Recommendations | Acne vulgaris: management | Guidance

1.1 Information and support for people with acne vulgaris

1.1.1

Give people with acne clear information tailored to their needs and concerns. Topics to cover include:

the possible reasons for their acne
treatment options, including over the counter treatments if appropriate
the benefits and drawbacks associated with treatments
the potential impact of acne
the importance of adhering to treatment (see also the section on providing information in the NICE guideline on medicines adherence)
relapses during or after treatment, including:
- when and how to obtain further advice
- treatment options should a relapse occur.
  
  See also the NICE guideline on patient experience in adult NHS services (particularly recommendations 1.5.11 to 1.5.19) for advice on how to tailor information and communication based on the person's needs.

1.1.2

Include parents and carers in discussions if the person with acne would like them to be involved, or when support is needed (for example, for a person with cognitive impairment).

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on information and support for people with acne vulgaris.

Full details of the evidence and the committee's discussion are in evidence review A: information and support.

1.2 Skin care advice

1.2.1

Advise people with acne to use a non-alkaline (skin pH neutral or slightly acidic) synthetic detergent (syndet) cleansing product twice daily on acne-prone skin.

1.2.2

Advise people with acne who use skin care products (for example, moisturisers) and sunscreens to avoid oil-based and comedogenic preparations.

1.2.3

Advise people with acne who use make-up to avoid oil-based and comedogenic products, and to remove make-up at the end of the day.

1.2.4

Advise people that persistent picking or scratching of acne lesions can increase the risk of scarring.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on skin care advice.

Full details of the evidence and the committee's discussion are in evidence review B: skin care advice for people with acne vulgaris and evidence review L: risk factors for scarring due to acne vulgaris.

1.3 Diet

1.3.1

Advise people that there is not enough evidence to support specific diets for treating acne.

For general advice about a balanced diet and how it could contribute to wellbeing see Public Health England's Eatwell Guide.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on diet.

Full details of the evidence and the committee's discussion are in evidence review C: dietary interventions for the treatment of acne vulgaris.

1.4 Referral to specialist care

1.4.1

Urgently refer people with acne fulminans on the same day to the on-call hospital dermatology team, to be assessed within 24 hours.

1.4.2

Refer people to a consultant dermatologist-led team or a nationally accredited GP with an Extended Role (GPwER) working within a consultant dermatologist-agreed pathway if any of the following apply:

there is diagnostic uncertainty about their acne
they have acne conglobata
they have nodulo-cystic acne.

1.4.3

Consider referring people to a consultant dermatologist-led team or a nationally accredited GPwER working within a consultant dermatologist-agreed pathway if they have:

mild to moderate acne that has not responded to 2 completed courses of treatment (see table 1)
moderate to severe acne which has not responded to previous treatment that contains an oral antibiotic (see table 1)
acne that is leading to scarring
acne with persistent pigmentary changes.

1.4.4

Consider referring people to a consultant dermatologist-led team or a nationally accredited GPwER working within a consultant dermatologist-agreed pathway if their acne of any severity is causing or contributing to persistent psychological distress or a mental health disorder.

1.4.5

Consider referral to mental health services if a person with acne experiences significant psychological distress or a mental health disorder, including those with a current or past history of:

suicidal ideation or self-harm
a severe depressive or anxiety disorder
body dysmorphic disorder.

When considering referral, take into account the person's potential treatment options (for example, oral isotretinoin). Also see the NICE guidelines on depression in children and young people for advice on recognition, depression in adults for advice on recognition and assessment, and self-harm for advice on self-harm.

1.4.6

Consider condition-specific management or referral to a specialist (for example a reproductive endocrinologist), if a medical disorder or medication (including self-administered anabolic steroids) is likely to be contributing to a person's acne.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on referral to specialist care.

Full details of the evidence and the committee's discussion are in evidence review D: referral to specialist care.

1.5 Managing acne vulgaris

The recommendations in this section cover mild to moderate and moderate to severe acne.

First-line treatment options

1.5.1

Offer people with acne a 12-week course of 1 of the following first-line treatment options, taking account of the severity of their acne and the person's preferences, and after a discussion of the advantages and disadvantages of each option (see table 1):

a fixed combination of topical adapalene with topical benzoyl peroxide for any acne severity
a fixed combination of topical tretinoin with topical clindamycin for any acne severity
a fixed combination of topical benzoyl peroxide with topical clindamycin for mild to moderate acne
a fixed combination of topical adapalene with topical benzoyl peroxide, together with either oral lymecycline or oral doxycycline for moderate to severe acne
topical azelaic acid with either oral lymecycline or oral doxycycline for moderate to severe acne.

