Skin and nail
Acne vulgaris
Last revised in February 2026
Acne vulgaris is a chronic skin condition in which blockage or inflammation of the hair follicles and accompanying sebaceous glands
Acne vulgaris: Summary
- Acne vulgaris is a chronic inflammatory skin condition affecting mainly the face, back and chest. It is characterized by blockage and inflammation of the pilosebaceous unit. It presents with lesions which can be non-inflammatory, inflammatory or a mixture of both.
- Up to 95% of adolescents in Western industrialized countries are affected by acne to some extent — 20 to 35% develop moderate or severe acne.
- Complications of acne include skin changes such as scarring, post-inflammatory hyperpigmentation or depigmentation and psychosocial problems such as depression and anxiety.
- All people with acne should be advised:
- To avoid over-cleaning the skin.
- To use a non-alkaline synthetic detergent cleansing product twice daily on acne-prone skin.
- To avoid oil-based comedogenic skin care products, make-up and sunscreens, and if make-up is used it should be removed at the end of the day.
- That persistent picking or scratching of lesions can increase the risk of scarring.
- That treatments may take 6-8 weeks to be effective and may irritate the skin, especially at the start of treatment.
- People with mild-to-moderate acne should be offered a 12-week course of one of the following first-line options to be applied once daily in the evening:
- A fixed combination of topical adapalene with topical benzoyl peroxide (0.1% or 0.3% adapalene with 2.5% benzoyl peroxide).
- A fixed combination of topical tretinoin with topical clindamycin (0.025% tretinoin with 1% clindamycin).
- A fixed combination of topical benzoyl peroxide with topical clindamycin (3% or 5% benzoyl peroxide with 1% clindamycin).
- People with moderate to severe acne should be offered a 12-week course of one of the following first-line options:
- A fixed combination of topical adapalene with topical benzoyl peroxide.
- A fixed combination of topical tretinoin with topical clindamycin.
- A fixed combination of topical adapalene with topical benzoyl peroxide, together with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
- Topical azelaic acid (15% or 20%) applied twice daily, with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
- Follow-up should be arranged at 12 weeks to assess whether the person's acne has improved and whether they have any adverse effects.
- Urgent referral should be arranged for people with acne fulminans on the same day to the on-call hospital dermatology team, to be assessed within 24 hours.
- Referral to a consultant dermatologist-led team should be considered for people if:
- Mild to moderate acne has not responded to two completed courses of treatment.
- Moderate to severe acne has not responded to previous treatment that includes an oral antibiotic.
- They have acne with scarring.
- They have acne with persistent pigmentary changes.
- Their acne of any severity, or acne-related scarring, is causing or contributing to persistent psychological distress or a mental health disorder.
Have I got the right topic?
From age 12 years onwards.
This CKS topic covers the management of acne vulgaris.
This CKS topic does not cover the management of acne secondary to drugs or an underlying condition.
There is a separate CKS topic on Rosacea - acne.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.
How up-to-date is this topic?
Changes
February 2026 — minor update. The recommendation of two independent prescribers of isotretinoin therapy for under 18s has been updated to a single prescriber in line with an SPC update.
Previous changes
January 2024 — minor update. The formatting of the prescribing section has been updated to conform to the structure of other topics.
November 2023 — minor update. Recommendations on advice to give people who are being referred for possible isotretinoin treatment, and details on follow-up added in line with the MHRA drug safety update Isotretinoin (Roaccutane): introduction of new safety measures, including additional oversight of the initiation of treatment for patients under 18 years of age.
November 2023 — minor update. Recommendations on advice to give people who are being referred for possible isotretinoin treatment, and details on follow-up added in line with the MHRA drug safety update Isotretinoin (Roaccutane): introduction of new safety measures, including additional oversight of the initiation of treatment for patients under 18 years of age.
April 2023 — reviewed. A literature search was conducted in March 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. The term 'Propionibacterium acnes' (P. acnes) has been altered to 'Cutibacterium acnes' (C. acnes) to reflect the current bacterial taxonomy. Reference to topical isotretinoin preparations has been removed as these are no longer available in the UK. No changes were made to clinical recommendations.
June 2021 — minor update. Recommendations have been updated to align with the new NICE guideline Acne vulgaris: management. Sections on referral, follow up, and relapse have been added.
August 2020 — minor update. Adverse effects of topic clindamycin added to Topical antibiotics section and a broken URL link updated.
March 2020 — minor update. Topic updated in line with revised SPC for Topical antibiotics.
December 2019 — minor update. The Basis for recommendation section was updated to clarify that third or fourth generation combined oral contraceptives are generally preferred in combination with topical agents if oral contraceptives are being considered as an alternative to systemic antibiotics in women with moderate acne not responding to topical treatment.
April 2018 — reviewed. A literature search was conducted in March 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.
September 2014 — minor update. Update to the adverse effects for benzoyl peroxide to include blisters.
July 2014 — minor update. Update to prescribing information to reflect the fact that there are reports of an interaction between clindamycin and vitamin K antagonists.
January 2014 — minor update. Minor typographical error corrected in prescribing information.
July 2013 — reviewed. A literature search was conducted in May 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Changes made to the document include:
- The recommendation that an oral antibiotic should always be combined with a topical treatment (but not a topical antibiotic).
- The recommendation that where possible, a topical antibiotic course should be limited to a maximum of 12 weeks.
- The Medicines and Healthcare Products Regulatory Agency (MHRA) warning that co-cyprindiol (Dianette®) should be considered only when topical treatment or systemic antibiotics has failed, due to the increased risk of venous thromboembolism associated with co-cyprindiol.
November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.
September 2011 — minor update. Changed the clindamycin 1% aqueous lotion prescriptions from 50mLs to 30mLs, and amended the price and number of days accordingly (the 50mL lotion has been removed from the Drug Tariff).
July 2011 — minor update. Minor typographical error corrected.
June 2011 — minor update. Change to recommendation regarding need for additional contraception during or after a course of tetracycline - additional contraception is no longer required when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less.
October 2010 — technical update. The management section of this topic has been simplified to improve clarity and navigation. There have been no changes to the clinical content or meaning of the recommendations.
December 2009 — minor update. Upper age range on the co-cyprindiol prescription lowered to 50 years.
August 2009 — minor update. Addition of two randomized controlled trials to Topical drugs compared with each other, in the supporting evidence section.
January to June 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There have been no major changes to the recommendations.
September 2008 — minor typographical correction to the Changes section.
March 2008 — minor update. Tretinoin 0.025% cream discontinued and prescriptions removed.
October 2006 — minor update. Tretinoin 0.025% lotion discontinued and prescriptions removed. Issued in October 2006.
January to March 2006 — reviewed. Validated in June 2006 and issued in July 2006. The guidance was reviewed and updated following a full literature review.
October 2005 — minor technical update. Issued in November 2005.
July 2003 — minor update. Erythromycin 2% gel discontinued and prescriptions removed. Pack size of benzoyl peroxide 5% with erythromycin 3% gel updated.
September 2002 — written. Validated in December 2002 and issued in February 2003.
Update
New evidence
Evidence-based guidelines
HTAs (Health Technology Assessments)
No new HTAs since 1 March 2023.
Economic appraisals
No new economic appraisals relevant to England since 1 March 2023.
Systematic reviews and meta-analyses
- Huang, C. Y., Chang, I. J., Bolick, N., Hsu, W. T., Su, C. H., Hsieh, T. S., ... & Lee, C. C. (2023). Comparative Efficacy of Pharmacological Treatments for Acne Vulgaris: A Network Meta-Analysis of 221 Randomized Controlled Trials. The Annals of Family Medicine, 21(4), 358-369. [Full text]
- Shields, A., Ly, S., Wafae. B., et al. (2023) Safety and Effectiveness of Oral Nutraceuticals for Treating Acne. JAMA Dermatology. [Free Full-text]
- Santer, M., Burden-Teh, E., Ravenscroft, J. (2023) Managing acne vulgaris: an update. Drug and Therapeutics Bulletin 62:6-10. [Free Full-text]
- Yuan, Y., Wang, Y., Xia, J., et al. (2024) Topical, light‐based, and complementary interventions for acne: an overview of systematic reviews. The Cochrane Database of Systematic Reviews, 2024. [Free Full-text]
Primary evidence
No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2023.
New policies
No new national policies or guidelines since 1 March 2023.
New safety alerts
No new safety alerts since 1 March 2023.
Changes in product availability
- All Wales Medicines Strategy Group recommends trifarotene (Aklief®) cream for the treatment of acne vulgaris. It is recommended for the cutaneous treatment of acne vulgaris of the face and/ or the trunk in patients from 12 years of age and older, when many comedones, papules and pustules are present. It represents an additional treatment option within an existing therapeutic class. See more here.
- New product Winlevi (clascoterone) 10 mg/g cream. Clascoterone is an androgen receptor inhibitor (though exact mechanism of action for treatment of acne is not fully known), and is licensed as a twice daily cream for the topical treatment of acne vulgaris in patients 12 years of age and older. See more here.
Goals and outcome measures
Goals
To support primary healthcare professionals to:
- Make a diagnosis of acne vulgaris.
- Recognise and treat acne vulgaris in primary care and where appropriate to refer to secondary care.
- Discuss prognosis, treatment expectations and the importance of adherence to drug regimens.
- Recognise the association of acne with psychological distress and manage appropriately.
Outcome measures
No outcome measures were found during the review of this topic.
