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An evidence-based acne guideline from the National Institute for Health and Care Excellence (NICE) provides updated recommendations for managing acne, including both the physical manifestations of the disease as well as its psychological affect. An overview of the guideline was published in the British Journal of Dermatology.

Treatment Recommendations

In the NICE guideline, specific fixed-combination topicals are recommended as first-line therapy if these treatments target 1 or more factors involved in the pathogenesis of acne. This recommendation is made based on evidence confirming that topical combination therapies are more effective and improve treatment adherence better than monotherapies. If fixed-combination therapies are contraindicated, or if a topical antibiotic or retinoid are not acceptable, the NICE guideline recommends benzoyl peroxide as an alternative approach.

Recommended fixed combination first-line therapies include:

• Topical adapalene with topical benzoyl peroxide (once daily in the evening; any severity)
• Topical tretinoin with topical clindamycin (once daily in the evening; any severity)
• Topical benzoyl peroxide with topical clindamycin (once daily in the evening; mild to moderate acne)

Alongside specific fixed combination therapies or azelaic acid, the guideline recommends second-generation oral tetracyclines, such as lymecycline or doxycycline, as first-line therapy for moderate to severe acne. Trimethoprim or an oral macrolide could be considered in cases in which lymecycline or doxycycline are contraindicated or not tolerated. Specifically, the guideline recommends:

• Topical adapalene with topical benzoyl peroxide plus either oral lymecycline or oral doxycycline (moderate to severe acne)
• Topical azelaic acid plus either oral lymecycline or oral doxycycline (moderate to severe acne)

The guideline also recommends the twice-daily use of non-alkaline cleansing products as part of maintenance in patients with acne-prone skin. No evidence was found to support recommendations for dietary interventions.

The recommended course of oral antibiotics is 12 weeks, which the guidelines suggest could reduce the risk for antimicrobial resistance. If acne has cleared at the 12-week review, the guideline suggests clinicians should consider maintenance options. The guideline-recommended maintenance options include topical adapalene, topical azelaic acid, topical benzoyl peroxide, or a combination regimen of topical adapalene with topical benzoyl peroxide.

The NICE guideline suggests clinicians may wish to consider continuing oral and topical treatments for up to 12 additional weeks if acne is improving but not yet clear. In mild to moderate acne, the NICE guideline recommends offering patients another first-line treatment option. In moderate to severe cases that failed to respond to a 12-week course of a first-line treatment that did not include an oral antibiotic, the guideline recommends that clinicians consider another option that includes an oral antibiotic. In contrast, referral should be made to a consultant dermatologist-led team in moderate to severe acne cases that showed no benefit on a 12-week oral antibiotic course.

Only “exceptional” cases should continue antibiotics for longer than 6 months, the guideline committee stated. Clinicians are recommended to perform 3 monthly reviews and halting antibiotics as soon as possible.

Oral isotretinoin is recommended for severe acne, including acne that poses a risk for permanent scarring and is resistant to standard therapy with systemic antibacterial and topical treatments. Several recommendations for isotretinoin are made in regard to initiation, dosage, monitoring, and treatment duration:

• Initiation
  • Oral isotretinoin could be considered in patients older than 12 years of age who have severe acne resistant to adequate course of standard treatment with systemic antibiotics and topical therapy. Examples of these forms of acne include:
    • Acne at risk for permanent scarring
    • Acne conglobata
    • Acne fulminans
    • Nodulo-cystic acne
  • Take into consideration a patient’s psychological wellbeing and refer them to mental health services before treatment initiation
  • Follow Medicines and Healthcare products Regulatory Agency (MHRA) safety advice on isotretinoin for severe acne and MHRA pregnancy prevention program if the patient can become pregnant
• Dosage
  • Prescribe at a standard daily dose of 0.5 mg/kg to 1 mg/kg
  • Consider dose adjustment with a reduced daily dose (<0.5 mg/kg) for patients at increased risk for adverse events
• Monitoring
  • Psychological wellbeing should be monitored during treatment
  • Mental health services should be encouraged in patients with signs/symptoms of mental health deterioration during treatment
• Treatment duration
  • Oral isotretinoin should be continued until a patient reaches a total cumulative dose of 120 mg/kg to 150 mg/kg, but treatment could be discontinued sooner if there is an adequate response and no new acne lesions for 4 to 8 weeks

The NICE guidelines note that the combined oral contraceptive pill could be considered as a first-line treatment “if hormonal contraception is required,” but notes that current data for this treatment does not show clear efficacy.

Photodynamic therapy is recommended for adults with moderate to severe acne who have found other treatments either ineffective, not tolerated, or contraindicated.

Although  evidence is presented for the use of glycolic acid peels, CO2, laser monotherapy, and CO2 laser for acne scars, the NICE guidelines suggest not all of these treatments are feasible and the use of these options “will depend on the type of scarring and clinical judgment.”

Mental health is also emphasized in the guideline. Specifically, dermatologists and other clinicians who manage patients with acne are encouraged to assess and support mental health issues associated with the disorder.

Disclosure: Several authors declared affiliations with the pharmaceutical industry. Please refer to the original article for a full list of disclosures.

Reference

Layton AM, McDonald BS, Mohd Mustapa MF, Levell NJ. National Institute for Health and Care Excellence (NICE) acne guideline: what’s the latest for dermatologists? Br J Dermatol. Published online November 28, 2021. doi:10.1111/bjd.20888