**Table 1 Treatment choices for mild to moderate and moderate to severe acne vulgaris**
Acne severity	Treatment	Advantages	Disadvantages
Any severity	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening	Topical Does not contain antibiotics	Not for use during pregnancy Use with caution during breastfeeding (see recommendation 1.5.8) Can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics
Any severity	Fixed combination of topical tretinoin with topical clindamycin, applied once daily in the evening	Topical	Not for use during pregnancy or breastfeeding (see recommendation 1.5.8) Can cause skin irritation (see recommendation 1.5.7), and photosensitivity
Mild to moderate	Fixed combination of topical benzoyl peroxide with topical clindamycin, applied once daily in the evening	Topical Can be used with caution during pregnancy and breastfeeding.	Can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics
Moderate to severe	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening, plus either oral lymecycline or oral doxycycline taken once daily	Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is a Medicines and Healthcare products Regulatory Agency (MHRA) requirement for subsequent oral isotretinoin, which is only recommended for severe acne (see recommendation 1.5.10 and the MHRA guidance on new safety measures for isotretinoin)	Not for use in pregnancy, during breastfeeding (see recommendation 1.5.8), or under the age of 12 Topical adapalene and topical benzoyl peroxide can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics Oral antibiotics may cause systemic side effects and antimicrobial resistance Oral tetracyclines can cause photosensitivity
Moderate to severe	Topical azelaic acid applied twice daily, plus either oral lymecycline or oral doxycycline taken once daily	Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin, which is only recommended for severe acne (see recommendation 1.5.10 and the MHRA guidance on new safety measures for isotretinoin)	Not for use in pregnancy, during breastfeeding (see recommendation 1.5.8), or under the age of 12 Oral antibiotics may cause systemic side effects and resistance Oral tetracyclines can cause photosensitivity

1.5.2

Consider topical benzoyl peroxide monotherapy as an alternative treatment to the options in table 1, if:

these treatments are contraindicated, or
the person wishes to avoid using a topical retinoid, or an antibiotic (topical or oral).

1.5.3

For people with moderate to severe acne who cannot tolerate or have contraindications to oral lymecycline or oral doxycycline, consider replacing these medicines in the combination treatments in table 1 with trimethoprim or with an oral macrolide (for example, erythromycin).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on first-line treatment options.

Full details of the evidence and the committee's discussion are in:

Factors to take into account during consultations

1.5.4

Take into account that acne of any severity can cause psychological distress and mental health disorders.

1.5.5

Discuss the importance of completing the course of treatment, because positive effects can take 6 to 8 weeks to become noticeable (see also the section on supporting adherence in the NICE guideline on medicines adherence).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on factors to take into account during consultations.

Full details of the committee's discussion are in:

Factors to take into account when choosing a treatment option

1.5.6

Take into account that the risk of scarring increases with the severity and duration of acne.

1.5.7

To reduce the risk of skin irritation associated with topical treatments, such as benzoyl peroxide or retinoids, start with alternate-day or short-contact application (for example washing off after an hour). If tolerated, progress to using a standard application.

1.5.8

When discussing treatment choices with a person with childbearing potential, cover:

that topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy and
that they will need to use effective contraception, or choose an alternative treatment to these options.

1.5.9

If a person receiving treatment for acne wishes to use hormonal contraception, consider using the combined oral contraceptive pill in preference to the progestogen-only pill (if oral isotretinoin treatment is likely to be used, also see recommendations 1.5.19 and 1.5.20).

1.5.10

If clinical judgement indicates a person may need treatment with oral isotretinoin for their acne in future:

be aware that oral isotretinoin should not be used unless adequate courses of standard therapy with systemic antibiotics and topical therapy have been tried, in line with the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on new safety measures for isotretinoin and
take this into account when choosing any initial treatment option.

1.5.11

Do not use the following to treat acne:

monotherapy with a topical antibiotic
monotherapy with an oral antibiotic
a combination of a topical antibiotic and an oral antibiotic.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on factors to take into account when choosing a treatment option.