Audit criteria
No audit criteria were found during the review of this topic.
QOF indicators
No QOF indicators were found during the review of this topic.
QIPP - Options for local implementation
No QIPP indicators were found during the review of this topic.
NICE quality standards
No NICE quality standards were found during the review of this topic.
Background information
What is it?
Acne vulgaris is a chronic inflammatory skin condition affecting mainly the face (99% of cases), back (60% of cases) and chest (15% of cases).
- Acne is characterised by blockage and inflammation of the pilosebaceous unit (the hair follicle, hair shaft and sebaceous gland). It presents with lesions which can be non-inflammatory, inflammatory or a mixture of both.
- Non-inflamed lesions are known as comedones which may be open (blackheads), closed (whiteheads) or microcomedones (clinically invisible).
- Inflammatory acne lesions include papules and pustules (5 mm or less in diameter) — in more severe disease these can develop into larger deeper pustules, nodules or cysts.
- Most people with acne have a mixture of inflammatory and non-inflammatory lesions.
- Acne usually starts at puberty and resolves as adolescence ends.
- Persistent acne can last into adulthood for a smaller number of people. A smaller proportion may experience acne for the first time in adulthood.
- There is no universally agreed grading system for acne but it is often categorised by lesion type and severity into:
- Mild acne — predominantly non-inflamed lesions (open and closed comedones) with few inflammatory lesions.
- Moderate acne — more widespread with an increased number of inflammatory papules and pustules.
- Severe acne — widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present.
- Conglobate acne is a rare and severe form of acne found most often in men – it presents with extensive inflammatory papules, suppurative nodules (which may coalesce to form sinuses) and cysts on the trunk and upper limbs.
- Acne fulminans is a sudden severe inflammatory reaction that precipitates deep ulcerations and erosions, sometimes with systemic effects (such as fever, arthralgia and myalgia).
- Neonatal acne can be present at birth or can develop after delivery, generally before the child reaches six weeks old. It is typically characterized by papules and pustules on the forehead, cheeks and/or nose, and is expected to resolve spontaneously in a few weeks to a few months.
[Gollnick, 2016; Zaenglein, 2016; Bagatin, 2019; Leung, 2021; BMJ Best Practice, 2023]
What causes it?
- The pathogenesis of acne is not completely understood but is thought to involve several processes including:
- Altered follicular keratinocyte proliferation leading to formation of follicular plugs (comedones).
- Androgen-induced seborrhoea (increased sebum production) within the sebaceous follicles which usually occurs around puberty.
- Proliferation of bacteria (such as Cutibacterium acnes — formerly known as Propionibacterium acnes) within sebum in hair follicles.
- Inflammation of the pilosebaceous unit.
- Studies have suggested that other factors may contribute to the pathogenesis of acne such as:
- Genetic factors — a high concordance between identical twins and a tendency towards severe acne in people with a positive family history has been identified.
- Racial and ethnic factors — the prevalence, severity, clinical presentation and sequelae of acne varies between different population groups.
- Diet — recent studies suggest there may be a correlation between acne and high glycaemic index diets. Other foods inconclusively linked with acne include milk and whey proteins, and dairy or meat products high in leucine. While diets including sufficient levels of omega-3 fatty acids and γ-linoleic acid may be associated with reduced acne lesions.
- Hormonal factors — females with acne may notice increased eruptions slightly prior to, or in the first few days of their menstrual period. Additionally, people with endocrinological disorders including hyperandrogenism or polycystic ovarian syndrome may develop acne.
[Zaenglein, 2016; Xu, 2019; Heng, 2020; Baldwin, 2021; Leung, 2021; Meixiong, 2022; PCDS, 2022; BMJ Best Practice, 2023]
How common is it?
- An estimated 9% of people are affected by acne worldwide.
- Prevalence varies widely in different geographical areas with Western industrialized countries having much higher rates of acne than some non-industrialised countries.
- Up to 95% of adolescents in Western industrialized countries are affected by acne to some extent — 20 to 35% develop moderate or severe acne [Williams, 2012; Zouboulis, 2015; Heng, 2020].
- Of people with acne approximately [BMJ Best Practice, 2023]:
- 85% are aged 12–24 years.
- 8% are aged 25–34 years.
- 3% are aged 35–44 years.
- Acne is more common in males during adolescence but in adulthood, incidence is higher in women.
- Acne is one of the most common skin conditions in the United Kingdom leading to 3.5 million visits to primary care every year [Dawson, 2013].
What are the complications?
- Skin changes
- Scarring — acne may result in hypertrophic or atrophic scars which can be extensive.
- Keloid scar tissue development has been reported to be 5 to 16 times more common in people with darker skin types.
- Post-inflammatory hyperpigmentation or depigmentation can occur.
- This may be more common in people with darker skin types — the aetiology of which is currently unclear.
- Scarring — acne may result in hypertrophic or atrophic scars which can be extensive.
- Psychosocial effects
- Acne is associated with significant psychological problems including an increased risk of depression, suicide, anxiety, reduced attachment to friends, and low self-esteem.
- Systemic comorbidities
- Acne is closely associated with several systemic comorbidities, including obesity, diabetes mellitus, hyperlipidemia, hypertension, and metabolic syndrome.
[Asai, 2016; Leung, 2021; Chiang, 2022; Wang, 2022; BMJ Best Practice, 2023]
What is the prognosis?
- Acne is a chronic disease that can persist for many years — it tends to affect adolescents and usually resolves after the end of growth.
- Males may be more likely to experience severe acne, and severe acne can be more persistent.
- It may persist into adulthood as a continuation of adolescent acne or due to development of late-onset disease.
- Females are more likely than males to have acne in adulthood:
- Estimates indicate that acne may persist in up to 5% of affected females between the ages of 40 and 49.
- The predictive factors for persistence into adulthood are not clear.
- Females are more likely than males to have acne in adulthood:
[Bagatin, 2019; Heng, 2020; Leung, 2021; BMJ Best Practice, 2023]
Diagnosis of acne vulgaris
What are the clinical features of acne vulgaris?
- Acne affects areas of the body with a high density of pilosebaceous glands such as the face, chest and back. Clinical features vary widely depending on severity and the person affected.
- Comedones must be present for a diagnosis of acne to be made — if not present other diagnoses should be considered.
- Suspect acne in a person presenting with:
- Non-inflammatory lesions (comedones) which may be open (blackheads) or closed (whiteheads).
- Inflammatory lesions such as:
- Papules and pustules – superficial raised lesions (less than 5 mm in diameter).
- Nodules or cysts (larger than 5mm in diameter) – deeper, palpable lesions which are often painful and may be fluctuant. In very severe acne nodules may track together and form sinuses (acne conglobata).
- Scarring — atrophic/ice pick or hypertrophic/keloid scars may be seen.
- Pigmentation — post-inflammatory depigmentation or hyperpigmentation may be present.
- Seborrhoea — commonly present.
- There is no universally agreed scoring system for acne severity but categorising into mild, moderate and severe can be helpful in the selection of appropriate treatment and monitoring of response:
- Mild acne — predominantly non-inflamed lesions (open and closed comedones) with few inflammatory lesions.
- Moderate acne — more widespread with an increased number of inflammatory papules and pustules.
- Severe acne — widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present.
- Images of acne and its clinical variants can be viewed at www.dermnetnz.org.
Basis for recommendation
The recommendations on the clinical features of acne are based on clinical guidelines Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne [Eichenfield, 2013], Management of acne: Canadian clinical practice guideline [Asai, 2016], A consensus-based practical and daily guide for the treatment of acne patients [Gollnick, 2016], European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016], Guidelines of care for the management of acne vulgaris [Zaenglein, 2016], and Acne: acne vulgaris [PCDS, 2022], and expert opinion in review articles [Leung, 2021; BMJ Best Practice, 2023].
How should I assess a person with suspected acne vulgaris?
Take a history asking about:
- Duration, type and distribution of lesions.
- Previous treatment (including over-the-counter medications) and response.
- Exacerbating factors such as flares with menstruation, contraceptives, cosmetics, face creams or hair pomades.
- Systemic features — some rare subtypes of acne (acne fulminans) can present with systemic features including fever, arthralgia, and myalgia.
- Psychosocial impact of acne — ask about psychological problems including anxiety and low mood.
- Family history including endocrine disorders, polycystic ovarian syndrome, acne and other skin conditions.
- Possible underlying causes:
- Drug history — some medications can cause or exacerbate acne form rashes including androgens, corticosteroids, isoniazid, ciclosporin, and lithium.
- Hyperandrogenism — may present with irregular periods, androgenic alopecia or hirsutism in women.
Examine the person:
- Look for clinical features of acne such as non-inflammatory comedones and inflammatory papules, pustules, nodules and scarring.
- Comedones must be present for a diagnosis of acne to be made. If not present, consider alternative diagnoses.
- Record the type and distribution of lesions and severity.
- Look for signs of other disorders that can present with acne such as hyperandrogenism or polycystic ovarian syndrome.
- For more information, see the CKS topic on Polycystic ovary syndrome.
Investigations
- Most people with acne do not require any investigations.
- Consider appropriate investigations/referral to endocrinology for people presenting with clinical features of polycystic ovarian syndrome (such as menstrual irregularity and hirsutism), or other endocrinopathy. For more information, see the CKS topic on Polycystic ovary syndrome.
