral and topical antibiotics should not be used together and should never be used as monotherapy.2 The oral contraceptive pill is not a treatment of choice for mild-to-moderate acne; in women who have acne and choose hormonal contraception,  consider using the combined oral contraceptive pill in preference to the progestogen-only pill.2

Information for patients on acne can be found on the British Association of Dermatologists (BAD) website under Patient information leaflets A–Z (www.bad.org.uk).4 BAD have also developed a website that provides impartial advice about acne for patients (www.acnesupport.org.uk).5

Key points

  • Good skin care advice is important for all levels of disease severity—patients should be advised to use synthetic detergent cleansing products and avoid products that are oil-based or comedogenic
  • Acne treatment selection is based upon an assessment of disease severity
  • Treatments should be prescribed taking a stepwise approach, allowing 12 weeks before reviewing and amending the treatment regimen
  • Antibiotics (either topical or oral) should never be prescribed as monotherapies
  • Oral and topical antibiotics should never be prescribed at the same time
  • The mental health of individuals with acne should always be considered when making decisions about treatment and possible referral.

Rebecca Penzer-Hick

Senior Clinical Lecturer, Department of Clinical & Pharmaceutical Sciences, University of Hertfordshire, Hatfield

The guideline referred to in this article was produced by the National Guideline Centre for NICE.

The views expressed in this article are those of the authors and not necessarily those of NICE.

NICE. Acne vulgaris: management. NICE, 2021. Available at: www.nice.org.uk/ng198

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 in implementing new guidance at a system level. Our aim is to help you to consider how to deliver improvements to healthcare within the available resources.

  • Establish a multi-professional team to review NICE Guideline 198 on the management of acne vulgaris
  • Update local formularies with clear choices of pharmacological intervention options graded by the severity of acne
  • Ensure that the contraindications of relevant products for women who are, or who may become, pregnant are clearly listed
  • Define indicators for specialist referral and consideration of systemic retinoid therapy
  • Agree processes for monitoring the use of systemic retinoids following their prescription by specialists.

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. NICE. Acne vulgaris: how common is it? NICE Clinical Knowledge Summary. Available at: cks.nice.org.uk/topics/acne-vulgaris/background-information/prevalence/ (accessed 4 November 2021).
  2. NICE. Acne vulgaris: management. NICE Guideline 198. NICE, 2021. Available at: www.nice.org.uk/ng198
  3. NICE. Acne vulgaris: topical retinoids. NICE Clinical Knowledge Summary. Available at: cks.nice.org.uk/topics/acne-vulgaris/prescribing-information/topical-retinoids/ (accessed 4 November 2021).
  4. British Association of Dermatologists website. Patient information leaflets (PILs). www.bad.org.uk/for-the-public/patient-information-leaflets (accessed 4 November 2021).
  5. Acne Support website. Acne support. www.acnesupport.org.uk/ (accessed 4 November 2021).

Credit:

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