Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Acne vulgaris - Management
View full scenario no prescriptions

What information should I give about acne?

  • Reassure the person about the natural course of the condition, but do not trivialize it. Advise that:
    • Acne is one of the most common disorders, affecting nearly everyone at some point in their life.
    • Acne will improve. It is primarily a skin disorder of the young, and will usually clear up in later life without leaving significant scarring.
    • Treatments are effective but take time to work (typically up to 8 weeks) and may irritate the skin, especially at the start of treatment.
  • Dispel popular myths about acne. In particular inform the person that:
    • Acne is not caused by poor hygiene, and there is no evidence it is improved by cleaning. In fact, excessive washing can aggravate acne.
    • Diet has little or no effect on acne. For example, there is no evidence that chocolate or fatty foods cause or aggravate acne. However if the person notices that a particular food triggers flares of acne then it is reasonable to avoid it.
    • Picking at acne does not improve it, and may cause scarring. Occasionally it may be beneficial to drain large purulent lesions, but this should be done under medical supervision.
    • Stress probably does not cause acne, although there is a correlation between stress and acne, and unsightly lesions may cause increased levels of stress.
    • Acne is not infectious and cannot be passed on to other people. The main bacterium involved in the inflammation, Propionibacteria acnes, is naturally present on skin but, in acne, it colonizes follicles.
    • Sunlight probably has little benefit in acne, and there is no evidence to support active sunbathing or exposure to other sources of ultraviolet light. Excessive sun exposure should be avoided by all people, especially when taking drugs such as topical or oral retinoids, or oral tetracyclines.
Basis for recommendation

Providing reassurance

  • The prognosis of acne is good for most people, with less than 12% of women and 3% men being affected after 25 years of age. However, the condition should not be trivialized, as it may last for several years and have a negative psychological impact in some people. A balanced understanding of the disease course and its impact on everyday life is required [Acne Working Group, 2008].

Myths about acne

  • Experts believe that dispelling 'myths' is an integral component of the management of acne [ICSI, 2006].
  • Evidence on the myths about acne is based mainly on poor-quality data from uncontrolled trials and observational studies, and expert opinion.
  • There is insufficient evidence from observational studies or controlled trials to indicate that changes in diet, use of hygiene measures, or exposure to sunlight is beneficial in the management of acne.
  • There is a consensus of expert opinion that stress does not cause acne, although it is widely believed it can exacerbate the psychological reaction to acne [ICSI, 2006].

What self-care advice should I give to a person with acne?

  • Advise about washing and skin care. In general, it is recommended that people with acne:
    • Do not wash more than twice a day.
    • Use a mild soap or cleanser and lukewarm water (as very hot or cold water may worsen acne).
    • Do not use vigorous scrubbing when washing acne-affected skin, and the use of abrasive soaps, cleansing granules, astringents, or exfoliating agents should be discouraged (advise use of a soft wash-cloth and fingers instead).
    • Should not attempt to 'clean' blackheads. Scrubbing or picking acne is liable to worsen the condition.
    • Ideally, should avoid excessive use of makeup and cosmetics. If they must be used, advise that a non-comedogenic, water-based product should be used sparingly (advise that details of cosmetic ingredients are displayed on the product label), and that all makeup should be removed completely at night.
    • Use a fragrance-free, water-based emollient if dry skin is a problem (several topical acne drugs dry the skin). The use of ointments or oil-rich creams should be avoided as these can clog pores.
  • Advise about non-prescription treatments.
    • Benzoyl peroxide is a useful topical drug available over-the-counter. However, there is a lack of evidence of benefit for other over-the-counter drugs.
    • Complementary and alternative medicines (for example herbal medicines) are not usually harmful but there is a general lack of evidence to support their use.
Basis for recommendation