Basis for recommendation
The recommendations on the assessment of acne are based on clinical guidelines Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne [Eichenfield, 2013], Management of acne: Canadian clinical practice guideline [Asai, 2016], A consensus-based practical and daily guide for the treatment of acne patients [Gollnick, 2016], European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016], Guidelines of care for the management of acne vulgaris [Zaenglein, 2016], and Acne: acne vulgaris [PCDS, 2022], and expert opinion in review articles [Leung, 2021; BMJ Best Practice, 2023].
Ask about the psychosocial impact
- Acne is associated with significant psychological problems including an increased risk of depression, anxiety, reduced attachment to friends, low self-esteem and in some cases suicidal ideation. Identification of the extent of psychological impact is needed to direct management appropriately [Zaenglein, 2016; Leung, 2021; BMJ Best Practice, 2023].
Grade severity
- There is no universally agreed grading scale but it is generally accepted in the guidelines that categorising into mild, moderate and severe can be helpful in the selection of appropriate treatment and monitoring of response [Gollnick, 2016; Nast, 2016].
Investigations
- Guidelines agree that generally no investigations are needed for the majority of people with acne. However, further investigation/referral to endocrinology is recommended for people presenting with acne and additional signs of androgen excess to identify an underlying cause [Gollnick, 2016; Nast, 2016; Zaenglein, 2016; PCDS, 2022].
What else might it be?
The differential diagnosis for acne includes:
- Rosacea — for more information, see the CKS topic on Rosacea - acne.
- Perioral dermatitis — a relatively common chronic inflammatory skin eruption which presents around the eyes, nostrils, mouth, and occasionally the genitals. Most common in lighter-skinned, young to middle-aged women (20–45 years).
- Folliculitis and boils — for more information, see the CKS topic on Boils, carbuncles, and staphylococcal carriage.
- Drug-induced acne — some drugs can cause or exacerbate acneiform eruptions including dioxins (chloracne), corticosteroids, antiseizure medications (phenytoin, carbamazepine, phenobarbital, valproate, lamotrigine, levetiracetam and oxcarbazepine), lithium, isoniazid, ciclosporin, vitamins B1, B6 and B12 and anabolic steroids.
- Keratosis pilaris — a very common, dry skin condition caused by keratin accumulation in the hair follicles, and is typically found in children and young adults.
Basis for recommendation
The information on the differential diagnosis of acne is based on clinical guidelines Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne [Eichenfield, 2013], European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016], Guidelines of care for the management of acne vulgaris [Zaenglein, 2016], and Acne: acne vulgaris [PCDS, 2022], and expert opinion in review articles [DermNet NZ, 2022; DermNet NZ 2022; Asadi-Pooya, 2021; Leung, 2021; BMJ Best Practice, 2023].
Management
Scenario: Management of acne vulgaris in primary care
From age 12 years onwards.
How should I manage a person with acne vulgaris in primary care?
If urgent referral is not indicated and acne can be managed in primary care:
- Give the person clear information tailored to their needs and concerns, including:
- The possible reasons for acne.
- Treatment options, including over-the-counter treatments if appropriate.
- When discussing treatment choices with a person with childbearing potential, cover:
- That topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy.
- That they will need to use effective contraception, or choose an alternative treatment to these options.
- The benefits and drawbacks associated with treatments.
- The potential impact of acne.
- The importance of adhering to treatment as positive effects can take 6–8 weeks to become noticeable.
- Relapses — when and how to obtain further advice and treatment options.
- Advise the person:
- To avoid over-cleaning the skin (which may cause dryness and irritation). Acne is not caused by poor hygiene.
- To use a non-alkaline (skin pH neutral or slightly acidic) synthetic detergent cleansing product twice daily on acne-prone skin.
- To avoid oil-based comedogenic skin care products, make-up and sunscreens, and if make-up is used it should be removed at the end of the day.
- That persistent picking or scratching of lesions can increase the risk of scarring.
- That treatments may irritate the skin, especially at the start of treatment.
- To reduce the risk of skin irritation associated with topical treatments, start with alternate-day or short-contact application (for example washing off after an hour).
- That there is not enough evidence to support specific diets for treating acne, but provide advice on how to maintain a healthy diet.
- Patient information is available from:
- For people with mild to moderate acne:
- Offer a 12-week course of one of the following first-line options to be applied once daily in the evening:
- A fixed combination of topical adapalene with topical benzoyl peroxide (0.1% or 0.3% adapalene with 2.5% benzoyl peroxide).
- A fixed combination of topical tretinoin with topical clindamycin (0.025% tretinoin with 1% clindamycin).
- A fixed combination of topical benzoyl peroxide with topical clindamycin (3% or 5% benzoyl peroxide with 1% clindamycin).
- Consider topical benzoyl peroxide as monotherapy as an alternative if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic.
- Creams or lotions may be preferable for people with dry or sensitive skin and less greasy gels may be preferable for people with oily skin.
- Concentration or application frequency of topical treatments may need to be reduced or lowered if skin irritation occurs.
- Advise the person that frequency of application can be gradually increased from once or twice a week to daily if tolerated.
- Offer a 12-week course of one of the following first-line options to be applied once daily in the evening:
- For people with moderate to severe acne:
- Offer a 12-week course of one of the following first-line options:
- A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening.
- A fixed combination of topical tretinoin with topical clindamycin to be applied once daily in the evening.
- A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening, together with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
- Topical azelaic acid (15% or 20%) applied twice daily, with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
- Consider topical benzoyl peroxide as monotherapy as an alternative if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic (oral or topical).
- For people who cannot tolerate or have contraindications to oral lymecycline or oral doxycycline, consider replacing these with trimethoprim or with an oral macrolide (for example, erythromycin).
- Combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women.
- Oral progesterone-only contraceptives or progestin implants with androgenic activity may exacerbate acne, third and fourth-generation combined oral contraceptives are generally preferred.
- Co-cyprindiol (Dianette®) or other ethinylestradiol/cyproterone acetate-containing products may be considered in moderate to severe acne where other treatments have failed but require careful discussion of the risks and benefits with the patient. Use should be discontinued 3 months after acne has been controlled and prescription guided by the UK Medical Eligibility Criteria for Contraceptive Use and the Summary of Product Characteristics for the individual product.
- For further information on contraceptives, see the CKS topic on Contraception - combined hormonal methods.
- Offer a 12-week course of one of the following first-line options:
- Do not use the following to treat acne:
- Monotherapy with a topical antibiotic.
- Monotherapy with an oral antibiotic.
- A combination of a topical antibiotic and an oral antibiotic.
- For people with acne-related scarring:
- Discuss their concerns and provide information, including:
- Possible reasons for their scars.
- Treatment of ongoing acne to help prevent further scarring.
- Possible treatment options for acne-related scarring.
- The way their scars may change over time.
- Psychological distress.
- Refer to a consultant dermatologist-led team with expertise in scarring management if acne-related scarring is severe and persists a year after acne has cleared.
- Discuss their concerns and provide information, including:
- Arrange follow up.
Basis for recommendation
The recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Acne vulgaris: management [NICE, 2023], clinical guidelines Evidence-based recommendations for the diagnosis and treatment of pediatric acne [Eichenfield, 2013], Strengthening of warnings about use of Dianette and other brands of co-cyprindiol [CoSRH, 2013], Management of acne: Canadian clinical practice guideline [Asai, 2016], A consensus-based practical and daily guide for the treatment of acne patients [Gollnick, 2016], European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016], Guidelines of care for the management of acne vulgaris [Zaenglein, 2016], and Acne: acne vulgaris [PCDS, 2022], Cochrane systematic reviews [Liu, 2020; Fraison, 2020; Yang, 2020], and expert opinion in review articles [Xu, 2019; Leung, 2021; BMJ Best Practice, 2023].
General advice
- Cleansing — acne is not caused by poor hygiene. Aggressive washing can aggravate acne and should be avoided [Eichenfield, 2013; Gollnick, 2016; PCDS, 2022].
- Healthy diet — the role of diet in acne remains poorly understood — emerging data suggests that high glycaemic index (GI) diets may exacerbate acne [Zaenglein, 2016; PCDS, 2022]. Other foods inconclusively linked with acne include milk and whey proteins, and dairy or meat products high in leucine. While diets including sufficient levels of omega-3 fatty acids and γ-linoleic acid may be associated with reduced acne lesions [Baldwin, 2021].
Topical treatment
- UK, European, and International guidelines [Asai, 2016; Gollnick, 2016; Nast, 2016; Zaenglein, 2016; PCDS, 2022] recommend the use of topical agents including benzoyl peroxide, topical retinoids, and topical antibiotics for mild to moderate acne.
- Benzoyl peroxide is antibacterial and mildly comedolytic — it is effective in mild to moderate acne and both comedones and inflamed lesions respond well [Zaenglein, 2016; BNF, 2023].
- Addition of benzoyl peroxide to topical antibiotic therapies is recommended to reduce the risk of antibiotic resistance [Asai, 2016; Gollnick, 2016; Nast, 2016; Zaenglein, 2016; PCDS, 2022].
- A 2020 Cochrane systematic review indicated that studies which utilised participant self‐assessment of acne severity suggest acne improvement may be more likely with benzoyl peroxide treatment (as monotherapy or add‐on treatment) than with placebo or no treatment. However, the risk of treatment discontinuation was also higher with benzoyl peroxide treatment compared with placebo or no treatment. Given the most common causes of withdrawal (erythema, pruritus and skin burning), the authors concluded that discontinuation was likely due to treatment tolerability rather than due to major safety concerns. The review also found that evidence regarding the risk of adverse effects was very uncertain when benzoyl peroxide was compared with adapalene, erythromycin, or salicylic acid, but there was a higher risk of mild to moderate adverse events when benzoyl peroxide was compared with topical clindamycin [Yang, 2020].
