Acne Vulgaris - Leeds Pathway

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1. Background Information / Important Principles

Quick info:
Important Principles:

  • Mild to moderate acne should be managed in primary care
  • Several different agents may need to be tried alone or in combination.
  • Early treatment (or referral for treatment) is key to preventing acne scarring – DO NOT DELAY
  • Do not use combinations of agents with similar properties or actions e.g. topical plus systemic antibiotics.
  • Inform patients that response to topical and all treatment is slow and allow at least 12 weeks before review.
  • Start topical treatment gradually i.e. 1-2 hours initially building up tolerance to over night use. Always use a moisturiser with these products
  • Review compliance with treatment to ensure treatment is being followed as recommended (particularly with topical treatment)
  • It is not good practice to prescribe oral antibiotics with topical antibiotics
  • Ensure adequate contraception with oral tetracyclines
  • Once condition is stabilised consider withdrawing antibiotic treatment. Maintain with non-antibiotic topical treatment.
  • Maintain patients on antibiotics no longer than strictly necessary

Leeds Health Pathways - Acne Vulgaris

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2.  Information Resource for Patients and Carers

Quick info:
Patient Support Group:
The Acne Academy

Dermatology Department
Harrogate & District Foundation Trust
Lancaster Park Road
Harrogate
HG2 7SX

Tel: 01707 226023

Patient Information Leaflets:
British Association of Dermatologists Patient Information Leaflets:
Acne
Isotretinoin (Male)
Isotretinoin (Female)

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3. Development and Updates to this Pathway

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Developed March 2014

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4. Training and Further Resources

Quick info:
Additional Resources:
Derm Net NZ: The Dermatology Resource
British Association of Dermatologists
Primary Care Dermatology Society

Leeds Health Pathways - Acne Vulgaris

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6.  Mild

Quick info:
Mild
Clinical Features
Uninflamed lesions - open and closed comedones (blackheads).
Sometimes with papules/pustules.

Global Alliance to Improve Outcomes in Acne state that in addition to comedonal acne, topical retinoids alone or in combination should be used as first line therapy for inflammatory acne. Topical retinoids are also the preferred agent for maintenance therapy rather than long term maintenance with antibiotics which leads to bacterial resistance. The goal is to minimise the use of antibiotics.

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7.  Moderate

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Moderate
Clinical Features
Greater number or more extensive inflamed lesions.

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8. Moderate- Severe

Quick info:
Moderate- Severe
Clinical Features

Papules / pustules with deeper inflammation and some scarring.

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9. Severe

Quick info:
Severe
Clinical Features
Confluent or nodular lesions usually with significant scarring.

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10. Treatment

Quick info:
Treatment

Mild
Topical retinoid e.g. Differin and benzoyl peroxide (BPO) preparations e.g. Quinoderm cream (+/- topical antibiotics) e.g. Duac

Mild - moderate
(avoid retinoids in pregnancy)

1st line - Topical retinoid in comedonal acne patients (they should be applied to the entire acne prone area once a day in the evening as a thin film using finger tip amounts. One finger tip would be appropriate for facial coverage) or BPO in patients with comedone and inflamed lesions.

2nd line - topical antibiotic with either BPO or topical retinoid. Combinations reduce resistance development - max duration of use is recommended to be 12 weeks

3rd line - combination of topical BPO and retinoid (e.g. Epiduo) Please see Leeds Formulary for further prescribing guidance

Starting 5% and increasing to 10% may reduce the irritancy of BPO. Use lowest strength BPO to reduce irritancy. Counsel patients about bleaching effect.

Fixed dose combinations may be more effective in aiding compliance.

Offer skin care advice to patients regarding use of non comedogenic and hypoallergenic cleansing and moisturising agents as part of daily routine.

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11. Treatment

Quick info:
Treatment
Systemic antibiotics with non-antibiotic topical agents
Lymecycline should be considered 1st Line due to cost and compliance (once daily) Erythromycin used in pregnancy and children under 12
Treatment should be continued for 6 months
Failure of response after 12 weeks - consider change of antibiotics, a reasonable alternative would be doxycycline.

For further guidance see Leeds Health Pathways (LHP) Acne Vulgaris Treatment Guidance

(avoid retinoids in pregnancy)

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12. Treatment

Quick info:
Treatment
Systemic treatment with antibiotics as per 'Treatment' on 'Moderate' stem.
Consider additional hormone therapy in women i.e. Ethinyloestradiol/Cypoterone acetate (co-cyprindiol, Dianette), Ethinyloestradiol/Drospirenone (Yasmin)

Combined Hormonal Contraception (CHC) use may improve acne and thus can be considered in those who also require contraception. Overall, few differences have been found between CHC types in terms of their effectiveness for treating acne (1) so patient preferences and previous response to different CHC should be considered. Hormonal therapies can be slow to act but impact on seborrhoea and benefits are seen at 3- 6 months.

