Dr Aileen Tincello explains how the European Dermatology Forum guideline simplifies the assessment and treatment of acne

  • Assess acne in terms of its effect on quality of life as well as its severity
  • Acne should be graded according to one of the following four categories:
    • comedonal
    • mild-to-moderate papulopustular acne
    • severe papulopustular acne/moderate nodular acne
    • severe nodular/conglobate acne
  • Comedonal acne should be treated with topical retinoids not topical antibiotics
  • Treat mild-to-moderate papulopustular acne with a benzoyl peroxide-combination therapy or a combination of oral antibiotics and topical adapalene if the condition is more widespread
  • Use oral isotretinoin for severe papulopustular acne and severe nodular acne—the potential for scarring can be reduced or avoided by not delaying referral
  • Use lymecycline or doxycycline in preference to tetracycline, minocycline, or erythromycin
  • A topical retinoid should be used as maintenance treatment following remission.

Acne is an extremely common skin condition affecting adolescents. Various studies from western industrialised countries quote a prevalence of 50%–95%, with 20%–35% experiencing moderate to severe acne.14 There is a wide range of both topical and systemic treatments available for acne, and GPs are often besieged by representatives of the pharmaceutical industry claiming that their particular product is superior to others. In addition many GPs may find it bewildering as to which treatment(s) to use when and for how long, whether to use combinations, and when to refer to a dermatologist.

The recent guideline on the treatment of acne from the European Dermatology Forum (EDF) was developed with the objectives of:5

  • improving the care of patients with acne
  • reducing long-term effects, including scarring
  • promoting adherence to therapy
  • reducing antibiotic resistance.

The EDF guideline is an extensive document running to 62 pages and is therefore unlikely to be read in its entirety by the average GP. It was compiled using information from existing guidelines and systematic reviews following searches in the Medline, Embase, and Cochrane databases.5 The guideline covers the assessment and grading of acne, followed by a very detailed analysis of the most effective types of treatment, and includes numerous tables of results. Identifying the salient information within the guideline is quite a challenge; it would be vastly improved by having a summary of the key points contained within it, or perhaps a shorter version similar to the NICE quick reference guides; however, it does contain some important and useful advice, and this article attempts to summarise the main findings.

Assessment

The assessment of acne is important in order to grade its severity, which will enable the clinician to initiate appropriate therapy. Acne can be assessed from two points of view: severity and effect on quality of life.5

Severity

As stated in the guideline, over 25 different methods of grading acne have been developed.5 This has undoubtedly led to confusion among GPs who need a simple and practical system to direct treatment. The EDF guideline seeks to solve this problem by dividing cases of acne into four categories, and then defining treatment options for each one:1

  • comedonal acne
  • mild-to-moderate papulopustular acne
  • severe papulopustular acne/moderate nodular acne
  • severe nodular acne/conglobate acne.

I think that the EDF approach is a workable solution, which is more easily remembered than many of the other acne grading systems available.

 

Quality of life

Establishing how the patient feels about their acne and how it is affecting them is of paramount importance. Several quality-of-life questionnaires exist that can be used as a measure. Sensibly, the guideline comments that these need to be easy to use, meaningful, and readily accessible.5 In my experience the 10-minute consultation does not lend itself to this more lengthy type of formal assessment and I personally do not use them; however, I would always want to ascertain how the patient feels about their acne, regardless of its extent. A patient with very mild comedonal acne can sometimes be far more affected by their condition than one might expect.

Therapeutic options

Comedonal acne

Comedonal acne is defined by non-inflamed lesions and includes both open and closed comedones. There is evidence showing that the most effective treatments for comedonal acne are topical retinoids, such as adapalene and tretinoin, followed by benzoyl peroxide and azeleic acid.5 It is important to note that the use of topical antibiotics as monotherapy is not recommended, and neither are oral antibiotics nor hormonal antiandrogens. The recommendations simplify treatment of comedonal acne but still permit choice.

Mild-to-moderate papulopustular acne

There is a wider choice of treatment for inflammatory lesions. A combination of either benzoyl peroxide + adapalene or benzoyl peroxide + clindamycin have a high strength of recommendation; azelaic acid, benzoyl peroxide, and topical retinoids are also suitable options for monotherapy.5

As mentioned previously, the use of topical antibiotics as monotherapy is not recommended and so the days of using topical erythromycin or clindamycin singly are over. Combined use of oral antibiotics and topical adapalene is recommended for more widespread disease.5 Systemic therapy with hormonal antiandrogens, antibiotics, or oral isotretinoin is not recommended.5

Severe papulopustular/moderate nodular acne

The strongest evidence for treatment of severe papulopustular/moderate nodular acne was for oral isotretinoin;1 by implication, prompt referral to secondary care is therefore important. I think this point cannot be over emphasised; in my experience there are many patients still being treated in primary care with oral antibiotics or topical treatments for too long who subsequently develop scarring unnecessarily. In addition, it is known that antibiotic resistance may occur, and can lead to reduced therapeutic effect in patients with acne and systemic infections with Propionibacterium acnes in patients who do not have acne.5

Some patients will not be suitable for oral isotretinoin or may not want this treatment—these individuals can be offered oral antibiotics either in combination with adapalene, azelaic acid, or adapalene + benzoyl peroxide.

