Neil Skolnik, MD


March 23, 2022

This transcript has been edited for clarity.

I'm Dr Neil Skolnik, and today I'm going to talk about the National Institute for Health and Care Excellence (NICE) guidelines on the management of acne. We take care of acne all the time in the office, and recommendations have changed in important ways. Moreover, acne is not typically covered in traditional CME programs for primary care.

Let's start with basic skincare for patients with acne. Avoid oil-based moisturizers, makeup, and sunscreens. If makeup is used, take it off at night.

Next is diet. Diet is often mentioned in acne management, but the guidelines clarify that there is no evidence showing that one diet works better than another in regard to treatment of acne.

Let's move on to first-line treatment. It's important to understand that it takes 6-8 weeks to see the effects of treatment once it's started, and a course of therapy is considered 12 weeks long.

First-line therapy no longer comprises a single agent. Start with a fixed-dose topical combination, even for mild acne. Essentially, we choose from one of four classes:

  • Benzoyl peroxide

  • Retinoids; either tretinoin or adapalene

  • Vitamin A derivatives

  • Topical antibiotics; Owing to the risk for antimicrobial resistance, erythromycin is no longer recommended. An alternative is azelaic acid, a natural acid found in grains, (barley, wheat, and rye) that has comedolytic, antibacterial, and anti-inflammatory properties.

First-line therapy starts by combining two of the above four classes, such as adapalene–benzoyl peroxide, tretinoin-clindamycin, or benzoyl peroxide–clindamycin. Benzoyl peroxide is never combined with a topical retinoid because the latter oxidizes the former, reducing the effectiveness of benzoyl peroxide.

If tetracycline antibiotics can't be used, prescribe either trimethoprim or a macrolide. Topical azelaic acid can be used alone or with a tetracycline antibiotic.

All of the topical agents can be irritating, so patients should start by applying them either every other day or just for an hour then washing the product off until tolerance develops. Also, the topical agents can cause phototoxicity, so it's worth reminding patients to use sunscreen. Benzoyl peroxide can cause bleaching of hair and fabrics (including pillowcases).

For more severe acne, it's reasonable to add an oral antibiotic. Use the adapalene–benzoyl peroxide combination topically, along with a tetracycline-based oral antibiotic (minocycline or doxycycline).

The initial course of treatment is considered to be 12 weeks with follow-up to see how the patient is doing. If needed, continue the antibiotic for another 12 weeks. But it's recommended not to continue antibiotics for more than 6 months to minimize the development of antimicrobial resistance.

If someone has a good response, drop the antibiotic. Continue with maintenance therapy — either using a fixed combination (adapalene-benzoyl peroxide) or monotherapy (adapalene, benzoyl peroxide, or azelaic acid). If the response is insufficient, switch to one of the other topical combinations. If you didn't start with an oral antibiotic, you can add it at that point.

In regard to oral contraceptives for acne, the guidelines state that there's not enough evidence of effectiveness. I do want to note that they are mentioned as being effective in the 2016 American Academy of Dermatology Guidelines, and a meta-analysis of 32 studies published in the Journal of the American Academy of Dermatology in 2014 showed a reduction in inflammatory lesions by about 60%.

So, what do we do with that? I'm not sure that I'd recommend oral contraceptives as primary treatment for acne, but if someone wants to be on an oral contraceptive for contraceptive use, we should expect to see improvement in their acne. Spironolactone is mentioned as benefiting women with polycystic ovary syndrome (PCOS).

If the patient's acne is severe and hasn't responded over a 3- to 6-month period of therapy, then consider referral to a dermatologist primarily for consideration of isotretinoin or photodynamic therapy.

These guidelines have a lot of really important information for something that we see commonly in the office. I'm Dr Neil Skolnik, and this is Medscape.

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