Advice on hygiene measures

Over-the-counter (OTC) treatments

  • Most OTC products are not recommended because there is a lack of evidence from clinical trials to support their efficacy [Sharpe, 1995; Brown and Shalita, 1998; Ravenscroft, 2005; Strauss et al, 2007].
    • Salicylic acid is a common ingredient in OTC acne treatments. It is a keratolytic drug that has some anti-comedone activity, but there is a lack of evidence from controlled trials to confirm this, and it is considered less effective than the topical retinoids.
    • Abrasives (such as aluminium oxide) and sulphur (available combined with resorcinol, as Eskamel®) have been used historically, but lack evidence from controlled trials. Some products containing aluminium oxide are abrasive and can irritate inflamed skin.
    • Nicotinamide (available as Nicam®) has been reported as being as effective as topical clindamycin in open-label cohort studies [Dos et al, 2003; Sardesai and Kambli, 2003], but CKS identified no randomized controlled trials to confirm this.
    • However, there is substantial placebo-controlled trial evidence to support the use of benzoyl peroxide in the treatment of acne.

Complementary and alternative medicine (CAM)

  • There is little evidence to support the use of CAM in the treatment of acne.
    • A review of CAM treatments for acne found an overall lack of good quality evidence of beneficial effect; studies were limited in number and most were methodologically poor or underpowered [Magin et al, 2006].
    • One systematic review (search date: October 2002) found two trials that investigated the efficacy of herbal remedies in acne [Martin and Ernst, 2003]. Both studies were small and of poor methodological quality.
      • One trial compared tea tree oil with benzoyl peroxide. There was no placebo group and the study lacked the statistical power to show equivalence or superiority of the regimens.
      • In the other trial, the herb Ocimum gratissimum (dissolved in alcohol and added to oil) was compared with benzoyl peroxide and placebo. However, as various concentrations were investigated, the groups were too small to allow any firm conclusions.

How should I treat mild acne?

  • In mild acne, open and closed comedones (blackheads and whiteheads) predominate. Although the physical severity of the condition is limited and scarring is unlikely, the psychosocial impact may be disproportionate in some people, which is an indication for more aggressive treatment.
  • Prescribe a single topical treatment.
    • Prescribe a topical retinoid (tretinoin, isotretinoin, or adapalene) or benzoyl peroxide (especially if papules and pustules are present) as first-line treatment.
    • Prescribe a topical antibiotic or azelaic acid if both topical retinoids and benzoyl peroxide are poorly tolerated.
    • Combined treatment is rarely necessary for mild acne.
  • Consider prescribing a standard combined oral contraceptive in women who require contraception, particularly if the acne is having a negative psychosocial impact.
Basis for recommendation

Recommendations for treatment are based on international guidelines [ICSI, 2006; Strauss et al, 2007] and narrative reviews [Webster, 2002; James, 2005; Ravenscroft, 2005; Zaenglein and Thiboutot, 2006; Acne Working Group, 2008], and reflect published data from randomized controlled trials (RCTs) where available, and otherwise, expert opinion.

Topical retinoids

  • Topical retinoids normalize follicular keratinization, promote drainage of comedones, and inhibit new comedone formation. They have been used historically mainly to treat comedones, but they are also effective at treating inflammatory lesions (if used in the longer term) by inhibiting microcomedone formation [Thiboutot, 2000; Wolf, 2002]. This is supported by good evidence from placebo-controlled trials [Purdy and DeBerker, 2008].

Topical benzoyl peroxide

  • Benzoyl peroxide is a potent bactericide and significantly reduces the population of Propionibacterium acnes in the sebaceous follicle [Thiboutot, 2000]. There is good evidence from placebo-controlled trials that benzoyl peroxide reduces both inflammatory and non-inflammatory lesions [Purdy and DeBerker, 2008].

Topical antibiotics

  • Topical antibiotics reduce colonization of sebaceous follicles by P. acnes and may also have an anti-inflammatory effect. Most evidence from placebo-controlled trials has addressed the effectiveness of topical antibiotics at reducing inflammatory acne lesions, and most experts believe they are of limited use for the treatment of mild acne [Dreno, 2004; ICSI, 2006].

Azelaic acid

  • Azelaic acid is a second-line option that should be considered for mild acne if other treatments are unsuitable [Acne Working Group, 2008]. There is a lack of trial evidence to support the use of azelaic acid in comparison with data available for other topical treatments, and the clinical effect of azelaic acid has been reported to be disappointing by some experts [Brown and Shalita, 1998; James, 2005].

