Acne

Mild

Non-inflamed comedones

Inflamed papules and pustules

Papular pustular acne of the back and shoulders

Moderate

More extensive inflamed lesions on face and trunk

Some acne cysts of neck and open comedones 

Severe

Severe cystic acne with scarring. Deep inflamed cysts and scarring

Mild to Moderate Acne

Patients with mild to moderate acne can usually be managed in Primary Care.  Prolonged treatment may be required with regular review to encourage patient compliance.

Topical Treatment for 3 months then review

• Benzoylperoxide
• Retinoids: Adapalene, Isotretinoin, Tretinoin
• Topical antibiotic combined with benzoyl peroxide, retinoids or zinc to reduce antimicrobial resistance

Systemic Therapy

Assess response to oral antibiotics at three months.  If poor response, change to alternative oral antibiotic but continue for six months minimum.

Under 12 years old:

• Erythromycin or Clarithromycin bd

12 years and over:

• Lymecycline 408mg
• Doxcycline 100mg od
• Erythromycin or Clarithromycin 500 mg bd
• Minocycline may have additional side effects so is not a preferred second line treatment

In Women

Consider additional anti-androgen treatment e.g. Cyproterone and ethinyloestradiol combination or the combined oral contraceptive

Severe cystic acne with scarring

Commence systemic antibiotic therapy and refer immediately for consideration of systemic isotretinoin, indicating the reasons justifying an urgent referral.

Dermatology Referral Criteria

• Severe nodular/cystic acne  with scarring
• Treatment failure:
  for consideration of oral Isotretinoin for patients with a poor response to at least six months of one or two different antibiotics plus topical therapy
• Severe psychological upset

Consider starting females of reproductive potential on hormonal contraception at point of referral