9th June 2025

Management

Treatment is based on the severity and usually a combination of medications are needed to treat acne. 

• Mild to moderate acne:
  • 12 week course of one of the following 
    • Topical adapalene (retinoid) + topical benzoyl peroxide
    • Topical tretinoin (retinoid) + topical clindamycin
    • Topical benzoyl peroxide + topical clindamycin 
  • Topical benzoyl peroxide monotherapy if above contraindicated or patient preference 
  • Dry or sensitive skin – creams or lotions rather than gels
  • Oily skin – consider less greasy gels 
  • If skin irritation occurs with treatment then modify concentration or frequency of application 
• Moderate to severe acne: 
  • 12 week course of one of the following
    • Topical adapalene (retinoid) + topical benzoyl peroxide 
    • Topical tretinoin (retinoid) + topical clindamycin 
    • Topical adapalene (retinoid) + topical benzoyl peroxide + oral lymecycline/ doxycycline 
    • Topical azelaic acid + oral lymecycline/doxycycline 
  • Topical benzoyl peroxide monotherapy if above contraindicated or patient preference 
  • Trimethoprim/oral macrolide (erythromycin) if contraindication or not tolerated oral lymecycline/doxycycline 
  • Combined oral contraceptive + topical agents (if systemic antibiotics not tolerated in women) 
    • Useful in women with hormonal involvement for acne (acne related to menstrual periods, ovarian/adrenal hyperandrogenism and polycystic ovary syndrome) 
    • Third and fourth generation combined oral contraceptives 
    • Co-cyprindol or other ethinylestradiol/cyproterone acetate-containing products 
    • Discontinue 3 months after acne controlled 
  • Spironolactone
    • Used for its anti-androgenic effects for women only
    • Useful to limit use of long-term antibiotics or for individuals who prefer not to take isotretinoin
    • Contraindicated in pregnancy
  • Oral isotretinoin
    • Indicated in severe or scarring disease, or if insufficient response to other treatment or rapid relapse on stopping it; also in cases with marked psychosocial impact
    • Extremely effective
    • Potently teratogenic; women of child-bearing potential must be enrolled on to a pregnancy prevention programme
    • Common adverse effects comprise mucocutaneous dryness; reports of effects on mental health (e.g. depression, irritability) and sexual dysfunction
• Pregnant women 
  • Safe topical agents – azelaic acid, benzoyl peroxide, clindamycin, erythromycin 
  • Erythromycin can be used in pregnancy if systemic treatment is clearly required