Acne

• Acne


  An inflammatory disease of the pilosebaceous follicles, causing comedones, papules and pustules on the face (99% of cases), chest (60%) and upper back (15%)
• Acne affects approximately 80% to 95% of adolescents
• Diagnosis of acne is usually straightforward, and most patients presenting in the community pharmacy will generally be seeking appropriate advice on correct product selection rather than wanting someone to put a name to their rash
• Most cases seen in the pharmacy setting will be mild and can be managed appropriately without referral to the doctor
• More persistent and severe cases of acne need referral for more potent topical or systemic treatment
• Acne often causes significant psychological impact, such as lack of confidence, low self-esteem and depression
• Acne lesions


  • Develop at the onset of puberty
  • Girls tend to develop acne at an earlier age than boys
  • The peak incidence for girls is between the ages of 14 and 17 years compared with 15 and 19 years for boys
• Up to 12% of women and 3% of men aged 25 to 40 years continue to get facial acne or develop acne (late-onset acne) after adolescence
• Acne persists in a very small proportion of patients (5% of women and 1% of men) into their 40s
• White patients are more likely to experience moderate to severe acne than black patients, although black skin is prone to worse scarring
• Acne formation


  1. Increased testosterone levels

  2. Sebaceous glands produce excess oil

  3. Epithelial cells lining the follicle undergo change

  4. Follicle opening becomes blocked

  5. Bacteria proliferate in the stagnant oil

  6. Inflammation and pus formation

  7. Pustule bursts on the skin surface
• Acne symptoms


  • Predominantly open and closed comedones, with a small number of active lesions normally confined to the face
  • Predominantly blackheads and whiteheads, with very few inflammatory lesions (comedonal acne, most common in Asian and Afro-Caribbean patients)
  • Seborrhoea is commonly present
  • Certain jobs can predispose patients to acne-like lesions and are commonly associated with long-term contact with oils
• Skin care for acne

  • Don't wash more than normal — twice a day
  • Use a mild soap (non-alkaline) and lukewarm water
  • Don't scrub hard when washing acne-affected skin
  • Use a soft wash-cloth and fingers instead
  • Excess washing and scrubbing may cause more inflammation, dryness and irritation and possibly make acne worse
  • The black tip of a blackhead is melanin and can't be removed by cleaning or scrubbing
  • Use a fragrance-free, water-based moisturiser cream if topical acne preps dry the skin
  • Avoid oil-based comedogenic skin care products, make-up and sunscreens
  • Remove make-up at end of the day
  • Persistent picking or scratching of lesions can increase risk of scarring
  • Insufficient evidence to support specific diets but maintain health diet
• Mild-moderate acne treatment


  • Topical adapalene 0.1% or 0.3% with topical benzoyl peroxide 2.5%
  • Topical tretinoin 0.025% with topical clindamycin 1%
  • Topical benzoyl peroxide 3% or 5% with topical clindamycin 1%
  • Topical benzoyl peroxide as monotherapy if other options are contraindicated or patient wants to avoid retinoid or antibiotic, e.g. pregnancy
  • Creams/lotions may be preferable for dry or sensitive skin
  • Less greasy gels may be preferable for oily skin
  • Concentration or application frequency of topical therapy may need to be reduced if skin irritation occurs and can be increased gradually from once a week to daily if tolerated
• Moderate-severe acne treatment


  • Topical adapalene 0.1% or 0.3% with topical benzoyl peroxide 2.5% once a day in the evening
  • Topical tretinoin 0.025% with topical clindamycin 1% once a day in the evening
  • Topical adapalene with topical benzoyl peroxide (once a day in the evening) and oral lymecycline 408mg or oral doxycycline 100mg once a day
  • Topical azelaic acid 15% or 20% twice a day and oral lymecycline 408 mg or oral doxycycline 100mg once a day (oral tetracycline)
  • Topical benzoyl peroxide as monotherapy (as stated previously)
  • Oral contraceptives in combo with topical agents as alternative to systemic antibiotics in women
• Review of acne treatment