- Topical retinoids are comedolytic, anti-comedogenic, anti-inflammatory, and inhibit formation of microcomedones (the precursors to acne lesions) [Gollnick, 2016].
- Topical retinoids have been found to be effective in the treatment of comedonal acne and when used in combination with other drugs for all acne variants [Dawson, 2013; Gollnick, 2016; Zaenglein, 2016].
- The European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016] recommends that adapalene is used in preference to other topical retinoids (such as tretinoin and isotretinoin).
- Topical retinoids are contraindicated in pregnancy, and use should therefore be avoided in those planning a pregnancy, or discontinued in those who have become pregnant [NICE, 2023].
- Topical antibiotics are thought to work through anti-inflammatory and anti-bacterial effects [Zaenglein, 2016].
- Topical monotherapy with antibiotics is not recommended because of the risk of antibiotic resistance [Eichenfield, 2013; Asai, 2016; Gollnick, 2016; Nast, 2016; Zaenglein, 2016; Xu, 2019].
- The American Academy of Dermatology [Zaenglein, 2016] recommend Clindamycin 1% solution or gel as the preferred topical antibiotic for acne.
- Azelaic acid.
- Azelaic acid is mildly effective as a comedolytic, antibacterial, and anti-inflammatory agent [Zaenglein, 2016].
- It is recommended as second-line treatment in several guidelines [Gollnick, 2016; Nast, 2016; PCDS, 2022].
- A 2020 Cochrane systematic review and meta-analysis suggested that azelaic acid may not be as effective as benzoyl peroxide [Liu, 2020].
- Some people may prefer azelaic acid to benzoyl peroxide as it is less likely to cause skin irritation [BNF, 2023].
- Salicylic acid has keratolytic properties, but there is limited evidence regarding the safety and efficacy of topical salicylic acid in the treatment of acne [Liu, 2020]. It is also considered a less effective comedolytic than topical retinoids [BMJ Best Practice, 2023].
- Benzoyl peroxide is antibacterial and mildly comedolytic — it is effective in mild to moderate acne and both comedones and inflamed lesions respond well [Zaenglein, 2016; BNF, 2023].
Systemic antibiotics
- UK, European, and International guidelines and expert opinion recommend combining systemic antibiotics with an appropriate topical agent, such as benzoyl peroxide or a topical retinoid to reduce bacterial resistance and target the different pathophysiological mechanisms in acne [Zaenglein, 2016; Bienenfeld, 2017; Baldwin, 2021; PCDS, 2022].
- Although tetracycline and doxycycline have been shown to be superior to placebo in reducing inflammatory acne lesions these drugs should not be prescribed in isolation due to the risk of selection of antibiotic resistant bacteria [Asai, 2016].
- Minocycline is not recommended for use in acne as it is associated with an increased risk of drug induced lupus, skin pigmentation, and hepatitis [PrescQIPP, 2020; PCDS, 2022].
- Preference should be given to once daily treatments, which may provide better adherence, using a tetracycline antibiotic with a better safety profile than minocycline (doxycycline or lymecycline) [PrescQIPP, 2020].
- Macrolides should be avoided in the treatment of acne (unless tetracyclines are contraindicated or cannot be tolerated) due to increased bacterial resistance [Eichenfield, 2013; Zaenglein, 2016; Bienenfeld, 2017; Xu, 2019].
- Data regarding the use of trimethoprim in treating acne are limited, but evidence of efficacy has been provided, and studies have shown that it may be particularly effective in treating acne refractory to tetracycline treatment [Baldwin, 2021].
- Evidence suggests that there is little additional benefit in using antibiotics for more than 3 months and, in addition, prolonged use increases the resistance of Cutibacterium acnes [Xu, 2019; PCDS, 2022].
- Those relapsing quickly after stopping treatment may benefit from a 6 month treatment course [PCDS, 2022].
- Antibiotic courses can be repeated in the future if required [PCDS, 2022].
Oral contraceptives
- Several guidelines recommend use of oral contraceptives as an alternative to oral antibiotics in women with moderate to severe acne where topical treatments have failed [Asai, 2016; Gollnick, 2016; Zaenglein, 2016; PCDS, 2022].
- NICE recommends that if a person receiving treatment for acne wishes to use hormonal contraception that the combined oral contraceptive pill should be considered in preference to the progestogen-only pill, and that for women with polycystic ovary syndrome (PCOS) if the chosen first-line treatment is not effective, adding ethinylestradiol with cyproterone acetate (co-cyprindiol) or an alternative combined oral contraceptive pill to their treatment should be considered [NICE, 2023].
- NICE did not make any recommendations on the use of oral contraceptives to manage acne in women who do not have PCOS or in women who had not already chosen hormonal contraception.
- The risks and benefits must be assessed on an individual basis — the combination of oestrogen with cyproterone and some other progestogenic hormones is associated with a 1.5–2 fold increased incidence of venous thromboembolism (VTE) compared with levonorgestrel-containing combined pills [CoSRH, 2013].
- Cyproterone with ethinylestradiol (co-cyprindiol) is licensed as a second-line treatment for women with severe acne when treatment with topical therapy or systemic antibiotics has failed. It should not be used solely as a contraceptive and use of an additional hormonal contraceptive with co-cyprindiol is contraindicated. Continuation of treatment should be evaluated regularly by a clinician and the patient advised to be vigilant for signs and symptoms of VTE [MHRA, 2013]. The UK Medical Eligibility Criteria for Contraceptive Use provides further guidance for the prescription of ethinylestradiol/cyproterone acetate-containing products [CoSRH, 2019].
- The College of Sexual and Reproductive Healthcare guidance on combined hormonal contraception has highlighted the increased risk of thrombosis associated with use of co-cyprindiol pills (Dianette® and Clairette®) — all women being prescribed combined hormonal contraceptives, including Dianette® should be alerted to the increased risk of thrombosis compared to non-use or use of levonorgestrel-containing combined pills. However, the absolute risk is still low if prescribed appropriately and is less than the risk associated with pregnancy [CoSRH, 2013].
- There is a large evidence base regarding the efficacy of oral contraceptives in the management of acne vulgaris:
- A meta-analysis of 32 randomized controlled trials found that although antibiotics may be superior at 3 months, combined oral contraceptives (COCPs) are equivalent to antibiotics at 6 months in reducing acne lesions [Koo, 2014].
- The weighted mean inflammatory lesion reduction following a 3-month course of oral antibiotic treatment was found to be 53.2% compared to 35.6% for a 3-month course of COCPs.
- The weighted mean inflammatory lesion reduction following a 6-month course of oral antibiotic treatment was 57.9% compared to 61.9% for a 6-month course of COCPs.
- A Cochrane meta-analysis has examined the effectiveness of combined oral contraceptives (COCPs) for the treatment of facial acne compared to placebo or other active therapies in women (n = 31 trials, 12,579 women). Six COCPs were evaluated in placebo-controlled trials and found to be effective in reducing inflammatory and non-inflammatory facial acne lesions. Few important and consistent differences could be identified between COCP types in their effectiveness [Arowojolu, 2012].
- A second Cochrane meta-analysis described the results of four trials which assessed the efficacy of metformin in acne treatment compared with oral contraceptives (OCPs) [Fraison, 2020].
- One small trial assessed acne improvement using the visual analogue scale, and found no evidence of an improvement with metformin.
- Three small trials assessed acne improvement subjectively, and when the results of these trials were combined, metformin treatment was shown to be less effective than OCP treatment.
- A meta-analysis of 32 randomized controlled trials found that although antibiotics may be superior at 3 months, combined oral contraceptives (COCPs) are equivalent to antibiotics at 6 months in reducing acne lesions [Koo, 2014].
Choice of oral contraceptive
- A Cochrane systematic review found that [Arowojolu, 2012]:
- Combined oral contraceptives (COCs) containing chlormadinone or cyproterone acetate seem to improve acne better than levonorgestrel, however, this finding was based on limited evidence.
- A COC containing drospirenone was more effective than norgestimate or nomegestrol acetate, but the trials used different methods to assess acne severity assessments.
- Comparisons between other COCs were either conflicting or showed no significant difference in their ability to reduce acne.
- The information that third or fourth generation COCs may be preferred is based on expert opinion in a consensus guideline and a narrative review.
- No definitive data on efficacy and tolerability comparing the available COCs are available in the literature although, theoretically, the ones containing progestins with an anti-androgenic potential and no androgenic effect should be preferred [Bettoli, 2015].
- Acne may be exacerbated if females are taking oral contraceptives or have progestin implants with androgenic activity. Third- or fourth-generation pills with anti-androgenic activity are preferred [Gollnick, 2016].
Treatment of adult female acne
The following information is provided for general information purposes as women with adult female acne (AFA) are likely to be managed in secondary care:
- A 2019 clinical guideline defines adult female acne (AFA) as acne affecting women over the age of 25 [Bagatin, 2019].
- In women with AFA, acne may have persisted continuously or intermittently since adolescence, or may present for the first time in adulthood.
- AFA may persist until the postmenopausal period.
