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Acne vulgaris -NICE guidance

why acne happens treatment options impact of acne benefits / drawbacks – of treatments treatment related issues as
○ compliance inform that positive effect can take 6-8 weeks to become apparent
○ relapses

mild to moderate -People with 1 or 
more of
 non-inflammatory lesions 
( comedones- they can be open or closed ) any number upto 34 inflammatory lesions – when they become red and / or tender bumps ie papules and pustules ( with or without non-inflammatory lesions ) up to 2 nodules ( when the lesions progress to become larger and more tender )

moderate to severe- either or both
 35 or more inflammatory lesions 3 or more nodules

acne fulminans -very rare form presents as acute , painful , ulcerating and haemorrhagic , crusted lesions-onset can be sudden with fever and pain in multiple joints less than 200 cases have been described

Grading -Grading of severity can also vary between guidelines – a good reference point can be found on the Dermnetz website – please refer to www. dermnetz.org/topics/acne-vulgaris for further information

Skin care advice -use non-alkaline synthetic detergent – Syndet
( a mixture of synthetic surfactants which is neutral to slightly acidic pH similar to skin ) advice to avoid oil based comedogenic ( which can block skin pores ) preparations people who use make up should avoid comedogenic preparations and remove make up at the end of the day avoid picking and scratching – ↑↑ ed risk scarring

TOPICAL ADAPELENE + 
TOPICAL BENZOYL PEROXIDE ( BP ) 0.1 % adapalene
 + 2.5 % BP
 0.3 % adapalene
+ 2.5 % BP
 use once daily in the evening not during pregnancy caution during breastfeeding warn about skin irritation , photosensitivity , bleaching of hairs and fabrics if the person wishes to avoid using a topical retinoid or an antibiotics or their are other CIs – topical BP monotherpay can be used as an alternative option to reduce risk of irritation with BP or retinoids – start with alternate day or short contact application

TOPICAL TRETINOIN + 
TOPICAL CLINDAMYCIN 0.025 % tretinoin +
 1 % clindamycin
applied OD every evening not during pregnancy or breastfeeding warn about skin irritation , photosensitivity

TOPICAL BENZOYL PEROXIDE ( BP ) + 
TOPICAL CLINDAMYCIN 3 % formulation with BP + 1 % clindamycin
 5 % BP +
1 % clindamycin
 OD every evening can cause skin irritation , photosensitivity , bleaching of hair and fabrics

TOPICAL ADAPALENE +
TOPICAL BENZOYL PEROXIDE
and

ORAL LYMECYLCINE OR
ORAL DOXYCYLINE 408 mg lymecycline od 100 mg Doxycline od

TOPICAL AZELAIC ACID
 ( BD ) +
ORAL LYMECYCLINE OR ORAL DOXYCYLINE OD

TOPICAL AZELAIC ACID
 ( BD ) +
ORAL LYMECYCLINE OR ORAL DOXYCYLINE OD Trimethoprim or an oral macrolide for
 e.g erythromycin

treat with a 1st line agent as above if that does not work consider adding co-cyprindiol or another COCP if using co-cyprindiol

monotherapy with a topical antibiotic monotherapy with an oral antibiotic a combination of topical and an oral antibiotic

women childbearing age-topical retinoids and oral tetracycline are contraindicated during pregnancy or if she is planning a pregnancy inform that they need effective contraception or an alternative treatment the committee recommends to consider use of a combined oral contraceptive pill in preference to progesterone only pill if the person receiving treatment for acne wishes to use hormone contraception

enquire about response , side effects if on oral antibiotic and acne completely clear – consider stopping antibiotic but cont topical treatment if on oral antibiotic – improved but not completely cleared -cont oral abx + topical Rx for another 12 weeks use of topical or oral antibiotic for more than 6 months only in exceptional circumstances ( review 3 monthly and stop antibiotic as soon as possible ) beware risk of antibiotic resistance if acne has cleared – look at maintenance options below if after 12 week 1st line treatment has not worked

Relapse following response to oral isotretinoin

continue skin care advice that maintenance treatment is not always necessary after completion of treatment ( relapse may not always happen ) if they have a hx of frequent relapses – consider maintenance treatment committee recommends
○ fixed combination of topical adapalene and topical BP as maintenance Rx
○ if above is not tolerated or any 1 component is contraindicated consider topical monotherapy with adapalene , azelaic acid or benzoyl peroxide review maintenance treatment after 12 weeks

acne fulminans -arrange an assessment within 24 hrs diagnostic uncertainty you suspect they have acne conglobata or nodulocystic acne mild to moderate acne that has not responded to 2 courses of treatment moderate to severe acne that hasnot responded to previous treatments with oral antibiotic acne with scarring acne with persistent pigmentary changes if acne is causing psychological distress or mental health disorder

Acne with significant psychological distress or mental health disorder including those with 
a current or past history of suicidal ideation or self harm severe depressive or anxiety disorder body dysmorphic disorder

condition specific management for e.g in those with acne and PCOS with additional features of hyperandrogenism or those with a medical disorder or medication ( including self administered anabolic steroids ) to a reproductive endocrinologist

References

  1. Acne vulagaris management NICE Guideline 198 published June 2021 https://www.nice.org.uk/guidance/ng198/chapter/recommendations#mild-to-moderate-acne
  2. Zito PM, Badri T. Acne Fulminans. [Updated 2021 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459326/
  3. American Skin Association Acne https://www.americanskin.org/resource/acne.php

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