  • Review at 12 weeks
  • If using oral antibiotic: consider stopping but continue topical treatment, or continue alongside topical treatment for further 12 weeks
  • Exceptional circumstance to continue topical or oral antibiotic for more than 6 months
  • Maintenance treatment not always necessary, consider in history of frequent relapse
  • Topical adapalene with topical benzoyl peroxide, or topical monotherapy with adapalene, azelaic acid or benzoyl peroxide
  • If treatment failure: offer another first-line option, or if oral antibiotic was used or 2 different options used, consider referral to dermatologist
• Duration of acne treatment

  • Up to 4 weeks for any sign of improvement
  • Good response by 6-8 weeks
  • Up to 4 months for maximum response
  • Stopping treatment results in acne response
  • Maintenance treatment, usually with benzoyl peroxide or topical retinoid. May have unrealistic expectations of duration
• Benzoyl peroxide


  Mild antibacterial action, comedolytic effect, induces peeling of skin and encourages comedone removal, reduces breakdown of sebum into irritant fatty acids which cause inflammation in sebaceous ducts
• Benzoyl peroxide usage


  • 2.5%, 5% and 10% - start with lowest strength
  • Oxygen is released from benzoyl peroxide on the skin hence it acts as a bleaching agent on clothing, skin and hair
  • Increased risk of sunburn
  • Wash skin 20-30 mins before using
  • Avoid contact with eyes and mucous membranes
  • To prevent skin irritation: use the lowest strength first, gradually increase the strength, use a water-based prep, apply once daily at first and wash off after several hours, gradually increase the strength of time left on the skin, use twice-daily when used to it, stop using if skin becomes irritated until the irritation goes, then try again with a lower strength or reduce the time it is left on your skin before washing off
• Other OTC options for acne

  • Nicotinamide: topical gel, applied twice a day, mild anti-inflammatory action, limited evidence of efficacy, may cause dryness and irritation
  • Antiseptic washes: efficacy is debatable
• Topical retinoids for acne

  • Adapalene — licensed in over 12 yrs
  • Tretinoin — licensed in over 12 yrs
  • Isotretinoin — licensed in adults
  • Apply once to twice a day (may be less if not well tolerated)
  • Use sparingly to cover whole affected area (not just visible spots)
  • Avoid in pregnancy, cautioned in breastfeeding
  • Increased photosensitivity
  • ADR: skin irritation (blistering, burning, dryness, erythema, pruritis etc); eye irritation
• Topical antibiotics for acne

  • UK licensed included clindamycin and erythromycin
  • Usually once to twice a day
  • Monotherapy not recommended due to antibiotic resistance
  • Systemic absorption can occur = possible interactions and side effects
• Azelaic acid for acne

  • Apply twice a day
  • Cautioned in pregnancy/breastfeeding
• Oral antibiotics for acne

  • Lymecycline or doxycycline can be added to topical preps (no monotherapy due to resistance risk)
  • Minocycline not recommended as increased risk of SE, e.g. lupus, skin pigmentation, hepatitis etc
  • Macrolides, e.g. erythromycin, not recommended due to P, acnes resistance but use if tetracyclines contraindicated, e.g. pregnancy, breastfeeding
• Oral contraceptives for acne

  • Oral POC or progestin implants with androgenic activity may exacerbate acne
  • 3rd and 4th generation COC generally preferred
  • Co-cyprindiol (Dianette) or other ethinylestradiol/cyproterone acetate-containing products may be considered if other treatments have failed
• Isotretinoin for acne


  • Prescribed under specialist care
  • For severe acne, e.g. nodular, risk of permanent scarring etc, which is resistant to standard therapy
  • Rare: sexual side effects, e.g. ED (erectile dysfunction), reduced libido, orgasm difficulty, genital hypoaesthesia
  • Neuropsychiatric reactions therefore monitor for signs of anxiety, depression, suicidal ideation, mood changes etc.
  • Pregnancy prevention programme (PPP) required: effective contraception must be used for at least 1 month before starting treatment, during and at least 1 month after stopping treatment, use at least 1 method of contraception but ideally 2 methods, oral POC not considered effective, barrier methods should be used in conjunction with another method, exclude pregnancy a few days before treatment, every month during the treatment (unless no risk of pregnancy) and 4 weeks after stopping, discontinue treatment and seek prompt medical attention if become pregnant or within 1 month of stopping
• Moderate or severe acne generally require antibiotic therapy
• Referral is required for OTC treatment failure, suspected rosacea, prepubertal or older people (acne's uncommon in these age groups)