Acne Vulgaris - Antibiotic Prescribing

Key factors in history

  • Family history of acne
  • Review regular medications that could exacerbate acne (such as oral steroids/anabolic steroids, progesterone-only contraception)
  • Whey protein supplements can exacerbate acne
  • Environmental factors can also exacerbate acne i.e. mask wearing, working in a fatty environment such as a fast food outlet or using hair pomades
  • Consider PCOS if menstrual irregularities also present

Exam

  • Open and closed comedones
  • Inflammatory lesions (papules and pustules)
  • Cysts/scarring (will need referral to specialist at first presentation if these are present)

It is important to document types of lesions, the distribution & grade of acne at baseline (mild, moderate or severe) to help guide initial treatment and judge response to treatment.

Mild inflammatory acne

mid inflammatory acne

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Mild comedonal acne

mild comedonal acne

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Papulo-pustular acne

Image-4-papulo-pustular-acne image-3-papulo-pustular-acne

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Nodulo-cystic acne​

Note: Dermatology referral necessary for consideration of isotretinoin

Image-5-Nodulo--cystic-acne

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Moderate to severe acne with scarring

Note: Dermatology referral necessary for consideration of isotretinoin

Image-5-who-to-refer-for-roaccutane-(moderate-to-severe-with-scarring)

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General Advice for Acne

  • Encourage patient to take photos to monitor progress.
  • Topical treatments may irritate skin at the start of treatment.
  • Response to treatment may not be achieved for 8 weeks.

Treatment

For people receiving treatment for acne who wish to use hormonal contraception, consider using the combined oral contraceptive pill in preference to the progesterone-only pill.

MILD ACNE
Drug Dose Duration +/- Notes
First line treatment:

Benzoyl Peroxide 
5% w/w gel (Acnecide®)

Apply twice weekly to affected area to start and slowly increase frequency as tolerated.

Once tolerated it can be applied every 24 hours.

Can take up to 2 months to take effect.

If effective consider ongoing treatment.

This product may bleach hair & colour fabrics.

Can cause photosensitivity.

Predominantly comedones:

Adapalene 0.1% w/w cream or gel

(Differin®)

Apply twice weekly to affected area to start and slowly increase frequency as tolerated.

Once tolerated it can be applied every 24 hours

Review after 3 months.

If effective consider ongoing treatment.

Contraindicated in pregnancy.

Apply after washing to dry skin.

Can cause photosensitivity.

Adapalene can be used in combination with Benzoyl Peroxide (see table above) or as a combination product (table below)

Adapalene 0.1%/ Benzoyl Peroxide 2.5% gel

(Epiduo®)

Apply twice weekly to affected area to start and slowly increase frequency as tolerated.

Review after 3 months.

If effective consider ongoing treatment.

Contraindicated in pregnancy

Apply after washing to dry skin.

This product may bleach hair & colour fabrics.

Can cause photosensitivity.

Inflammatory lesions (pustules)

Clindamycin/ Benzoyl peroxide 10 mg/g + 50 mg/g Gel

(Duac®)

Apply twice weekly to affected area to start and slowly increase frequency as tolerated.

Once tolerated it can be applied every 24 hours

Review and limit use to 3 months if possible (max. 6 months).

Topical antibiotics should not be used alone nor in combination with oral antibiotics as there is an increased risk of antibiotic resistance.

This product may bleach hair & colour fabrics.

Can cause photosensitivity.

Combination of inflammatory lesions and comedones

1st choice option

Adapalene 0.1%/ Benzoyl Peroxide 2.5% gel

(Epiduo®)

Apply twice weekly to affected area to start and slowly increase frequency as tolerated.

Once tolerated it can be applied every 24 hours.

Review after 3 months.

If effective consider ongoing treatment.

Contraindicated in pregnancy.

Apply after washing to dry skin.

This product may bleach hair & colour fabrics.

Can cause photosensitivity.

2nd line option: if above causes severe irritation or for hyperpigmentation

Azelaic acid 15% gel

(Skinoren®)
Apply every 12 hours

Review after 3 months.

If effective consider ongoing treatment.

MODERATE ACNE NOT RESPONDING TO TOPICAL TREATMENT
(Seek Specialist Advice in Pregnancy)

  • Oral antibiotic should be reviewed if no response seen after 12 weeks of therapy
  • *Oral and topical antibiotic should not be used in combination as there is an increased risk of antibiotic resistance.
Drug Dose Duration +/- Notes
1st choice options

Lymecycline

PLUS

Topical agent from table above (except Duac®)*

408mg every 24 hours

 

As above

Review and limit use to 3 months if possible (max. 6 months)

 
To be continued during & after for maintenance

Contraindicated for children <12yrs old and pregnancy.

Can cause photosensitivity.

Lymecycline 408mg equivalent to 300 mg of tetracycline base).

2nd choice option

Doxycycline

PLUS

Topical agent from table above (except Duac®)*

100mg every 24 hours

As above

Review and limit use to 3 months if possible (max. 6 months)

 
To be continued during & after for maintenance

Not suitable for children <12yrs old and pregnancy.

Can cause photosensitivity.

OR

Trimethoprim

PLUS

Topical agent from table above (except Duac®)*

200mg every 12 hours for 1 month then
300mg every 12 hours for 3 months

As above, to continue during and after oral antibiotic to prevent recurrence.

Not suitable in pregnancy.

Caution re Stevens Johnson Syndrome/ Toxic Epidermal Necrolysis).

Monitor full blood count when on trimethoprim long term.

Please note:

  • Repeat treatment, if necessary, should be with a previously effective antibiotic.
  • Minocycline is not routinely used for management of acne vulgaris but if transcribing from secondary care advise patient of and monitor for abnormal LFT’s, irreversible cutaneous pigmentation and reversible drug induced lupus. Minocycline can cause a blue-grey discolouration of inflamed skin.
SEVERE ACNE

Treatment as per moderate acne but refer for specialist advice. Consider referral for isotretinoin in the following instances:

  • Presence of nodulocystic acne
  • Failure of two different oral antibiotic courses (two 3-6 month courses) with appropriate topical agent.
  • Presence of scarring.

Patient Information

BAD PIl on Acne:

  • Wash skin once daily with gentle skin cleanser or water.
  • Advise not to scrub skin or use astringents as these may rupture comedones and promote inflammatory lesions.
  • Avoid greasy oils, scratching and avoid whey protein and anabolic steroids.
  • Explain limited evidence that diet, washing or hygiene affects acne.

ICGP Report: Acne Management in Primary Care

Acne ICGP Report 2016

Acne Management in Primary Care, ICGP 2016, Dr Johnny Loughnane, GP

Safe Prescribing (visit the safe prescribing page)

  • Doses are oral and for adults unless otherwise stated
  • Dosing in children quick reference dosage/weight guide
  • Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
  • Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed December 2021