- Genetic and hormonal factors contribute to the pathogenesis of AFA, but these are poorly defined.
- The guideline states [Bagatin, 2019]:
- AFA is a therapeutic challenge because it presents a tendency to relapse, even after cycles of oral antibiotics or isotretinoin.
- People with AFA may also have skin that is more sensitive than that of adolescents, with less tolerance to topical treatments.
- Frequent relapses may necessitate maintenance therapy, with topical azelaic acid, tretinoin or adapalene recommended as maintenance therapy in AFA.
People with skin of colour
- People with skin of colour (SOC) are at increased risk of post-inflammatory hyperpigmentation (PIH). A 2022 narrative review provided recommendations on the management of acne in people with SOC [Chiang, 2022]:
- Early treatment may help reduce the risk of PIH development.
- Topical therapy with retinoids and azelaic acid may have added benefits as these treatments can target both acne and PIH simultaneously.
- Topical retinoids, benzoyl peroxide and azelaic acid can cause dryness and irritation, and this can lead to hyperpigmentation in people with SOC.
- A clinical guideline advises that consideration should be given to initially using these treatments less frequently (every second or third day) and for shorter periods of time (such as in the evening and washed off before bed) [PCDS, 2022].
When should I refer people with acne?
- Urgently refer people with acne fulminans on the same day to the on-call hospital dermatology team, to be assessed within 24 hours.
- Refer people to a consultant dermatologist-led team if:
- There is diagnostic uncertainty.
- They have acne conglobata.
- They have nodulo-cystic acne.
- Fully inform the person (and their family and carers as appropriate) about the potential risks of isotretinoin treatment as well as the expected benefits before referral to the consultant-dermatologist-led team, and again before prescribing isotretinoin if that is the chosen treatment. Advise the person that:
- Isotretinoin is an effective treatment for acne that is severe or at risk of causing permanent scarring when other appropriate treatments have not been effective.
- All medicines have side effects, not every experiences them, and they should know what to do if they occur — this includes possible mental health and sexual function side effects.
- They should inform their healthcare professional if they have any personal or family history of mental health issues or any sexual function concerns.
- If taken during pregnancy, isotretinoin can seriously harm an unborn baby — they must not become pregnant during treatment with isotretinoin and for 1 month after isotretinoin is stopped.
- If they may be able to get pregnant they will be entered into the Pregnancy Prevention Programme before starting treatment with isotretinoin.
- They should take time to think about the information about the benefits and risks of isotretinoin and decide whether it is the right treatment for them.
- The prescribing doctor will check that they understand the information in the Acknowledgement of Risk Form – they need to agree to all applicable points in order to receive isotretinoin, and they should keep a copy of the completed form safe.
- They should read the Patient Reminder Card and keep it safe as it contains important safety information that they need to be aware of before and during treatment.
- If they are aged under 18 years, a single prescriber must agree that there is no other appropriate effective treatment option before they start isotretinoin.
- If they are already being treated with isotretinoin they should continue to follow their agreed treatment plan, but seek medical advice if they have any side effects or concerns.
- They should report side effects associated with isotretinoin directly to the MHRA via the Yellow Card scheme.
- Consider referring people to a consultant dermatologist-led team if:
- Mild to moderate acne has not responded to two completed courses of treatment.
- Moderate to severe acne has not responded to previous treatment that includes an oral antibiotic.
- They have acne with scarring.
- They have acne with persistent pigmentary changes.
- Their acne of any severity, or acne-related scarring, is causing or contributing to persistent psychological distress or a mental health disorder.
- Consider referring people to mental health services if a person with acne experiences significant psychological distress or a mental health disorder, including those with a current or past history of:
- Suicidal ideation or self-harm.
- A severe depressive or anxiety disorder.
- Body dysmorphic disorder.
- Consider condition-specific management or referral to an appropriate specialist if a medical disorder or medication (including self-administered anabolic steroids) is likely to be contributing to a person's acne.
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Acne vulgaris: management [NICE, 2023], and other clinical guidelines A consensus-based practical and daily guide for the treatment of acne patients [Gollnick, 2016], European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016], Guidelines of care for the management of acne vulgaris [Zaenglein, 2016], Guidance on the diagnosis and clinical management of acne [Archer, 2012], and Acne: acne vulgaris [PCDS, 2022].
- Expert opinion in guidelines is that people who have or are at risk of scarring or depigmentation due to acne and those with significant psychological distress should be referred for specialist treatment [Gollnick, 2016; Nast, 2016; Zaenglein, 2016; PCDS, 2022].
- A limited evidence base indicates that acne may be more strongly associated with mental health issues in sexual and gender minority (lesbian, gay, bisexual, and transgender) adolescents [Ragmanauskaite, 2020].
People with skin of colour (SOC)
- People with SOC are at increased risk of post-inflammatory hyperpigmentation (PIH) [Chiang, 2022].
- A clinical guideline suggests that early and more aggressive treatment may be needed in this patient group, including early referral for consideration of oral isotretinoin treatment [PCDS, 2022].
When considering referral for isotretinoin therapy
- Isotretinoin (13‐cis‐retinoic acid) is a vitamin A derivative that is highly effective as an anti‐acne therapy [Costa, 2018]. Oral isotretinoin is indicated in people with severe nodular or conglobate acne or acne fulminans, in those with a tendency for acne-related scarring, and in those with moderate to severe acne where standard therapies (including an oral antibiotic) have failed to control the condition [Costa, 2018; NICE, 2023].
- A 2018 Cochrane systematic review showed that when assessing efficacy of oral isotretinoin by comparing total inflammatory lesion counts, there is a lack of clear evidence from randomised controlled trials (RCTs) that oral isotretinoin treatment improves acne severity in comparison with standard oral antibiotic and topical treatment. However, in RCTs where acne severity was assessed by a physician, the evidence demonstrates a slight improvement in acne severity following oral isotretinoin use [Costa, 2018].
- Where referral for possible oral isotretinoin therapy is being considered, clinical guidelines suggest [PCDS, 2022; NICE, 2023]:
- Urea and electrolytes, liver function tests, and fasting lipids should be checked and documented.
- Females of reproductive potential must be informed that isotretinoin can cause serious harm to a developing baby if taken during pregnancy, and that they will need to follow a pregnancy prevention programme if they decide to use oral isotretinoin.
- A patient information leaflet may also be provided; information about isotretinoin is available from the British Association of Dermatologists.
- A single presciber must consider that there is no other appropriate effective treatment before initiation of isotretinoin therapy in patients under 18 years of age is taken directly from the updated SPC for Isotretonoin [EMC, 2026].
How should I follow up people with acne vulgaris?
- Review first-line treatment at 12 weeks to assess whether the person's acne has improved and whether they have any adverse effects.
- In people whose treatment includes an oral antibiotic, if their acne has:
- Completely cleared — consider stopping the antibiotic but continuing the topical treatment.
- Improved but not completely cleared — consider continuing the oral antibiotic, alongside the topical treatment, for up to 12 more weeks.
- Only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances. Review at 3-monthly intervals, and stop the antibiotic as soon as possible.
- If acne has cleared:
- Explain that maintenance treatment is not always necessary.
- Consider maintenance treatment in people with a history of frequent relapse after treatment.
- Consider a fixed combination of topical adapalene and topical benzoyl peroxide. If this is not tolerated, or if one component of the combination is contraindicated, consider topical monotherapy with adapalene 0.1%, azelaic acid 15% or 20%, or benzoyl peroxide 5%.
- Review maintenance treatments for acne after 12 weeks to decide if it should be continued.
- If acne fails to respond adequately to a 12-week course of a first-line treatment option and at review the severity is:
- If mild to moderate acne fails to respond adequately to two different 12-week courses of treatment options, consider referral to a consultant dermatologist-led team.
- If a person is taking oral isotretinoin for acne:
- Review the person approximately 1 month after initiation of treatment in a face-to-face (in-person) appointment.
- Monitor for adverse effects including mental health and sexual function adverse effects at each follow-up appointment including objective mental health patient-reported outcome measures.
- Advise the person to seek medical advice if they feel their mental health or sexual function is affected or is worsening, and to stop their treatment and seek urgent medical advice if these problems are severe.
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Acne vulgaris: management [NICE, 2023], and other clinical guidelines Management of acne: Canadian clinical practice guideline [Asai, 2016], A consensus-based practical and daily guide for the treatment of acne patients [Gollnick, 2016], European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016], Guidelines of care for the management of acne vulgaris [Zaenglein, 2016], How much do we know about maintaining treatment response after successful acne therapy? Systematic review on the efficacy and safety of acne maintenance therapy [Dressler, 2016], and Acne: acne vulgaris [PCDS, 2022].
Follow up
- Several guidelines [Asai, 2016; Gollnick, 2016; Nast, 2016; PCDS, 2022] recommend follow up to determine the need for ongoing patient education, escalation of treatment, or maintenance therapy.
- Side-effects and lack of knowledge about acne treatments are the two main reasons for non-adherence — appropriate dosage and application of treatment, the slow onset of action of acne treatments, and possible adverse events should be discussed when treatments are initiated [Gollnick, 2016].
- Topical agents should be applied to the entire area, not just visible spots so that microcomedones in surrounding skin which are not clinically visible are also treated [Gollnick, 2016].
Maintenance therapy
- Maintenance therapy helps to prevent recurrence of acne by suppressing development of microcomedones which can be present in normal looking skin [Gollnick, 2016].