Combined oral contraceptives (COCs)

  • COCs are recommended as a first-line adjunctive treatment for women who have acne [ICSI, 2006; Strauss et al, 2007]. There is good evidence from placebo-controlled trials that COCs are effective in reducing lesion count, acne severity, and the woman's perception of the condition [Arowojolu et al, 2007].

How should I follow up a person with acne?

  • Arrange follow up after about 6 weeks, and review the effectiveness and tolerability of treatment, as well as compliance with regimens.
  • Advise the person to return sooner if the acne deteriorates significantly despite treatment.
Basis for recommendation

Recommendations for following up people with acne are based on international [ICSI, 2006] and national [Acne Working Group, 2008] guidelines.

  • There is evidence from a randomized controlled trial involving both topical drugs and oral antibiotics that it may take about 6 weeks for an adequate response, although the maximal response may take up to 3 months [Ozolins et al, 2005].
  • Therefore, it is reasonable to assess response to treatment after a period of about 6 weeks, and continue treatment if the drug has had a positive effect. If it has not, it is reasonable to try other strategies (such as increasing treatment strength, switching treatments, or adding on treatments).

What should I do if mild acne fails to respond to treatment?

  • Check adherence to treatment.
  • If adherence is poor, this may be because the treatment is poorly tolerated. Consider:
    • Reducing the strength of treatment (for example, reducing from 5% to 2.5% benzoyl peroxide).
    • Switching to an alternative topical drug that causes less irritation (for example a topical antibiotic or azelaic acid).
    • Using a different formulation of drug (for example a cream instead of a drug with an alcoholic base).
  • If adherence is adequate, consider:
    • Increasing the drug strength and/or frequency of application.
    • Combining different topical products (if not already doing so). Benzoyl peroxide combined with erythromycin or clindamycin is particularly effective against both non-inflammatory and inflammatory acne.
Basis for recommendation

These are pragmatic recommendations that are in line with expert opinion from international [ICSI, 2006] and national [Acne Working Group, 2008] guidelines.

When should I refer a person with mild acne?

  • People who have severe psychosocial problems, including a morbid fear of deformity (body dysmorphic disorder), or people who have suicidal ideation, should be referred soonto psychiatry.
  • Refer for a routine appointment:
    • To endocrinology or gynaecology, those women suspected of having an underlying endocrinological cause of acne (such as polycystic ovary syndrome) that needs assessment.
    • To dermatology, people with features that make the diagnosis uncertain.
Basis for recommendation

Referral criteria for acne vulgaris are based on Referral advice: A guide to appropriate referral from general to specialist services, published by the National Institute for Health and Clinical Excellence (NICE). For people requiring referral 'immediately' or 'soon', NICE specify that 'Health authorities, trusts, and primary care organizations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category' [NICE, 2001].

Prescriptions

Benzoyl peroxide (gel)

Age from 12 years onwards
Benzoyl peroxide 2.5% aqueous gel
PanOxyl Aquagel 2.5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.76
OTC cost: £3.10
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% aqueous gel
PanOxyl Aquagel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.92
OTC cost: £3.38
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% aqueous gel
PanOxyl Aquagel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £2.07
OTC cost: £3.65
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% alcoholic gel
Panoxyl Acnegel 5
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.51
OTC cost: £2.66
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% alcoholic gel
Panoxyl Acnegel 10
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.69
OTC cost: £2.98
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.

Benzoyl peroxide (cream and wash)

Age from 12 years onwards
Benzoyl peroxide 4% cream
Benzoyl peroxide 4% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £3.30
OTC cost: £5.82
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 5% cream
Benzoyl peroxide 5% cream
Apply to the affected area(s) once or twice a day, after washing.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £1.89
OTC cost: £3.33
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.
Benzoyl peroxide 10% wash
Benzoyl peroxide 10% wash
Apply to the affected area once a day.
Supply 150 ml.
Age: from 12 years onwards
NHS cost: £4.00
OTC cost: £7.05
Licensed use: yes
Patient information: Wet the affected area with water and wash thoroughly with the Wash. Rinse well with warm water, then rinse with cold water, and pat dry with a clean towel. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.