VTE risk with all CHC is highest during the first 3 months of therapy, and after a break in therapy of more than one month, therefore frequent stopping and starting is discouraged.

VTE risk and Co-cyprindiol (Dianette®).
Co-cyprindiol is indicated for patients with moderate acne and some patients respond to this more than a usual CHC. It should not be used for contraception alone. Due to a historic pill scare the VTE risk with co-cyprindiol is of concern to many prescribers, however, following further review of the literature, the risk with co-cyprindiol is considered to be similar to 3rd generation CHC – see table below. (1) The relative risk is 2-2.5 fold but the absolute risk is actually a very small increase from 1st generation CHC – approximately an extra 5 cases per 10,000 per year.

EMA Estimated risk of developing VTE in a year according to type of CHC used:

Type of CHC used

Risk of developing VTE in a year (incidence in 10,000 women)

Women not using combined hormonal pill/patch/ring and not pregnant

~2

Women using CHC containing levonorgestrel, norethisterone or norgestimate eg. Microgynon 30, Loestrin, Cilest

~5–7

Women using CHC containing etonogestrel or norelgestromin eg NuvaRing, Evra Patch

~6–12

Women using CHC containing drospirenone, gestodene or desogestrel* eg Yasmin, Millinette, Gedarel
*Evidence suggests that co-cyprindiol is associated with similar VTE risk to combined oral contraceptive containing drospirenone, gestodene or desogestrel

~9–12

It is important to note that VTE risk is lower during CHC use than during pregnancy and the postpartum period

References: 1. FSRH Clinical Guideline: Combined Hormonal Contraception (January 2019, Amended July 2019) file:///C:/Users/chapmang03/AppData/Local/Microsoft/Windows/INetCache/IE/SXCO4P8S/fsrh-guideline-combined-hormonal-contraception-july-2019.pdf

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13. Treatment

Quick info:
Treatment
Treat as per moderate acne
Refer for systemic isotretinoin treatment.

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17. Maintenance

Quick info:
Topical retinoid therapy e.g. Adapalene (Differin) or Adapalene/ BPO (Epiduo)
(avoid in pregnancy)

To suppress comedonal activity.

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18. Criteria for Referral

Quick info:
If in doubt seek further advice from either community or secondary care providers.
The main reason for referring a patient with acne is for isotretinoin treatment. Females of child bearing age should be established on reliable contraception for at least a month prior to attendance and treatment with isotretinoin.

Please note community dermatology clinics can now start isotretinoin.

Criteria for Referral to Community Dermatology Clinics:

  • Severe to Moderate acne that has failed to respond to prolonged (i.e. more than six months) courses of systemic antibiotic treatment in addition to topical treatment (2 courses with a minimum of 3 months each).
  • Mild to moderate acne in patients who have an extreme psychological reaction to their acne and have failed to respond to prolonged courses of systemic antibiotic treatment and topical treatment.

Community Dermatology Exclusion Criteria (refer to secondary care services):

  • Severe nodular cystic acne
  • Acne in patients with depression or other psychiatric disease resistant to appropriate oral antibiotic therapy or hormonal therapy
  • Patients with hepatic or renal impairment, or other significant medical problems. Other significant medical problems may need prior discussion with community or secondary care.
  • Patients whose acne has relapsed rapidly following 2 previous course of isotretinoin
  • Patient is requiring the third course or more of isotretinoin

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19. Refer Community Dermatology Clinic

Quick info:
Isotretinoin (Roaccutane)
All community dermatology clinics can now start isotretinoin.
Straightforward cases will be offered one course of of isotretinoin (initial appointment and x4 follow-up appointments)

Patient requiring longer courses of treatment will be referred on to Secondary care providers

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20. Refer Secondary Care

Quick info:
Refer the following patients to secondary care services:

  • Severe nodular cystic acne
  • Acne in patients with depression or other psychiatric disease resistant to appropriate oral antibiotic therapy or hormonal therapy
  • Patients with hepatic or renal impairment, or other significant medical problems. Other significant medical problems may need prior discussion with community or secondary care.
  • Patients whose acne has relapsed rapidly following 2 previous course of isotretinoin
  • Patient is requiring the third course or more of isotretinoin

Key Dates

Published: 19-Jun-2015, by Leeds
Valid until: 31-May-2018

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