- A systematic review (n = 5 randomized controlled trials [983 participants] and 3 non-randomised controlled trials [261 participants]) concluded that evidence was insufficient to recommend specific maintenance therapies as initial treatments before the maintenance phase varied markedly [Dressler, 2016].
- The European evidence-based guideline for the treatment of acne [Nast, 2016] states that topical retinoids, topical retinoids/benzoyl peroxide, and azelaic acid are effective on microcomedones. Long-term or maintenance use of topical or systemic antibiotics should be avoided.
How should I manage relapse in people with acne vulgaris?
- If acne responds adequately to a course of an appropriate first-line treatment but then relapses, consider either:
- Another 12-week course of the same treatment, or
- An alternative 12-week treatment.
- If acne relapses after an adequate response to oral isotretinoin (prescribed under specialist care) and is currently:
- If acne relapses after a second course of oral isotretinoin (prescribed under specialist care) and is currently moderate to severe, further care should be decided by the consultant dermatologist-led team.
- If the person is no longer under the care of the consultant dermatologist-led team, offer re-referral.
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Acne vulgaris: management [NICE, 2023].
Prescribing information
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).
Benzoyl peroxide
Dose
- For children 12–17 years — apply to the skin 1–2 times a day, preferably after washing with soap and water, and start treatment with lower-strength preparations.
- For adults — apply to the skin 1–2 times a day, preferably after washing with soap and water, and start treatment with lower-strength preparations.
Contraindications and cautions
- Do not prescribe benzoyl peroxide to people with hypersensitivity to the active substance or any of the excipients.
- Avoid contact with broken skin, eyes, mouth and mucous membranes.
- Avoid excessive exposure to sunlight.
- Excessive application will not improve efficacy, but may increase the risk of skin irritation.
[Eichenfield, 2013; Zaenglein, 2016; Yang, 2020; ABPI, 2023a; BNF, 2023]
Adverse effects
- Skin irritation (dryness, discomfort, erythema, peeling and blistering) — reduce frequency or stop use until irritation settles then re-introduce at reduced concentration or frequency.
- Allergic contact dermatitis to benzoyl peroxide occurs in 1 in 500 people — consider if itching and swelling of the eyes occurs.
- To reduce the risk of skin irritation, consider starting treatment with alternate-day or short-contact application (e.g. washing off after an hour) and progress to standard application if this reduced level of treatment is tolerated.
- Increased risk of sunburn — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used.
- May bleach fabrics and hair.
[Eichenfield, 2013; Zaenglein, 2016; Yang, 2020; ABPI, 2023a; BNF, 2023]
Drug interactions
Benzoyl peroxide is often used in combination with other topical drugs, including topical antibiotics and retinoids [Zaenglein, 2016]. The following recommendations about combining topical preparations are pragmatic, based on what CKS considers to be good clinical practice:
- The combination of topical treatments can be achieved by alternating separate products, or using proprietary combination products. The choice should be made according to individual preference and cost, bearing in mind that combined proprietary drugs:
- Do not allow for individual titration of component drugs.
- Are usually formulated with an alcoholic base, which may irritate sensitive skin.
- May be more expensive than the individual generic component (which can be applied simultaneously with equivalent effects).
- Benzoyl peroxide is frequently combined with a topical antibiotic.
- If two separate products are used, they should be applied 12 hours apart. Typically, benzoyl peroxide is applied at night and the topical antibiotic in the morning. Avoid using two products that both have an alcoholic base as this may increase skin irritation.
- A combined proprietary product is available.
- Benzoyl peroxide combined with a topical retinoid is a useful choice, especially in the maintenance of acne.
- Apply the products once daily, 12 hours apart (for example the topical retinoid at night and benzoyl peroxide in the morning).
- Both these drugs can irritate the skin; consider using lower strengths or switching if this is a problem.
- A combined proprietary product is available.
Topical retinoids
Dose
- Adapalene and tretinoin is currently only available as a combination product containing clindamycin licenced for the treatment of acne in children over the age of 12 and adults in the UK.
- Topical adapalene and tretinoin/clindamycin products are applied thinly, once daily, in the evening or before sleeping — for information on specific products see the British National Formulary (BNF) and the Summary of Product Characteristics.
- If peeling due to the use of other irritant acne treatments is present, allow to subside before starting a topical retinoid — discontinue use if severe irritation occurs.
- Topical retinoids should be used sparingly to cover the whole affected area and not just on visible spots — if the person has sensitive skin, initiate therapy at a lower frequency (for example three times per week) and increase to daily use as tolerated.
- Concomitant use of a noncomedogenic moisturizer and sunscreen may also help tolerability.
Contraindications and cautions
- Do not prescribe to people with hypersensitivity to the active substance or to any of the excipients.
- Avoid use during pregnancy — women of child-bearing age must use effective contraception.
- Use with caution during breastfeeding — the amount of drug reaching the breast milk after topical application is likely too small to be harmful to the infant.
- Avoid in people with severe acne, perioral dermatitis, rosacea or a personal or family history of non-melanoma skin cancer.
- Avoid accumulation in angles of the nose and contact with eyes, nostrils, mouth and mucous membranes, eczematous, broken or sunburned skin.
- Avoid exposure to excess UV light (including sunlight and solariums) — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used.
- Avoid use of topical retinoids with keratolytic agents, abrasive cleaners, and comedogenic or astringent cosmetics.
[Eichenfield, 2013; Zaenglein, 2016] [ABPI, 2019; ABPI, 2022a; Han, 2021; BNF, 2023]
Adverse effects
- Skin irritation including discomfort, blistering of skin, burning, crusting, dryness, peeling, erythema, oedema, pruritus, stinging, contact dermatitis and temporary changes of skin pigmentation.
- To reduce the risk of skin irritation, consider starting treatment with alternate-day or short-contact application (e.g. washing off after an hour) and progress to standard application if this reduced level of treatment is tolerated.
- Eye irritation.
- Increased sensitivity to UV light — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used.
[Eichenfield, 2013; Zaenglein, 2016] [ABPI, 2019; ABPI, 2022a; Han, 2021; BNF, 2023]
Drug interactions
Topical retinoids are often used in combination with other topical drugs, including benzoyl peroxide and topical antibiotics [Zaenglein, 2016]. The following recommendations about combining topical preparations are pragmatic, based on what CKS considers to be good clinical practice:
The following recommendations are pragmatic, based on what CKS considers to be good clinical practice:
- The combination of topical treatments can be achieved by alternating separate products or by using proprietary combination products. The choice should be made according to individual preference and cost, bearing in mind that combined proprietary drugs:
- Do not allow for individual titration of component drugs.
- Are usually formulated with an alcoholic base, which may irritate sensitive skin.
- May be more expensive than the individual generic component (which can be applied simultaneously with equivalent effects).
- A topical retinoid combined with a benzoyl peroxide is a useful choice, especially in the maintenance of acne.
- Apply the products once daily, 12 hours apart (for example the topical retinoid at night and benzoyl peroxide in the morning).
- Both these drugs can irritate the skin; consider using lower strengths or switching if this is a problem.
- A combined proprietary product is available.
- A topical retinoid combined with a topical antibiotic is another option.
- If two products are used separately, they should be applied 12 hours apart (for example topical retinoid at night and topical antibiotic in the morning).
- Combined proprietary products are available.
- Other retinoids or drugs with a similar mode of action should not be used concurrently.
- Avoid use of topical retinoids with abrasive cleaners, comedogenic or astringent cosmetics.
[Eichenfield, 2013; Zaenglein, 2016] [ABPI, 2019; ABPI, 2022a; Han, 2021; BNF, 2023]
Topical antibiotics
Dose
- Topical antibiotics licenced in the UK for treatment of acne vulgaris include clindamycin and erythromycin.
- Application is usually once or twice a day and varies between agents — for information on specific products see the British National Formulary (BNF) and the Summary of Product Characteristics (SPC).
- Topical monotherapy with antibiotics is not recommended because of the risk of antibiotic resistance. Topical antibiotics should be prescribed in combination with benzoyl peroxide.
[ABPI, 2020; ABPI, 2021a; ABPI, 2022b; ABPI, 2022c; PCDS, 2022; ABPI, 2023b]
Contraindications and cautions
- Do not prescribe to people with hypersensitivity to the active ingredient, any lincamycin or macrolide antibiotics, or any of the product excipients.
- Prescribe with caution to
- People with a history of inflammatory bowel disease or a history of antibiotic-associated colitis.
- If diarrhoea occurs, the product should be discontinued immediately.
- People with atopy.
- People with a history of inflammatory bowel disease or a history of antibiotic-associated colitis.
- Use during pregnancy is only advised if clearly needed.
[Eichenfield, 2013; Asai, 2016; Gollnick, 2016; Nast, 2016; Zaenglein, 2016; ABPI, 2020; ABPI, 2021a; ABPI, 2022b; ABPI, 2022c; PCDS, 2022; ABPI, 2023b]
Adverse effects
- Skin irritation, dryness, urticaria, folliculitis, erythema and rarely sensitisation. The manufacturer's SPC notes that some people using clindamycin solution have suffered adverse drug reactions, including: hypersensitivity and severe skin reactions; anaphylactic shock/reaction; hypotension; oesophageal ulcers; oesophagitis; and abnormal liver function tests.
- Gastro-intestinal disturbances, colitis.
