Dr Thomas Poyner discusses where primary care can find information and guidance on the treatment of acne and the available therapeutic options

Acne is a very common problem for teenagers and the majority of patients will have self-medicated. The Acne Support Group has highlighted that patients who consult primary care frequently believe that they are not taken seriously (pers. comm). While there are recognised guidelines for the management of eczema and psoriasis in primary care, the same level of guidance for acne is absent. There is, however, a lot of information available to help primary care. This article discusses available information for GPs and how to access it on the internet.

Sources of information

A Prodigy (formerly Clinical Knowledge Summaries) clinical topic is available online, which covers the diagnosis and assessment of acne and the management of the mild, moderate, and severe forms of the condition (prodigy.clarity.co.uk/acne_vulgaris).1 The previous revision to this topic was in June 2009, and the next one is anticipated for 2013.

The Primary Care Dermatology Society website has guidance and guidelines for common skin conditions, including acne (www.pcds.org.uk).2 The British National Formulary is also a useful tool, either as a hard copy or online (www.bnf.org).3

Mild to moderate acne

Topical therapies are first-line treatment for mild to moderate acne. These include benzoyl peroxide, topical antibiotics, and topical retinoids. Benzoyl peroxide is probably underused because of its tendency to irritate the skin. This drug should be prescribed at a weak strength, and patients should be advised to wear an old t-shirt to avoid bleaching of clothing if it is applied to the back.1

Topical antibiotics provide a very cosmetically acceptable therapy, but the increasing prevalence of antibiotic resistance is a cause for concern. The Drugs and Therapeutics Bulletin has advised that: ‘… if they are indicated (e.g. acne associated with papules and pustules), they must be used in combination with a topical agent that has anti-resistance properties (e.g. benzoyl peroxide), not as monotherapy, and limited to short-term treatment (i.e. reviewed at 6–12 weeks).’4

Topical retinoids are effective in treating acne, and are especially useful when comedones (blackheads and whiteheads) predominate. They should be used until the patient’s skin is clear of comedones, as these can be the precursor of the inflammatory lesions.1

A 2% salicylic acid wash provides an alternative to topical retinoids for patients with numerous comedones.2,3 Azelaic acid (20% cream) has a similar action to benzoyl peroxide, but is less irritating and can be useful when acne is associated with pigmentary problems.1

Moderate to severe acne

Oral antibiotics are the mainstay treatment for moderate to severe acne. However, oral therapy should be combined with topical therapy wherever possible to reduce bacterial resistance and improve outcomes. The oral antibiotic can be combined with a topical benzoyl peroxide and/or a topical retinoid but should not be prescribed with a topical antibiotic (because of bacterial resistance).1

Oral antibiotics
The Prodigy summary recommends oral tetracyclines 500 mg twice daily as the first-line therapy for moderate acne. This pharmacological option is effective and inexpensive, but has to be taken on an empty stomach and can result in gastrointestinal side-effects. However, it cannot be taken during pregnancy or by children below the age of 12 years as it can stain foetal teeth and affect bone. Erythromycin 500 mg twice daily is an alternative option, but bacterial resistance is becoming an increasing problem with this drug.1

Previously, minocycline was frequently used as a second-line therapy but its use is in decline because of the risk of serious side-effects. If prescribed, patients should be checked for pigmentation problems.1 There is also a risk of autoimmune hepatitis and lupus-type syndrome, and the patient’s immunology status (antineutrophil antibodies and antineutrophil cytoplasmic antibodies) should be monitored on a regular basis.3 General practitioners could audit patients with acne to see if these checks have been performed.

If tetracycline is ineffective or not well tolerated, lymecycline is a possible alternative. Lymecycline is taken as a once-daily dosage (408 mg capsule),3 has no restrictions regarding food intake, and is generally well tolerated.

