BEDFORDSHIRE ACNE SUMMARY PATHWAY
Severe Moderate Mild
Nodular abscesses/cysts Increased inflamed lesions Open + closed + + non-inflammatory comedones Benzoyl Peroxide 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: Clindamycin 1% topical solution Mild soap/cleanser to wash 1-2 times per in alcohol or lotion (Dalacin ®) day 2nd Line: Erythromycin 2% solution Refer to specialist st Water based emollient if dry skin problem 1 line: topical antibacterial + either benzoyl (reserved when clindamycin Dermatology Service peroxide or topical retinoid contraindicated e.g. pregnancy)
Pre-treatment blood test for 2nd line: topical retinoid + benzoyl peroxide (this Topical Retinoid 1st line: topical retinoid or benzoyl isotretinoin option may be poorly tolerated) peroxide (especially if papules and st If female patient, consider 1 line: adapalene cream/gel 0.1% rd pustules are present) commencing combined oral 3 line: oral antibiotic + 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.* retinoids and benzoyl peroxide are poorly The use of barrier methods tolerated) alone is not sufficient Oral Antibiotics contraceptive cover for 1 st Line: Tetracyclines: commencing treatment with *If female (UKMEC 1 single UKMEC 2 condition) consider COC (combined oral contraceptive) (if not Lymecycline 408 mg once daily p.o.
isotretinoin contraindicated): OR Doxycycline 100mg daily p.o. st Follow the pregnancy 1 line: 30mcg ethinylestradiol and 150mcg levonorgestrel. 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; desogestrel, gestodene, 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/cyproterone) should not be used solely for contraception due to Oral antibiotics should be reviewed risk of VTE. Yasmin® (ethinylestradiol/drospirenone) and Qlaira® (estradiol valerate/dienogest): 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.