- A very low incidence of pseudomembranous colitis has been reported in people using topical clindamycin. Be alert to the development of antibiotic-associated diarrhoea or colitis and stop treatment immediately if diarrhoea occurs.
[Eichenfield, 2013; Asai, 2016; Gollnick, 2016; Nast, 2016; Zaenglein, 2016; ABPI, 2020; ABPI, 2021a; ABPI, 2022b; ABPI, 2022c; PCDS, 2022; ABPI, 2023b]
Drug interactions
- Systemic absorption can follow topical application — consider the possibility of interaction.
- For information on specific products see the British National Formulary and the Summary of Product Characteristics.
- Systemic clindamycin has neuromuscular blocking properties that may enhance the action of other neuromuscular blocking medications. Caution is advised where concomitant neuromuscular blocking medications are being used.
- The manufacturer's SPC for a parenteral clindamycin solution notes that some people prescribed this medication have suffered drug interaction problems with CYP450 3A4 inducers, including rifampicin, leading to a loss of effectiveness of the rifampicin.
- Some topical antibacterial preparations for acne containing alcohol may not be suitable for use with benzoyl peroxide.
[Eichenfield, 2013; Asai, 2016; Gollnick, 2016; Nast, 2016; Zaenglein, 2016; ABPI, 2020; ABPI, 2021a; ABPI, 2022b; ABPI, 2022c; PCDS, 2022; ABPI, 2023b]
Azelaic acid
Dose
- For children 12–17 years — apply twice daily. In people with sensitive skin, apply once daily (in the evening) for 1 week, then apply twice daily.
- For adults — apply twice daily. In people with sensitive skin, apply once daily for 1 week, then apply twice daily.
- In people with sensitive skin, apply once daily (in the evening) for 1 week, then apply twice daily.
- If skin irritation occurs reduce the amount used or frequency of application to once a day until the irritation ceases — temporarily interrupt treatment for a few days if required
How should I prescribe azelaic acid?
- Do not prescribe to people with hypersensitivity to the active substance or to any of the excipients.
- Avoid contact with eyes; avoid contact with mouth; avoid contact with mucous membranes.
- Caution is advised if considering prescribing to pregnant or breastfeeding women.
Adverse effects
- Skin irritation including dryness, discomfort, erythema, peeling, contact dermatitis, pruritus, and skin discoloration.
- Worsening of asthma (rare).
Drug interactions
- The manufacturer reports that formal interaction studies have not been performed, but also that drug interactions were not noted during any of the controlled clinical trials.
Oral antibiotics
Dose
- If acne fails to respond adequately to topical preparations alone an oral antibiotic such as lymecycline or doxycycline can be added.
- Minocycline is not recommended for use in acne as it is associated with an increased risk of adverse effects such as drug-induced lupus, skin pigmentation and hepatitis.
- Macrolide antibiotics (such as erythromycin) should generally be avoided due to high levels of C. acnes resistance but can be used if tetracyclines are contraindicated (for example in pregnancy).
- A topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing.
- Do not use topical and oral antibiotics together.
- For complete prescribing information on specific drugs see the British National Formulary (BNF) and the Summary of Products Characteristics.
[Eichenfield, 2013; Asai, 2016; Nast, 2016; Zaenglein, 2016; PrescQIPP, 2020; PCDS, 2022; BMJ Best Practice, 2023; BNF, 2023; NICE, 2023]
Contraindications and cautions
- Do not prescribe to people with hypersensitivity to the active ingredient or any of the excipients.
- Most tetracyclines are contraindicated in pregnant or breastfeeding women and children under the age of 12 years. Lymecycline is contraindicated in children 8 years and younger. In children aged 8 to 11 years, doxycycline use should be reserved for acute or severe infections.
- Avoid use of tetracyclines in myasthenia gravis (muscle weakness may be increased), systemic lupus erythematosus (may be exacerbated), hepatic and renal impairment.
- For erythromycin — avoid in acute porphyria, caution is advised in renal impairment. Electrolyte disturbances which can predispose individuals to QT interval prolongation. May aggravate myasthenia gravis.
[Eichenfield, 2013; Asai, 2016; Nast, 2016; Zaenglein, 2016; PrescQIPP, 2020; PCDS, 2022; BMJ Best Practice, 2023; BNF, 2023; NICE, 2023]
Adverse effects
- For all tetracyclines — anorexia, anaphylaxis; angioedema; blood disorders; exfoliative dermatitis; hepatotoxicity and liver failure; hypersensitivity reactions; pancreatitis; pericarditis; photosensitivity; rash; Stevens-Johnson syndrome; urticaria, antibiotic-associated colitis; benign intracranial hypertension; diarrhoea; dysphagia; headache; nausea; Henoch-Schönlein purpura, oesophageal irritation; visual disturbances; vomiting; permanent discoloration during tooth development.
- For erythromycin — appetite decreased, abdominal discomfort; diarrhoea; nausea; vomiting, headache, cholestatic jaundice; hepatotoxicity; rash, antibiotic-associated colitis; arrhythmias; pancreatitis; QT interval prolongation; Stevens-Johnson syndrome; toxic epidermal necrolysis, reversible hearing loss (sometimes with tinnitus).
[Eichenfield, 2013; Asai, 2016; Nast, 2016; Zaenglein, 2016; PrescQIPP, 2020; PCDS, 2022; BMJ Best Practice, 2023; BNF, 2023; NICE, 2023]
Drug interactions
- For full details of individual drugs, see the British National Formulary and the Summary of Products Characteristics.
Combined oral contraceptives
Which combined oral contraceptive should I prescribe?
For prescribing information on combined oral contraceptives, see the CKS topic on Contraception - combined hormonal methods, the British National Formulary and the Summary of Product Characteristics.
Supporting evidence
This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Acne vulgaris: management [NICE, 2023], clinical guidelines Evidence-based recommendations for the diagnosis and treatment of pediatric acne [Eichenfield, 2013], Management of acne: Canadian clinical practice guideline [Asai, 2016], A consensus-based practical and daily guide for the treatment of acne patients [Gollnick, 2016], European evidence-based (S3) guideline for the treatment of acne – update 2016 [Nast, 2016], Guidelines of care for the management of acne vulgaris [Zaenglein, 2016], and Acne: acne vulgaris [PCDS, 2022], Cochrane systematic reviews [Costa, 2018; Liu, 2020; Fraison, 2020; Yang, 2020], and expert opinion in review articles [Xu, 2019; Heng, 2020; Baldwin, 2021; Leung, 2021; BMJ Best Practice, 2023].The rationale for the primary care assessment and management of acne vulgaris is discussed in the relevant basis for recommendation sections.
How this topic was developed
This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of acne vulgaris.
Search dates
March 2018 - March 2023
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.
- (MH "Acne Vulgaris+")
- AB acne* OR TI acne*
- AB ( blackhead* or whitehead* or comedone* ) OR TI ( blackhead* or whitehead* or comedone* )
Sources of guidelines
- National Institute for Health and Care Excellence (NICE)
- Scottish Intercollegiate Guidelines Network (SIGN)
- Royal College of Physicians
- Royal College of General Practitioners
- Royal College of Nursing
- NICE Evidence
- World Health Organization
- Guidelines International Network
- TRIP database
- Agency for Healthcare Research and Quality
- National Health and Medical Research Council (Australia)
- Royal Australian College of General Practitioners
- British Columbia Medical Association
- Canadian Medical Association
- Alberta Medical Association
- Michigan Quality Improvement Consortium
- Singapore Ministry of Health
- National Resource for Infection Control
- RefHELP NHS Lothian Referral Guidelines
- Medline (with guideline filter)
- Driver and Vehicle Licensing Agency
- NHS Health at Work (occupational health practice)
Sources of systematic reviews and meta-analyses
- The Cochrane Library:
- Systematic reviews
- Protocols
- Database of Abstracts of Reviews of Effects
- Medline (with systematic review filter)
- EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
- NIHR Health Technology Assessment programme
- The Cochrane Library:
- NHS Economic Evaluations
- Health Technology Assessments
- Canadian Agency for Drugs and Technologies in Health
- International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
- The Cochrane Library:
- Central Register of Controlled Trials
- Medline (with randomized controlled trial filter)
- EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Sources of national policy
- Department of Health
- Health Management Information Consortium (HMIC)
Patient experiences
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
- British National Formulary (BNF)
- electronic Medicines Compendium (eMC)
- European Medicines Agency (EMEA)
- Medicines and Healthcare products Regulatory Agency (MHRA)
- UK Teratology Information Service (UKTIS)
- REPROTOX
- Scottish Medicines Consortium
- Stockley's Drug Interactions
- TERIS
- TOXBASE
- Micromedex
- UK Medicines Information
Stakeholder engagement
Our policy
The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:
- Clinical accuracy.
- Consistency with other providers of clinical knowledge for primary care.
- Accuracy of implementation of national guidance (in particular NICE guidelines).
- Usability.
Principles of the consultation process
- The process is inclusive and any individual may participate.
- To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
- Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
- Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
- External reviewers are not paid for commenting on the draft topics.
- Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
- All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
- All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.
Stakeholders
- Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
- Stakeholders identified from the following groups are invited to review draft topics:
- Experts in the topic area.
- Professional organizations and societies (for example, Royal Colleges).
- Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
- Guideline development groups where the topic is an implementation of a guideline.
- The British National Formulary team.
- The editorial team that develop MeReC Publications.
- Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.
