Acne vulgaris

Overview

Virtually every adolescent has a few “spots”, however, about 15% of the adolescent population have sufficient problems to seek treatment. In most patients, but not all, the acne clears up by the late teens or early 20s. More severe acne tends to last longer.

Some patients will have persistent acne lasting up to the age of 30 to 40 years, and beyond. These patients often have a family history of persistent acne.

Acne may scar - most of the time this is preventable by using the correct treatment given in a timely fashion (1). See Acne Scarring section below.

Guidelines

The following guidelines / resources may be helpful:

• (1)Acne vulgaris (pcds.org.uk) - includes link to a patient leaflet.
• Acne section of the BNSSG Formulary - includes a list of formulary approved topical treatments and advice on isotretinoin.
• CKS guidelines - Acne Vulgaris
• NICE Guidance NG198 Acne vulgaris: management
• (3)2023 MHRA advice on the introduction of new safety measures for isotretinoin
• British Association of Dermatologist, Acne referral guidance for primary care

General Patient information

• British Association of Dermatologists, General acne Patient Information Leaflet

Isotretinoin

Patients who have tried and are resistant to adequate courses of standard therapy with systemic antibacterials and topical therapy for the management of acne vulgaris (or have experienced issues with scarring) and require Dermatology Specialist team input, to discuss treatment options prior to referral.

Please see Acne section of the BNSSG Formulary for information on acne medications including on Isotretinoin.

Oral isotretinoin is a Red Drug on the BNSSG formulary for use under specialist supervision only. It is licensed for use in severe acne [(such as nodular or conglobate acne or acne at risk of permanent scarring) resistant to adequate courses of standard therapy with systemic antibacterials and topical therapy] (under expert supervision) (3).

The MHRA and NICE guidance highlights that when making a referral to a dermatology specialist the referrer (usually the GP) is to provide information about isotretinoin to the patient and provide counselling (where possible) regarding the expected benefits and risks of isotretinoin treatment.

Patient resources to support this can be found:

• Isotretinoin - British Association of Dermatologists (bad.org.uk) if aged 18 or over.

• Isotretinoin guide for young people – Medicines For Children - if aged under 18.

In particular, please consider counselling your patient on the following risks associated with isotretinoin:

• Need for effective contraception whilst on isotretinoin due to the medication’s teratogenicity, both during treatment and for the recommended timeframe after discontinuation to avoid unintended pregnancy. See ‘pregnancy prevention’ section for information on contraception below.
• Possible mental health side effects such as low mood, depression, anxiety, agitation, aggression, self-harm, suicidal thoughts/attempts (rare), psychosis (loss of touch with reality).
• Possible sexual function side effects. There have been rare reports of patients experiencing a lack of interest in sex (low libido), vaginal dryness, difficulty getting/keeping an erection, reduced sensation in the genitals.

These risks will also be discussed with the patient at their secondary care appointment, but it is good for the patient to be aware of the potential adverse effects and monitoring requirements associated with isotretinoin ahead of this appointment to allow them to consider other potential treatments.

Report side effects associated with isotretinoin via the MHRA yellow card scheme

Pregnancy prevention programme

Spironolactone

The recent ‘Spironolactone for acne in females’ (SAFA) study of spironolactone for acne has shown that it is an effective treatment for persistent acne in adult females. It can be used with a topical treatment instead of, or in addition to, antibiotics or hormonal treatments.

Please note: Spironolactone is contraindicated in pregnancy due to the risk of feminisation of a male foetus.

Referral

PCDS advises referral for acne vulgaris in the following scenarios (1):

• Severe acne - refer early
• Moderate acne only partially responding to treatment and starting to scar and/or causing significant hyperpigmentation (more common in patients with skin of colour)
• Patients with associated and severe psychological symptoms, regardless of the physical signs

If referring for possible isotretinoin treatment please consider the following:

• Bloods - check U&Es, LFTs, and fasting lipids. This is helpful for the secondary care team and can speed up the process for the patient if isotretinoin is appropriate.
• Contraception - Female patients during their reproductive years need to be on highly effective contraception (see advice in pregnancy prevention section above).
• Sharing patient’s current and past medical history (including mental health history and details of previous treatments for acne) with the specialist.
• Patient leaflet - provide a patient information leaflet on isotretinoin: 
• • Isotretinoin - British Association of Dermatologists (bad.org.uk) if aged 18 or over.
  • Isotretinoin guide for young people – Medicines For Children - if aged under 18 years.

Referral options

• Community dermatology - the community service can see and assess patients with acne (refer via eRS or managed referral) but cannot prescribe isotretinoin.
• Secondary care at UHBW and NBT - refer via eRS but please be aware that waits for outpatient appointments can be long. Please note individual cases cannot be expedited.

Acne Scarring

Severe Active Acne

Patients with active acne and significant scarring should be started on treatment (topical treatment and oral antibiotics) and referred at the same time (marked urgent).  The only exception may be some cases of early scarring in mild-moderate papulopustular acne (as opposed to nodular), when it may be deemed appropriate to commence treatment and review at 6 weeks - if there are no signs of significant improvement then refer. (1)

Post-inflammatory hyperpigmentation 

Post-inflammatory changes tend to improve very slowly (1). If pigmentation affects an exposed site, daily application of SPF 50+ broad-spectrum sunscreen is important to minimise darkening caused by UVR (2). Other treatments are non- formulary and secondary care referrals are not routinely funded (see long term scarring below).

Long term scarring

Up to 50% of scars (especially smaller scars) may improve naturally over 6-12 months. Treatment of established scars is difficult and while some patients will benefit from treatment others will not. Further information is available in PCDS (1).

Referral for treatment of scarring or camouflage is not routinely available on the NHS in BNSSG and is subject to the funding policies below:

• Cosmetic Surgery or Treatment - NHS BNSSG ICB
• Skin Camouflage Services - NHS BNSSG ICB

Resources

(1) Acne vulgaris (pcds.org.uk)

(2) ISOTRETINOIN | Drug | BNF content published by NICE

(3) MHRA Drug Safety Update October 2023, Isotretinoin (Roaccutane▼): introduction of new safety measures, including additional oversight of the initiation of treatment for patients under 18 years of age

(4) Postinflammatory hyperpigmentation | DermNet (dermnetnz.org)

(5) Report of The Commission on Human Medicines Isotretinoin Implementation Advisory Expert Working Group - GOV.UK (www.gov.uk)

(6) Summary of Medicine Characteristics for Isotretinoin 

National risk minimisation materials 

Once isotretinoin is prescribed then patients should be issued with the following national MHRA risk minimisation materials by the prescriber and the pharmacist:

• Acknowledgement of Risk Form
• Patient Reminder Card
• Pharmacist Checklist

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.