Full details of the evidence and the committee's discussion are in:

Factors to take into account at review

1.5.12

Review first-line treatment at 12 weeks and:

assess whether the person's acne has improved, and whether they have any side effects
in people whose treatment includes an oral antibiotic, if their acne has completely cleared consider stopping the antibiotic but continuing the topical treatment
in people whose treatment includes an oral antibiotic, if their acne has improved but not completely cleared, consider continuing the oral antibiotic, alongside the topical treatment, for up to 12 more weeks.

1.5.13

Only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances. Review at 3‑monthly intervals, and stop the antibiotic as soon as possible.

1.5.14

Be aware that the use of antibiotic treatments is associated with a risk of antimicrobial resistance (see the NICE guideline on antimicrobial stewardship).

1.5.15

If a person's acne has cleared, consider maintenance options (also see the section on maintenance).

1.5.16

If acne fails to respond adequately to a 12‑week course of a first-line treatment option and at review the severity is:

mild to moderate: offer another option from the table of treatment choices (see table 1)
moderate to severe, and the treatment did not include an oral antibiotic: offer another option which includes an oral antibiotic from the table of treatment choices (see table 1)
moderate to severe, and the treatment included an oral antibiotic: consider referral to a consultant dermatologist-led team or a nationally accredited GPwER working within a consultant dermatologist-agreed pathway.

1.5.17

If mild to moderate acne fails to respond adequately to 2 different 12‑week courses of treatment options, consider referral to a consultant dermatologist-led team or a nationally accredited GPwER working within a consultant dermatologist agreed pathway.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on factors to take into account at review.

Full details of the evidence and the committee's discussion are in:

Oral isotretinoin treatment

1.5.18

Consider oral isotretinoin for people older than 12 years who have a severe form of acne that is resistant to adequate courses of standard therapy with systemic antibiotics and topical therapy (table 1). For example:

nodulo-cystic acne
acne conglobata
acne fulminans
acne at risk of permanent scarring.

1.5.19

If a person with acne is likely to benefit from oral isotretinoin treatment:

Follow the MHRA guidance on new safety measures for isotretinoin. This includes:
- guidance on roles and responsibilities of referrers (usually the primary care clinician) and prescribers initiating, continuing and monitoring isotretinoin treatment
- requirements that the initiation of isotretinoin treatment in people under 18 requires agreement by 2 independent healthcare professionals that there is no other appropriate effective treatment before it is prescribed
- requirements for counselling people about potential mental health and sexual function side effects
- requirements for assessing and monitoring mental health and sexual function
- use of compulsory regulatory documents to minimise risk: patient acknowledgement of risk form and reminder card, and pharmacist checklist.
  
  See the Commission on Human Medicines Isotretinoin Implementation Advisory Expert Working Group report for more detail. [2023]

1.5.20

When making a referral to the consultant dermatologist-led team or the nationally accredited GPwER working within a consultant dermatologist-agreed pathway for the consideration of isotretinoin treatment:

fully inform the person (and their family and carers, as appropriate) about the potential risks of isotretinoin treatment as well as the expected benefits
provide details of the person's current and past medical history (including all current and previous mental health issues), and any relevant social and family history
for people under 18, document whether you are willing to become the second approved named healthcare professional who agrees that isotretinoin is the appropriate treatment. [2023]

1.5.21

When considering oral isotretinoin for acne take into account the person's psychological wellbeing (see recommendation 1.4.5), and refer them to mental health services before starting treatment if appropriate. See also MHRA requirements to assess mental health before starting isotretinoin treatment.

1.5.22

If a person for whom oral isotretinoin treatment is being considered has the potential to become pregnant:

explain that isotretinoin can cause serious harm to a developing baby if taken during pregnancy and
inform them that they will need to follow the MHRA pregnancy prevention programme as detailed on the isotretinoin acknowledgement of risk form.

1.5.23

Prescribe oral isotretinoin for acne treatment (see recommendation 1.5.18) at a standard daily dose of 0.5 to 1 mg/kg.

1.5.24

Consider a reduced daily dose of isotretinoin (less than 0.5 mg/kg) for people at increased risk of, or experiencing, adverse effects.

1.5.25

When giving isotretinoin as a course of treatment for acne:

continue until a total cumulative dose of 120 to 150 mg/kg is reached, but
if there has been an adequate response and no new acne lesions for 4 to 8 weeks, consider discontinuing treatment sooner.