Patient engagement
Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:
- Topic selection
- Scoping of topic
- Selection of clinical scenarios
- First draft internal review
- Second draft internal review
- External review
- Final draft and pre-publication
Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.
Evidence exclusion criteria
Our policy
Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.
Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.
Standard exclusions for scoping literature:
- Animal studies
- Original research is not written in English
Possible exclusions for reviewed literature:
- Sample size too small or study underpowered
- Bias evident or promotional literature
- Population not relevant
- Intervention/treatment not relevant
- Outcomes not relevant
- Outcomes have no clear evidence of clinical effectiveness
- Setting not relevant
- Not relevant to UK
- Incorrect study type
- Review article
- Duplicate reference
Organizational, behavioural and financial barriers
Our policy
The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.
- Feasibility
- Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
- Organizational and Financial Impact Analysis
- Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
- Eligible population
- Current interventions
- Likely uptake of new intervention or recommendation
- Cost of the current or new intervention mix
- Impact on other costs
- Condition-related costs
- In-direct costs and service impacts
- Time dependencies
- Cost-effectiveness or cost-benefit analysis studies are identified where available.
We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.
Declarations of interest
Our policy
Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:
- Personal financial interests
- Personal family interest
- Personal non-financial interest
- Non-personal financial gain or benefit
Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.
Who should declare competing interests?
Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.
Competing interests declared for this topic:
None.
References
- ABPI (2019) SPC for Treclin 1 %/0.025 % w/w Gel. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2020) SPC for Duac once daily 10mg/g + 50mg/g gel. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2021a) SPC for Dalacin T topical lotion or clindamycin phosphate topical lotion. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2021b) SPC for Finacea 15% gel. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2021c) SPC for Skinoren 20% cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2022a) SPC for Differin Gel. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2022b) SPC for Dalacin C phosphate sterile solution. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2022c) SPC for Duac once daily 10 mg/g + 30 mg/g gel. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2023a) SPC for Acnecide 5% w/w Gel. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- ABPI (2023b) SPC for Zineryt 40 mg + 12 mg powder and solvent for cutaneous solution. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
- Archer, C., Cohen, S. and Baron, S. (2012) Guidance on the diagnosis and clinical management of acne. Clinical and Experimental Dermatology 37(Suppl 1), 1-6. [Abstract]
- Arowojolu, A.O., Gallo M.F., Lopez, L.M. and Grimes, D.A. (2012) Combined oral contraceptive pills for treatment of acne (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
- Asadi-Pooya, A.A., Rostaminejad, M., Zeraatpisheh, Z. and Mirzaei Damabi, N. (2021) Cosmetic adverse effects of antiseizure medications; A systematic review. Seizure 91, 9-21. [Abstract] [Free Full-text]
- Asai, Y., Baibergenova, A., Dutil, M., et al. (2016) Management of acne: Canadian clinical practice guideline. Canadian Medical Association Journal 188(2), 118-126. [Abstract] [Free Full-text]
- Bagatin, E., Freitas, T.H.P., Rivitti-Machado, M.C., et al. (2019) Adult female acne: a guide to clinical practice. Anais Brasileiros de Dermatologia 94(1), 62-75. [Abstract] [Free Full-text]
- Baldwin, H. and Tan, J. (2021) Effects of Diet on Acne and Its Response to Treatment. American Journal of Clinical Dermatology 22(1), 55-65. [Abstract] [Free Full-text]
- Bettoli, V., Zauli, S. and Virgili, A. (2015) Is hormonal treatment still an option in acne today? British Journal of Dermatology 172(Suppl 1), 37-46. [Abstract]
- Bienenfeld, A., Nagler, A.R. and Orlow, S.J. (2017) Oral antibacterial therapy for acne vulgaris: an evidence-based review. American Journal of Clinical Dermatology 18(4), 469-490. [Abstract]
- BMJ Best Practice (2023) Acne vulgaris. BMJ Publishing Group. https://bestpractice.bmj.com
- BNF (2023) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
- Chiang, C., Ward, M. and Gooderham, M. (2022) Dermatology: how to manage acne in skin of colour. Drugs Context 11(2021-10-9). [Abstract] [Free Full-text]
- CoSRH (2013) Strengthening of warnings about use of Dianette and other brands of co-cyprindiol. College of Sexual and Reproductive Healthcare. http://www.cosrh.org [Free Full-text]
- CoSRH (2019) UK medical eligibility criteria for contraceptive use. College of Sexual and Reproductive Healthcare. https://www.cosrh.org [Free Full-text]
- Costa, C.S., Bagatin, E., Martimbianco, A.L.C., et al. (2018) Cochrane Review: Oral isotretinoin for acne. Issue 11. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
- Dawson, A.L. and Dellavalle, R.P. (2013) Acne vulgaris. BMJ 346, f2634. [Abstract]
- DermNet NZ (2022) Periorificial dermatitis. DermNet NZ. https://dermnetnz.org [Free Full-text]
- DermNet NZ (2022) Keratosis pilaris. DermNet NZ. https://dermnetnz.org [Free Full-text]
- Dressler, C., Rosumeck, S. and Nast, A. (2016) How much do we know about maintaining treatment response after successful acne therapy? Systematic review on the efficacy and safety of acne maintenance therapy. Dermatology 232(3), 371-380. [Abstract] [Free Full-text]
- Eichenfield, L.F., Krakowski, A.C., Piggott, C., et al. (2013) Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics 131(Suppl 3), S163-S186. [Abstract] [Free Full-text]
- EMC (2026) SPC for Roaccutane (isotretinoin) 10 and 20 mg soft capsules. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk [Free Full-text]
- Fraison, E., Kostova, E., Moran, L.J., et al. (2020) Cochrane Review: Metformin versus the combined oral contraceptive pill for hirsutism, acne, and menstrual pattern in polycystic ovary syndrome. Issue 8. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
- Gollnick, H.P., Bettoli, V., Lambert, J., et al. (2016) A consensus-based practical and daily guide for the treatment of acne patients. Journal of the European Academy of Dermatology and Venereology 30(9), 1480-1490. [Abstract]
- Han, J.J., Faletsky, A., Barbieri, J.S. and Mostaghimi, A. (2021) New Acne Therapies and Updates on Use of Spironolactone and Isotretinoin: A Narrative Review. Dermatology and Therapy 11(1), 79-91. [Abstract] [Free Full-text]
- Heng, A.H.S. and Chew, F.T. (2020) Systematic review of the epidemiology of acne vulgaris. Scientific Reports 10(1), 5754. [Abstract] [Free Full-text]
- Koo, E.B., Petersen, T.D. and Kimball, A.B. (2014) Meta-analysis comparing efficacy of antibiotics versus oral contraceptives in acne vulgaris. Journal of the American Academy of Dermatology 71(3), 450-459. [Abstract]
- Leung, A.K., Barankin, B., Lam, J.M., et al. (2021) Dermatology: how to manage acne vulgaris. Drugs Context 10(2021-8-6). [Abstract] [Free Full-text]
- Liu, H., Yu, H., Xia, J., et al. (2020) Cochrane Review: Topical azelaic acid, salicylic acid, nicotinamide, sulphur, zinc and fruit acid (alpha-hydroxy acid) for acne. Issue 5. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
- Meixiong, J., Ricco, C., Vasavda, C. and Ho, B.K. (2022) Diet and acne: A systematic review. JAAD International 7, 95-112. [Abstract] [Free Full-text]
- MHRA (2013) Cyproterone acetate with ethinylestradiol (co-cyprindiol): balance of benefits and risks remains positive. Medicines and Healthcare products Regulatory Agency. http://www.gov.uk [Free Full-text]
- Nast, A., Dréno, B., Bettoli, V., et al. (2016) European evidence-based (S3) guideline for the treatment of acne – update. Journal of the European Academy of Dermatology and Venereology 30(8), 1261-1268. [Abstract]
- NICE (2023) Acne vulgaris: management. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
- PCDS (2022) Acne: acne vulgaris. Primary Care Dermatology Society. https://www.pcds.org.uk [Free Full-text]
- PrescQIPP (2020) Minocycline prescribing. PrescQIPP. https://www.prescqipp.info [Free Full-text]
- Ragmanauskaite, L., Kahn, B., Ly, B. and Yeung, H. (2020) Acne and the Lesbian, Gay, Bisexual, or Transgender Teenager. Dermatologic Clinics 38(2), 219-226. [Abstract] [Free Full-text]
- Wang, Y., Zhu, M., Wu, S. and Zheng, H. (2022) Acne Comorbidities. Clinical, Cosmetic and Investigational Dermatology 15(2), 2415-2420. [Abstract] [Free Full-text]
- Williams, H.C., Dellavalle, R.P. and Garner, S. (2012) Acne vulgaris. Lancet 379(9813), 361-372. [Abstract]
- Xu, H. and Li, H. (2019) Acne, the Skin Microbiome, and Antibiotic Treatment. American Journal of Clinical Dermatology 20(3), 335-344. [Abstract] [Free Full-text]
- Yang, Z., Zhang, Y., Lazic Mosler, E., et al. (2020) Cochrane Review: Topical benzoyl peroxide for acne. Issue 3. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
- Zaenglein, A.L., Pathy, A.L., Schlosser, B.J., et al. (2016) Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology 74(5), 945-947. [Abstract] [Free Full-text]
- Zouboulis, C.C. and Bettoli, V. (2015) Management of severe acne. British Journal of Dermatology 172(Suppl 1), 27-36. [Abstract]