Other treatment options include doxycycline and trimethoprim: the former can be taken at a once-daily dosage of 100 mg, but can cause photosensitivity; trimethoprim is sometimes used as a third-line antibiotic, although this is an off-licence indication.3

Antibiotics should be effective after 3 months of therapy and maximum improvement usually occurs at 6 months. They may, however, need to be continued for longer—some patients are slow responders. Combining oral antibiotics with benzoyl peroxide and/or a topical retinoid (e.g. adapalene) helps to reduce bacterial resistance and treat more of the patho-physiological processes. General practitioners are often unsure when to stop oral antibiotics: if the patient has responded well to a course of oral antibiotics, it is not necessary to renew it; however continuing with their topical therapy will reduce the likelihood of the condition relapsing. If this happens, they can recommence their oral antibiotic.1 There is no evidence that oral antibiotics need to be reduced gradually before stopping although this may reassure some patients.

Severe acne

Oral isotretinoin is used for the systemic treatment of nodulocystic and conglobate acne, severe acne, scarring, acne that has not responded to repeated courses of a systemic antibacterial, or acne associated with psychological problems.3 Acne itself can result in major psychological problems and isotretinoin has been shown to actually help the psychological well-being of patients by treating their acne.5,6 Oral isotretinoin is a very useful drug that has major benefits for patients but is not without risk. Its prescribing is restricted to consultant-led units, although a few community units have managed to provide it.

The British Association of Dermatologists (BAD) has published a guideline on the safe introduction of oral isotretinoin.7 This guidance covers the local and systemic side-effects of oral isotretinoin. It advises that patients should have their fasting lipids checked before commencing isotretinoin, along with liver function tests, blood sugar, and a full blood count (patients with raised triglycerides are at increased risk of pancreatitis). Initiation of these investigations in primary care would help in the provision of seamless care. Although use of isotretinion can result in a whole range of side-effects, the two major concerns are teratogenicity and a possible link with depression.

Female patients who are receiving isotretinoin need to be made fully aware of the risks and should be entered into a pregnancy prevention programme. Ideally they should use two methods of contraception, such as the combined oral contraceptive (COC) pill and a barrier method. Patients should receive pregnancy tests before treatment, monthly during treatment, and 5 weeks after completing treatment.8

Patients and their families need to be aware that mood changes and depression can be associated with isotretinoin. A Swedish cohort study in 2010 showed one additional suicide attempt per 2300 6-month courses.9,10 It is important that a GP includes any previous history of depression or psychological problems in the referral letter. A history of depression is not a contraindication to oral isotretinoin but should heighten one’s vigilance to look out for psychological problems. All patients should be checked for psychological problems before and during a course of isotretinoin. The BAD guideline suggests the use of the following screening questions:

  • For most of the last 2 weeks, have you:7
  • been feeling unusually sad or fed up?
  • lost interest in things that used to interest you, or gave you pleasure?
  • been significantly more agitated, irritable, or short tempered?

Acne in female patients

Recently, there has been a reversal in the advice on the interaction of oral antibiotics and COC. Guidance from the Faculty of Sexual & Reproductive Healthcare (FSRH) states that additional contraceptive precautions are not required during or after courses of antibiotics that do not induce enzymes.3 Oral and topical erythromycin and topical benzoyl peroxide can be used in pregnancy.11

The Prodigy summary advises consideration of a COC for treatment of women with acne. This is supported by advice from FSRH, which says that clinicians should be aware that COCs can improve acne.12

The drug co-cyprindiol, which contains cyproterone acetate and ethinylestradiol, is useful in female patients.1 Its product licence is for severe acne in women refractory to prolonged oral antibacterial therapy and moderately severe hirsutism;3 it treats the acne and also provides contraception (although it is not licensed for the sole purpose of this latter indication). It is, however, slow to act and this is best combined with other acne therapies, and should not be used as monotherapy.13 Co-cyprindiol is associated with an increased risk of thromboembolic disease.1,3 Treatment should be discontinued three-to-four menstrual cycles after the woman’s acne
has resolved and be replaced by an acne-friendly pill such as a COC pill.14 General practitioners could perform an audit to ensure that women whose acne has resolved are not still receiving co-cyprindiol.

Healthcare professionals should be aware that progesterone-only contraceptive treatments can aggravate acne.3

When to refer

NICE advises that patients with acne should be referred if:15

  • they have severe or a severe variety of acne
  • they have severe social or psychological problems
  • there is a risk of or they are developing scarring
  • the condition is refractory
  • a suspected underlying endocrinological cause (e.g. polycystic ovary syndrome) requires assessment.

