Acne

Disclaimer These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Introduction

Acne is a common condition that predominantly affects young adults and adolescents (approximately 85%)^{1, 3}.

The pathogenesis of acne can be explained by four main causes:

1. Increased sebum production
2. Cutibacterium acnes overgrowth
3. Inflammation
4. Abnormal follicular keratinisation

Areas with highest density of sebaceous glands are affected the most by acne, for example face, neck, chest, shoulders and upper back.

Acne is generally classified as mild, moderate or severe and based on number of lesions, cosmetic impact and impact on quality of life. Acne treatments often take at least 6-12 weeks before improvement is noted regardless of the treatment method³. The aim of treatment is to reduce the number of comedones, inflammatory lesions and likelihood of permanent pigmentary changes as well as to prevent scarring.

Pre-referral investigations

For current guidelines on assessment, management and referral guidelines on Acne please visit HealthPathways WA.

Pre-referral management

General measures

• Wash the face twice a day with a cleanser designed for acne
  • Avoid heavy cleansing
  • Salicylic acid containing products can be helpful to unblock pores
• Use non-comedogenic, oil free products
  • Avoid greasy cosmetics
  • Oil free sunscreen for the face
  • Carefully remove make up
• Avoid scrubbing/exfoliating affected area
• Avoid picking or squeezing lesions
• Regular exercise (ideally with shower or face wash within 30 minutes of exercise)⁴
• Low GI, low dairy diet

Specific measures

Mild acne: General measures and non-prescription options

These topical agents aim to reduce excess oil, slough, dead skin cells and reduce bacterial overgrowth. They should be applied to the whole affected area and not just a spot treatment. These treatments have no effect on comedones but will help reduce bacteria on the skin and inflammatory flares.

• Benzoyl peroxide comes in many different preparations ranging from 2.5-10%
  • Preparations include gel, cream and body wash
  • Choose a preparation that suits the patient depending on their history and location of acne
  • Note that Benzoyl peroxide can bleach coloured fabric (e.g., clothes, towels, pillowcases, sheets)
• Antiseptic washes such as chlorhexidine 4% and triclosan 1%

Azelaic acid

• Gel and lotion
• Helpful in patients with darker skin type

These preparations may cause irritation and dryness. Reduce frequency of application if this happens and stop using the product if severe irritation occurs³.

For comedonal acne a topical retinoid needs to be used. The base of the topical retinoid affects the irritancy.

For mild comedonal acne with minimal inflammation, commence adapalene 0.1% cream applied once daily at night. If the cream feels too greasy adapalene 0.1% gel can be used. Tretinoin 0.05% is an alternative if available.

These need to be applied as field rather than spot treatments (to capture micro-comedones and prevent oil gland swelling) at night and washed off in the morning to avoid photosensitivity. Slow introduction can minimise side effects. If they cause too much dryness, then oral options need to be considered.

For mild inflammatory acne topical antiseptics or antibiotics are suggested e.g., topical clindamycin, or a combination product such as Epiduo gel (which contains adapalene and benzoyl peroxide in a gel base) or Acnatac gel (clindamycin and tretinoin gel). These are to be used once daily for 6 weeks then review.

Mild acne: prescription options

Moderate to severe comedonal acne needs a topical retinoid with sufficient strength (e.g. adapalene 0.1%), but if the comedones fail to clear, consideration of the oral contraceptive pill or referral to a dermatologist for oral isotretinoin should occur.

The oral contraceptive pill (OCP) should be considered for treatment of female patients with a history of acne symptoms associated with menstruation or partial response to standard treatments. The antiandrogen properties and suppression of ovulation is helpful for reducing comedone activity.
The OCP should not be used for girls who have had at least 12 months of regular periods. Other relative contraindications to the pill (family history of venous thromboembolism, hypertension, migraines with aura) need to be considered.

It may take 3 to 6 months for the OCP to reach optimal efficacy.

While waiting for the OCP to become effective, add:

• an oral antibiotic and topical treatment
  • the oral antibiotic can be ceased after the OCP becomes effective

There is minimal evidence for different forms of OCPs over each other for acne. Here are some examples available in Australia (all non-PBS):

• Pills containing gestodene (e.g. Minulet)
• Pills containing drospirenone (e.g. Yaz, Isabelle, Yasmin)
• Pills containing cyproterone acetate (e.g. Brenda-35 ED, Diane-35 ED)
• Pills containing desogestrel (e.g. Madeline, Marvelon 28)

Moderate to severe inflammatory acne

For moderate to severe inflammatory acne, oral antibiotics can help clear the inflammatory component but need to be combined with a treatment for comedones, otherwise cessation of the antibiotics tends to result in recurrence of the inflammatory acne. Please continue a topical retinoid, or the oral contraceptive pill as this is what treats the comedones.

Antibiotics helpful for acne include:

• Doxycycline 50-100mg per day
• Minocycline 50-100mg per day

Note: Tetracycline antibiotics should not be given to children under 8 years old due to risk of permanent discolouration of the teeth and may cause enamel dysplasia, which may increase the risk of dental caries.

Second line antibiotics include:

• Erythromycin ethyl succinate 400-800mg twice daily
• Erythromycin 250-500mg twice daily

If the response to the topical retinoid is not adequate after 6 weeks, consider an alternative retinoid (if using tretinoin), or reassess the dominant type of acne present and consider a topical combination (e.g. benzoyl peroxide and adapalene)

Severe Acne or Acne with Scarring

Please consider an early referral of these patients for specialist management that often will involve the use of isotretinoin in combination with other treatments (for example the oral contraceptive pill, antibiotics and topical antiseptic washes). Patients who are severely affected psychologically by their acne or those who present with a family history of severe scarring and resistant to other treatments should also be referred for specialist care.

Please refer to HealthPathways WA. For more information on management of mild, moderate and severe acne.

When to refer

• Failed response to conventional therapy (oral and/or systemic)
  • Please note a trial of oral systemic agents are needed for at least 3-6 months to reach maximal efficacy
• Associated significant psychosocial impact
• Severe scarring acne or a strong family history of scarring

Essential Information to include in your referral

• Treatments patient has trialled
• Severe scarring acne or a strong family history of scarring
• Ongoing signs or symptoms which remain problematic

How to refer

• Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
• Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals are made via the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au)
• Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456222 to discuss referral with the on-call Dermatologist

References

1. Acne [Internet]. Mayo Clinic. 2022 [cited 2022 Aug 23]. Available from: https://www.mayoclinic.org/diseases-conditions/acne/symptoms-causes/syc-20368047
2. Eichenfield L et al. Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. Pediatrics 2013. May (131): Supp 3.
3. Therapeutic Guidelines (2022). Therapeutic Guidelines- Acne. Available at: https://tgldcdp-tg-org-au.pklibresources.health.wa.gov.au/viewTopic?etgAccess=true (Accessed: October 27, 2022).
4. UpToDate (2022) Acne-pathogenesis, clinical manifestations, and diagnosis of acne vulgaris, Acne. UpToDate Inc. Available at: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-acne-vulgaris?search=acne&topicRef=42&source=see_link#H9 (Accessed: October 27, 2022).

Reviewer/Team:	Dermatology team	Last reviewed:	Nov 2022
		Review date:	Nov 2025

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