1.5.26

If a person is taking oral isotretinoin for acne:

review their psychological wellbeing during treatment, and monitor them regularly for symptoms or signs of developing or worsening mental health problems or sexual dysfunction
tell them to seek medical advice if they feel their mental health or sexual function is affected or is worsening, and to stop their treatment and seek urgent medical advice if these problems are severe. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on oral isotretinoin treatment.

Full details of the evidence and the committee's discussion are in evidence review F1: management options for moderate to severe acne – network meta-analyses and evidence review F2: management options for moderate to severe acne – pairwise comparisons.

Use of oral corticosteroids in addition to oral isotretinoin

1.5.27

If an acne flare (acute significant worsening of acne) occurs after starting oral isotretinoin, consider adding a course of oral prednisolone.

1.5.28

When a person with acne fulminans is started on oral isotretinoin, consider adding a course of oral prednisolone to prevent an acne flare.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on use of oral corticosteroids in addition to oral isotretinoin.

Full details of the evidence and the committee's discussion are in evidence review J: addition of oral corticosteroids to oral isotretinoin for the treatment of severe inflammatory acne vulgaris.

Physical treatments

1.5.29

Consider photodynamic therapy for people aged 18 and over with moderate to severe acne if other treatments are ineffective, not tolerated or contraindicated.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on physical treatments.

Full details of the evidence and the committee's discussion are in evidence review F1: management options for moderate to severe acne – network meta-analyses and evidence review F2: management options for moderate to severe acne – pairwise comparisons.

Use of intralesional corticosteroids

1.5.30

Consider treating severe inflammatory cysts with intralesional injection of triamcinolone acetonide (0.1 ml of triamcinolone acetonide per cm of cyst diameter, at 0.6 mg/ml diluted in 0.9% sodium chloride). This should be done by a member of a consultant dermatologist-led team or a nationally accredited GPwER working within a consultant dermatologist-agreed pathway.

In June 2021 this was an off-label use for triamcinolone acetonide. See NICE's information on prescribing medicines for more information.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on use of intralesional corticosteroids.

Full details of the evidence and the committee's discussion are in evidence review K: intralesional corticosteroids for the treatment of individual acne vulgaris lesions.

Treatment options for people with polycystic ovary syndrome

1.5.31

For people with polycystic ovary syndrome and acne:

treat their acne using a first-line treatment option (see recommendation 1.5.1 and table 1)
if the chosen first-line treatment is not effective, consider adding ethinylestradiol with cyproterone acetate (co-cyprindiol) or an alternative combined oral contraceptive pill to their treatment
for those using co-cyprindiol, review at 6 months and discuss continuation or alternative treatment options.

1.5.32

Consider referring people with acne and polycystic ovary syndrome with additional features of hyperandrogenism to an appropriate specialist (for example, a reproductive endocrinologist).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatment options for people with polycystic ovary syndrome.

Full details of the evidence and the committee's discussion are in evidence review G: management options for people with acne vulgaris and polycystic ovary syndrome.

1.6 Relapse

1.6.1

If acne responds adequately to a course of an appropriate first-line treatment (see recommendation 1.5.3 and table 1) but then relapses, consider either:

another 12‑week course of the same treatment, or
an alternative 12‑week treatment (see table 1).

1.6.2

If acne relapses after an adequate response to oral isotretinoin and is currently mild to moderate, offer an appropriate treatment option (see table 1).

1.6.3

If acne relapses after an adequate response to oral isotretinoin and is currently moderate to severe, offer either:

a 12-week course of an appropriate treatment option (see table 1), or
re-referral, if the person is no longer under the care of the consultant dermatologist-led team or the nationally accredited GPwER working within a consultant dermatologist-agreed pathway.

1.6.4

If acne relapses after a second course of oral isotretinoin and is currently moderate to severe, further care should be decided by the consultant dermatologist-led team or the nationally accredited GPwER working within a consultant dermatologist-agreed pathway. If the person is no longer under their care, offer re-referral.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on relapse.

Full details of the evidence and the committee's discussion are in evidence review H: management options for refractory acne.

1.7 Maintenance

1.7.1

Encourage continued appropriate skin care (see recommendations 1.2.1 to 1.2.4).

