BEDFORDSHIRE SUMMARY PATHWAY

Severe Moderate Mild

Nodular abscesses/cysts Increased inflamed lesions Open + closed + + non-inflammatory comedones Predominance inflammatory papules/ Increased papules/pustules + Gel 2.5%, 5%, 10% pustules leading to more extensive some papules/pustules scarring Cream 5% Wash 10% Already Risk of Unlikely to scarring Scarring scar Topical Antibacterials

Promote self-care. 1st Line: 1% topical solution Mild soap/cleanser to wash 1-2 times per in alcohol or lotion (Dalacin ®) day 2nd Line: 2% solution Refer to specialist st Water based emollient if dry problem 1 line: topical antibacterial + either benzoyl (reserved when clindamycin Dermatology Service peroxide or topical contraindicated e.g. pregnancy)

 Pre-treatment blood test for 2nd line: topical retinoid + benzoyl peroxide (this Topical Retinoid 1st line: topical retinoid or benzoyl option may be poorly tolerated) peroxide (especially if papules and st  If female patient, consider 1 line: cream/gel 0.1% rd pustules are present) commencing combined oral 3 line: oral + either benzoyl peroxide (Differin) contraceptive pill at least one or a topical retinoid nd 2 line: Azelaic acid (if both topical Pharmaceutical specials are not recommended month prior to treatment.* and benzoyl peroxide are poorly  The use of barrier methods tolerated) alone is not sufficient Oral contraceptive cover for 1 st Line: : commencing treatment with *If female (UKMEC 1 single UKMEC 2 condition) consider COC (combined oral contraceptive) (if not 408 mg once daily p.o.

isotretinoin contraindicated): OR 100mg daily p.o. st  Follow the pregnancy 1 line: 30mcg and 150mcg . Recommended choice*: Ovranette® or prevention programme (refer Rigevidon® (branded generics of Microgynon 30®) which is both cost-effective and has lowest VTE risk, 2nd Line: Erythromycin 500mg twice to isotretinoin SPC should be used first line irrespective of presenting symptoms as any COC may improve the symptoms, daily p.o. (when tetracyclines are www.medicines.org.uk ) unless previously tried contraindicated (e.g. pregnancy) or not  Prescribe oral antibiotic in 2nd line: COC with progestogen that has minimal androgenic effect; , , or tolerated) combination with a topical norgestimate. Recommended choice(s): Cilest®, or Gedarel® 30/150 (branded generic of Marvelon®), or drug (Benzoyl peroxide or a Millinette® 30/75 (branded generic of Femodene®)  Do not prescribe oral antibiotics topical retinoid) as an interim 3rd line: COC with anti-androgen progesterone. These should be reserved where symptoms remain alone treatment. uncontrolled following an adequate trial (minimum 3 months) of at least 2 other COCs, including one with  Do not combine a topical and oral  If evidence of psychosocial progestogen that has minimal androgenic effect. antibiotic morbidity refer to Psychiatry Co-cyprindiol (Dianette®, ethynylestradiol/) should not be used solely for contraception due to  Oral antibiotics should be reviewed risk of VTE. Yasmin® (ethinylestradiol/) and Qlaira® ( valerate/): No after 6 weeks and continued up to a conclusive evidence of superiority over other currently available COCs and are therefore not cost effective maximum duration of 3 months options. Yasmin is associated with increased VTE risk.