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Mild to moderate acne in people aged 12 and over: from over-the-counter products to prescribed topical treatment, a summary of the Pharmacy First pathway with referral criteria and self-care advice.
Consider rosacea, perioral dermatitis, folliculitis or keratosis pilaris1
Referral
Urgent (GP or A&E depending on circumstances)
●
Suspected acne fulminans (sudden, severe, ulcerated or crusted acne with fever, malaise or joint pain): same-day referral to general practice for urgent dermatology assessment; A&E if systemically unwell1,2
●
Current suicidal thoughts or self-harm: urgent mental health support first (NHS 111 mental health option, or A&E or 999 if immediate risk; under 18, also follow local safeguarding procedures). Acne treatment can continue once immediate safety is addressed1,2
General practice
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35 or more inflammatory lesions, or 3 or more nodules1,2
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Nodulo-cystic acne, or acne conglobata (urgent appointment)1,2
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Suspected rosacea or perioral dermatitis; acne less likely: general practice or other provider as appropriate1,2
●
Unable to apply topical treatment effectively, or oral treatment required1,2
Advise the person to try OTC treatment first (if they haven't already), such as benzoyl peroxide, plus self-care1
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Offer a prescription if OTC treatment has been tried for 6–8 weeks without adequate improvement, or is unsuitable or not tolerated1
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Treat only if there has been no prescribed course from this pathway or another service in the past 12 months, and no prescribed topical treatment used for 6–8 weeks without adequate improvement, or worsening1,2
●
Offer a 12-week course of topical treatment only, plus self-care1
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If the shelf life is under 12 weeks, a second prescription at a separate consultation completes the course1
●
Topical retinoids: do not prescribe in pregnancy or when planning a pregnancy (discuss contraception). If breastfeeding, check NICE NG198 for information on specific products. Record pregnancy status, the contraception discussion and the advice given1,2
NICE CKS first-line options, applied once daily in the evening for 12 weeks
●
Adapalene with benzoyl peroxide (adapalene 0.1% or 0.3% with benzoyl peroxide 2.5%)3
Topical retinoids: avoid in severe acne, perioral dermatitis, rosacea, or a personal or family history of non-melanoma skin cancer; avoid eyes, nostrils, mouth and broken skin3
●
Benzoyl peroxide: avoid eyes, mouth and broken skin; may bleach fabrics and hair3
●
Topical clindamycin: caution with a history of inflammatory bowel disease or antibiotic-associated colitis; stop if diarrhoea occurs3
●
All: increased sunburn risk, so use sunscreen or protective clothing3
Self-care and advice
Self-care
●
Apply thinly to the whole area prone to spots, not just individual spots, avoiding the eyes and lips1,3
●
Benzoyl peroxide and retinoids can irritate: start on alternate days or wash off after an hour, then increase as tolerated1,3
●
Do not apply other skin products at the same time of day1
●
Use non-alkaline cleanser twice daily; avoid over-cleaning, and avoid oil-based and comedogenic products1,3
●
Avoid picking spots, which increases the risk of scarring1,3
●
Provide patient information: British Association of Dermatologists acne leaflet1,4
Safety-netting advice for patient
●
Improvement can take 6–8 weeks: complete the 12-week course1,3
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