1.7.2

Explain to the person with acne that, after completion of treatment, maintenance treatment is not always necessary.

1.7.3

Consider maintenance treatment in people with a history of frequent relapse after treatment.

1.7.4

Consider a fixed combination of topical adapalene and topical benzoyl peroxide as maintenance treatment for acne. If this is not tolerated, or if 1 component of the combination is contraindicated, consider topical monotherapy with adapalene, azelaic acid, or benzoyl peroxide (see also recommendation 1.5.7 on starting topical treatment).

1.7.5

Review maintenance treatments for acne after 12 weeks to decide if they should continue.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on maintenance.

Full details of the evidence and the committee's discussion are in evidence review I: maintenance treatment for acne vulgaris.

1.8 Management of acne-related scarring

1.8.1

If a person has acne-related scarring, discuss their concerns and provide information in a way that suits their needs. Topics to cover include:

possible reasons for their scars
treatment of ongoing acne to help prevent further scarring (see recommendations 1.5.1 to 1.5.3 and recommendation 1.5.18)
possible treatment options for acne-related scarring
the way their acne scars may change over time
psychological distress.

1.8.2

If a person's acne-related scarring is severe and persists a year after their acne has cleared:

refer the person to a consultant dermatologist-led team with expertise in scarring management
in a consultant dermatologist-led team setting, consider CO₂ laser treatment (alone or after a session of punch elevation) or glycolic acid peel.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on managing acne-related scarring.

Full details of the evidence and the committee's discussion are in evidence review M: management of acne vulgaris-associated scarring.

Terms used in this guideline

Acne conglobata

A severe form of nodulo-cystic acne with interconnecting sinuses and abscesses.

Acne fulminans

A very serious form of acne conglobata associated with systemic symptoms.

Comedogenic

An ingredient that is likely to block skin pores.

Consultant dermatologist-led team

This team may include associate specialists, junior doctors and other healthcare professionals with appropriate dermatology expertise, skills and training.

Fixed combination of topical adapalene with topical benzoyl peroxide

Formulation with either of these 2 concentrations:

0.1% adapalene with 2.5% benzoyl peroxide
0.3% adapalene with 2.5% benzoyl peroxide.

Fixed combination of topical benzoyl peroxide with topical clindamycin

Formulation with either of these 2 concentrations:

3% benzoyl peroxide with 1% clindamycin
5% benzoyl peroxide with 1% clindamycin.

Fixed combination of topical tretinoin with topical clindamycin

Formulation with:

0.025% tretinoin with 1% clindamycin.

Mild to moderate acne

Acne severity varies along a continuum. For mild to moderate acne, this includes people who have 1 or more of:

any number of non-inflammatory lesions (comedones)
up to 34 inflammatory lesions (with or without non-inflammatory lesions)
up to 2 nodules.

Moderate to severe acne

Acne severity varies along a continuum. For moderate to severe acne this includes people who have either or both of:

35 or more inflammatory lesions (with or without non-inflammatory lesions)
3 or more nodules.

Nationally accredited GP with an Extended Role (GPwER) working within a consultant dermatologist-agreed pathway

GPs with an interest in dermatology can apply to be nationally accredited as a GPwER in dermatology through the British Association of Dermatologists (BAD). The BAD also administers the process of transition of existing GPs with a Special Interest (GPwSI) in dermatology to the new system. From October 2023, prescriptions for isotretinoin can be initiated by nationally accredited GPwERs working within a consultant dermatologist-agreed pathway who have expertise in the use of systemic retinoids for the treatment of severe acne, and a full understanding of the risks of isotretinoin treatment and monitoring requirements. Prescriptions can also be initiated by GPwSIs who are currently prescribing isotretinoin within a consultant dermatologist-agreed pathway if they were signed off locally before the introduction of GPwER accreditation in 2018. See the Commission on Human Medicines Isotretinoin Implementation Advisory Expert Working Group report for details of all clinicians who can prescribe isotretinoin either within a consultant dermatologist-agreed pathway or under consultant dermatologist supervision.

Oral lymecycline or oral doxycycline

Formulation of either:

408 mg lymecycline daily
100 mg doxycycline daily.

Synthetic detergent (syndet)

A synthetic detergent (syndet) is a blend of synthetic surfactants and is formulated to have neutral to slightly acidic pH similar to the skin. It is widely available in both solid and liquid forms as a skin cleansing product.