Patients with painful, deep nodules or cysts (nodulocystic acne) are at high risk of scarring and GPs should not await hospital appointments before initiating treatment. Compliance with therapies should be checked during consultations and prior to referral. It is vital that females receive contraceptive advice as failure to establish adequate effective contraception delays initiation of oral isotretinoin.

The PCDS website has advice on scarring,2 and patients are increasingly wanting to know about lasers and acne. Further evidence is needed to strengthen the case for more NHS funding for the use of lasers to treat acne scarring. The simple message is always try to prevent scarring rather than treat it!

Other guidance

In the absence of UK national guidance, some healthcare professionals may find the American Academy of Dermatology guideline on the management of acne useful (www.aad.org).16 European guidance on acne is expected later this year (www.acne-guidelines.com) and will provide guidance for this common dermatological problem. The BAD website (www.bad.org.uk) is an excellent resource, and includes a patient information leaflet on acne.

 
  • Acne is a common skin condition that can usually be managed in primary care
  • However, specialist referral is indicated for those with nodulocystic acne for consideration of treatment with oral isotretinoin
  • A simple local pathway could summarise the Prodigy guidance and include local formulary choices for topical and systemic treatments at the correct doses; such pathways can define when patients should be referred
  • GPwSIs or specialist nurse skin specialists could be employed in primary or community care to avoid paying full tariff costs for outpatients (but isotretinoin therapy is limited to consultant-only use)
  • Tariff price for dermatology outpatients = £119 (new), £67 (follow up).a
  1. Prodigy. Acne vulgaris—management. prodigy.clarity.co.uk/acne_vulgaris (accessed 13 September 2011).
  2. Primary Care Dermatology Society website. www.pcds.org.uk/component/content/article/50-image-atlas-detailed-articles/168-acne#f (accessed 15 September 2011).
  3. British National Formulary. BNF 62. September 2011. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2011.
  4. What role for topical antibacterials in acne? Drug Ther Bull 2010; 48 (12): 141–144.
  5. McGrath E, Lovell C, Gillison F et al. A prospective trial of the effects of isotretinoin on quality of life and depressive symptoms. Br J Dermatol 2010; 163 (6): 1323–1329.
  6. Chia C, Lane W, Chibnall J et al. Isotretinoin therapy and mood changes in adolescents with moderate to severe acne: a cohort study. Arch Dermatol 2005; 14 (5): 557–560.
  7. Goodfield M, Cox N, Bowser A et al. Advice on the safe introduction and continued use of isotretinoin in acne in the U.K. 2010. Br J Dermatol 2010; 162 (6): 1172–1179.
  8. Medicines and Healthcare products Regulatory Agency website. Isotretinoin for severe acne. www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Product-specificinformationandadvice/Product-specificinformationandadvice-G-L/Isotretinoinforsevereacne/index.htm (accessed 16 September 2011).
  9. Sundström A, Alfredsson L, Sjölin-Forsberg G et al. Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study. BMJ 2010; 341: c5812.
  10. Magin P, Sullivan J. Suicide attempts in people taking isotretinoin for acne. BMJ 2010; 341: c5866.
  11. Faculty of Sexual & Reproductive Healthcare. Drug interactions with hormonal contraception. FSRH Clinical Effectiveness Unit, January 2011, updated September 2011.
  12. Faculty of Family Planning & Reproductive Health Care. First prescription of combined oral contraception. FSRH Clinical Effectiveness Unit, 2006, updated 2007. Available at: www.fsrh.org/pdfs/FirstPrescCombOralContJan06.pdf
  13. Zouboulis C, Rabe T. Hormonal antiandrogens in acne treatment. J Dtsch Dermatol Ges 2011; 8 (Suppl 1): S60–S74.
  14. Arowojolu A, Gallo M, Lopez L et al. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev 2007; (1): CD004425.
  15. National Institute for Clinical Excellence. Referral advice: a guide to appropriate referral from general to specialist service. London: NICE, 2001. Available at: www.nice.org.uk/media/94D/BE/Referraladvice.pdf
  16. Strauss J, Krowchuk D, Leyden J et al. American Academy of Dermatology/American Academy of Dermatology Association. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007; 56 (4): 651–663. G