It is important to highlight that oral antibiotics and hormonal antiandrogens should always be used in combination with a topical treatment to increase effectiveness and to prevent antibiotic resistance.5 Another interesting point is that despite widespread use of ethinylestradiol in combination with cyproterone acetate, in preference to other hormonal combinations, there is no clear evidence that this therapy is superior.5

Severe nodular/conglobate acne

The treatment of severe nodular/conglobate acne remains straightforward and requires early referral for oral isotretinoin. Oral antibiotics with topical treatment can be used as second-line treatment.5

Choice of oral antibiotic

Traditionally oxytetracycline and erythromycin have been used to treat acne. More recently minocycline, doxycycline, and lymecycline have also been used.

Evaluation of the literature showed that all of the tetracycline group antibiotics have similar efficacy.5 The EDF guideline however recommends lymecycline and doxycycline because of the more severe side-effect profile of minocycline and the less practical nature of using oxytetracycline (usually four-times daily on an empty stomach).5 Erythromycin along with clindamycin now demonstrate the highest drug resistance and should not be used.

Interestingly, the guideline makes no mention of trimethoprim, which is used widely by my local dermatologists in Leicester and appears to be effective. A number of older trials have investigated the use of trimethoprim in acne:

  • a 1993 trial recommended trimethoprim as a third-line agent6
  • a 1982 trial found it to be as effective as oxytetracyline in reducing lesions counts and reducing severity.7

Duration of treatment

In my opinion, information on duration of treatment for acne is a major omission in the EDF guideline. The chronic nature of the condition and the need for long-term treatment and maintenance following remission is discussed (see below), along with the risk of antibiotic resistance and a warning against prolonged antibiotic courses, but no timescale is mentioned.5 There is no advice on how long to continue the intervention phase before moving on to maintenance treatment or how long to try a particular treatment before changing to an alternative option.

My view based on clinical experience would be to initiate treatment and review at 2 months. If there is no improvement, a change in treatment would be indicated. Once improvement is seen the patient should stay on the oral antibiotic (with a topical treatment) until remission is achieved. If there is continued improvement it is perfectly reasonable to stay on an oral antibiotic even for over 1 year; however, regular review is essential and once remission is achieved a topical retinoid should be substituted. If, alternatively, there is a poor response to several antibiotics, then assessment as to whether oral isotretinoin might be required is reasonable even in milder cases.

Maintenance therapy

The final section of the EDF guideline discusses maintenance therapy. There is evidence that using a topical retinoid will reduce the number of microcomedones on the skin, thus reducing relapse after successful treatment.5

I was pleased to see that this section also includes some brief guidance on patient education as I believe that this area merits more attention. I have seen many patients who have stopped and started a variety of treatments over several years without ever achieving a satisfactory resolution of their acne. Adolescents are notoriously non-compliant with treatment regimens and so I feel it is very important at the first consultation to give the patient good advice about acne. I like to include the following information:

  • acne is a chronic condition, lasting through most of adolescence
  • adherence to treatment will aid recovery
  • the patient will need to attend regular review to adjust treatment
  • maintenance therapy prevents relapse and therefore is as important as acute therapy.

Conclusion

The EDF guideline brings a common-sense approach to the management of acne, updating and making the assessment and treatment options more straightforward than previously. I think GPs should find it easy to implement, but I do wish that it included an easy-to-read summary of the recommendations.

 

  • The European Dermatology Forum guideline helps simplify the assessment and treatment of acne
  • Local formularies should identify:
    • drugs to be used in primary care and their cost
    • the need for co-prescription with topical agents where necessary
  • Local referral pathways should identify access to specialist dermatology services, including GPwSI and primary care services if commissioned (these can result in savings against the PbR tariff)
  • Commissioners could scope with providers the benefits of specialist community dermatologist nurses to help support patients and primary care in the management of acne and encourage compliance with effective treatment
  • Tariff prices:a dermatology outpatients = £112 (new), £69 (follow up).
  1. Amado J, Matos M, Abreu A et al. The prevalence of acne in the north of Portugal. J Eur Acad Dermatol Venereol 2006; 20 (10): 1287–1295.
  2. Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of common skin conditions in Australian school students: 3. acne vulgaris. Br J Dermatol 1998; 139 (5): 840–845.
  3. Nijsten T, Rombouts S, Lambert J. Acne is prevalent but use of its treatments is infrequent among adolescents from the general population. J Eur Acad Dermatol Venereol 2007; 21 (2): 163–168.
  4. Smithard A, Glazebrook C, Williams H. Acne prevalence, knowledge about acne and psychological morbidity in mid-adolescence: a community-based study. Br J Dermatol 2001; 145 (2): 274–279.
  5. European Dermatology Forum. Guideline on the treatment of acne. Berlin: EDF, 2011. Available at: www.euroderm.org/images/stories/guidelines/Guideline-on-the-Treatment-of-Acne.pdf
  6. Bottomly W, Cunliffe W. Oral trimethoprim as a third-line antibiotic in the management of acne vulgaris. Dermatology 1993; 187 (3): 193–196.
  7. Gibson J, Barley C, Harvey S, Barth J. Oral trimethoprim versus oxytetracycline in the treatment of inflammatory acne vulgaris. Br J Dermatol 1982; 107 (2): 221–224.G