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13.6 Preparations for acne

Azelaic acid cream
Benzoyl peroxide cream, gel, lotion
Clindamycin lotion
Erythromycin solution
Panoxyl cream, gel
Adapalene cream, gel

Note: adapalene has now replaced tretinon (Retin-A) as it is less irritant

 

13.6.2 Oral preparations for acne

Co-cyprindiol 2000/35 tablets (Cyproterone + ethinylestradiol) - see note
Isotretinoin capsules - oral retinoids pregnancy prevention reminder - link to Drug Safety Update June 2013 - see notes below

Notes:

1. Treatment depends on whether the acne is predominantly inflammatory or comedonal. Significant comedonal acne responds well to retinoids. Both comedones and inflamed lesions respond well to benzoyl peroxide, azelaic acid or a topical antibiotic.

2. Azelaic acid has combined antibacterial and comedolytic properties, and so is useful for mild to moderate acne. It may be preferred by some patients as it causes less local skin irritation than benzoyl peroxide. It is also useful for post-inflammatory depigmentation.

3. Co-cyprindiol is for severe acne or hirsutism only - see MHRA prescribing advice, including risks (especially VTE) vs benefits.

4. Isotretinoin should be prescribed only by or under the supervision of a consultant dermatologist.


5. Isotretinoin has been linked with psychiatric disorders e.g. depression, anxiety, and rarely suicidal thoughts. Counsel and monitor patients accordingly. Link to Drug Safety Update December 2014 – risk of psychiatric disorders


Topical Antibiotics

Cross resistance, especially between erythromycin and clindamycin is an increasing problem. To avoid this:

  • when possible use non-antibiotic antimicrobials (benzoyl peroxide)

  • avoid concomitant treatment with different oral and topical antibiotics

  • use effective antibiotics for repeat courses

Usual maximum duration of treatment 10-12 weeks to minimise problems.

Topical clindamycin in a lotion is aqueous based and so is less irritating to dry or scaly skin than the alcoholic solution or erythromycin solution.

Mild acne, oily, greasy skin:
Benzoyl peroxide or topical erythromycin or clindamycin solution topical retinoids

 

Dry, sensitive skin:
Clindamycin lotion

 

Moderate and severe acne
6 months minimum treatment
First line - oxytetracyline or erythromycin +/- topical agents
Second line - doxycycline 50mg OD or lymecycline 100mg OD +/- topical agents

Notes:

1. In order to reduce the risk of the development of resistant organisms oxytetracycline should be used as first choice, as erythromycin is used extensively for systemic infections.

2. Minocycline is no longer recommended in the management of acne. It is restricted for specialist use in autoimmune bullous disorders and pyoderma gangrenosum. It is no more effective than other tetracyclines in treating Acne and is more expensive. It is also associated with serious side effects, e.g. there have been rare reports of hepatitis and SLE have been reported with its use. It should be used with caution in patients with hepatic dysfunction, in conjunction with alcohol and other hepatotoxic drugs. It is recommended that alcohol consumption should remain within the Government's recommended limits. It has also been associated with skin pigmentation. Patients should be advised to report any unusual pigmentation without delay and minocycline should be discontinued.

3. Very severe acne & nodulo-cystic acne: refer to skin clinic for possible isotretinoin treatment. 

For link to BNF section: 13.6 Acne and rosacea