Topical retinoids (tretinoin, isotretinoin, adapalene)

Age from 12 years onwards
Adapalene 0.1% cream
Adapalene 0.1% cream
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid excessive exposure to sunlight.
Adapalene 0.1% gel
Adapalene 0.1% gel
Apply thinly to the affected area(s) at night.
Supply 45 grams.
Age: from 12 years onwards
NHS cost: £11.40
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid excessive exposure to sunlight.
Isotretinoin 0.05% gel
Isotretinoin 0.05% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £6.18
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid excessive exposure to sunlight.
Tretinoin 0.025% gel
Tretinoin 0.025% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid excessive exposure to sunlight.
Tretinoin 0.01% gel
Tretinoin 0.01% gel
Apply thinly to the affected area(s) at night.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £5.61
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid excessive exposure to sunlight.

Topical antibiotics (clindamycin, erythromycin, erythromycin/zinc)

Age from 12 years onwards
Clindamycin 1% gel
Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £8.66
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Clindamycin 1% aqueous lotion
Clindamycin 1% aqueous lotion
Apply thinly to the affected area(s) twice a day.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.47
Licensed use: yes
Patient information: Avoid contact with the eyes, mouth and mucous membranes.
Erythromycin 2% alcoholic solution
Erythromycin 2% solution
Apply thinly to the affected area(s) twice a day, after washing.
Supply 50 ml.
Age: from 12 years onwards
NHS cost: £8.00
Licensed use: yes
Erythromycin 4% gel
Erythromycin 4% gel
Apply thinly to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £4.97
Licensed use: yes
Erythromycin 4% + zinc acetate 1.2% solution
Erythromycin 40mg/ml / Zinc acetate 12mg/ml lotion
Apply to the affected area(s) twice a day.
Supply 30 ml.
Age: from 12 years onwards
NHS cost: £7.71
Licensed use: yes

Azelaic acid (gel and cream)

Age from 12 years onwards
Azelaic acid 20% cream
Azelaic acid 20% cream
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £3.74
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes.
Age from 18 years onwards
Azelaic acid 15% gel (facial acne)
Azelaic acid 15% gel
Apply to the affected area(s) twice a day, after washing.
Supply 30 grams.
Age: from 18 years onwards
NHS cost: £7.48
Licensed use: yes
Patient information: Wash the affected area(s) with water and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes.

Combination products (BPO/antibiotic, topical retinoid/antibiotic)

Age from 12 years onwards
Benzoyl peroxide 5% + clindamycin 1% gel
Benzoyl peroxide 5% / Clindamycin 1% gel
Apply thinly to the affected area(s) at night.
Supply 25 grams.
Age: from 12 years onwards
NHS cost: £9.95
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Wash hands after use. This product may bleach clothing, hair, towels and bed linen.
Tretinoin 0.025% + erythromycin 4% alcoholic solution
Erythromycin 4% / Tretinoin 0.025% solution
Apply thinly to the affected area(s) once or twice a day.
Supply 25 ml.
Age: from 12 years onwards
NHS cost: £7.05
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid excessive exposure to sunlight.
Isotretinoin 0.05% + erythromycin 2% gel
Erythromycin 2% / Isotretinoin 0.05% gel
Apply thinly to the affected area(s) once or twice a day.
Supply 30 grams.
Age: from 12 years onwards
NHS cost: £7.78
Licensed use: yes
Patient information: Wash the affected area(s) with water or a mild cleanser and pat dry before use. Avoid contact with the eyes, mouth and other mucous membranes. Avoid excessive exposure to sunlight.

Anti-androgen and oestrogen (co-cyprindiol)

Age from 14 to 50 years
Cyproterone acetate 2mg + ethinylestradiol 35micrograms
Co-cyprindiol 2000microgram/35microgram tablets
Take one tablet once a day for 21 days. Start the next packet after a 7-day break. See package insert for full instructions.
Supply 63 tablets.
Age: from 14 years to 50 years
NHS cost: £3.92
Licensed use: yes
Patient information: Take the pill at the same time each day. If you forget one or more pills or experience diarrhoea or vomiting and are unsure what to do, seek the advice of a health professional.

© NHS Institute for Innovation and Improvement