Acne

What to consider in Primary Care before referring:

General Comments

• Mild to moderate acne should be managed in primary care.

• Several different agents may need to be tried alone or in combination.
• Do not use combinations of agents with similar properties or actions e.g. topical plus systemic antibiotics.
• Inform patient that response is usually slow and allow at least 12 weeks before review.

Treatment Aims

• To reduce the severity and length of illness.
• To reduce the psychological impact on the individual.
• To prevent long-term sequelae such as scarring

Treatment in primary care

Mild Acne

(Uninflamed lesions - open and closed comedones (blackheads), Sometimes with papules/pustules)

• Topical benzoyl peroxide preparations +/- topical antibiotic:
  Panoxyl
  Brevoxyl
  Quinoderm
  
  (Starting at 2.5% and increasing to 5% or 10% may reduce irritancy with benzoyl peroxide)

• Topical retinoids (avoid in pregnancy):
  Adapalene–Differin (least irritating)
  Isotretinoin - Isotrex
  Tretinoin - Retin-A
  
• Topical antimicrobial combination with retinoid
  Benzoyl peroxide / adapalene - Epiduo
  
  (Use topical retinoids at all stages of acne to help minimise formation of comedone).

• Topical antibiotic combination preparations e.g.
  Erythromycin/Zinc - Zineryt.
  Benzoyl peroxide/Erythromycin - Benzamycin
  Erythromycin/Isotretinoin - Isotrexin
  Erythromycin / tretinoin - Aknemycin Plus
  Clindamycin/Benzoyl Peroxide-DUAC
  
  (May be more effective and aid compliance)

Moderate Acne

(Greater number or more extensive inflamed lesions.)

• Systemic antibiotics
  Lymecycline 408mg bd
  (Lymecycline should be considered 1st line due to cost and compliance (once daily) Treatment should continue for 6 months minimum and repeat if necessary)
  
  Oxytetracycline 500mg bd
  Doxycycline 100mg od/bd
  Erythromycin 500mg bd
  Minocycline MR100mg od/bd
  (Minocycline should be prescribed as last option due to side effect profile)
  
  (Topical benzoyl peroxide or retinoids should be used in combination.  Use topical retinoids at all stages of acne to help minimise formation of comedone.)

Moderate – Severe Acne

(Papules/pustules with deeper inflammation and some scarring.)  

• Systemic treatment as above plus topical therapy.
• Consider additional hormone therapy in women.
• Ethinyloestradiol/Cyproterone acetate - (Dianette)

Severe Acne

(Confluent or nodular lesions usually with significant scarring.)

• Commence systemic therapy and refer immediately for systemic isotretinoin treatment

Referral threshold

• The main reason for referring a patient with acne is for Isotretinoin treatment.
• Females of child bearing age should preferably be established on an oral contraceptive prior to treatment with Isotretinoin.
• The indications for Isotretinoin treatment are as follows:
  1. Severe nodulo-cystic acne or acne fulminans (refer immediately)
  2. Moderate acne that has failed to respond to prolonged (i.e. more than six months) courses of systemic antibiotic treatment in addition to topical treatment.
  3. Mild to moderate acne in patients who have an extreme psychological reaction to their acne and have failed to respond to prolonged courses of systemic antibiotic treatment and topical treatment

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