How should I approach the management of acne vulgaris in a patient with significant scarring?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 14 August 2025Updated: 14 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

When managing acne vulgaris in a patient with significant scarring, the approach should primarily focus on preventing further scarring and addressing existing scars and their impact ,.

  • Discussion and Information: Discuss the patient's concerns and provide information tailored to their needs ,. This should cover possible reasons for their scars, the importance of treating ongoing acne to help prevent further scarring, potential treatment options for acne-related scarring, how their scars may change over time, and any psychological distress ,. Advise the patient that persistent picking or scratching of lesions can increase the risk of scarring ,.
  • Referral to Specialist Care: Refer the patient to a consultant dermatologist-led team with expertise in scarring management if acne-related scarring is severe and persists a year after their acne has cleared ,. Consider referral to a consultant dermatologist-led team or a nationally accredited GP with an Extended Role (GPwER) if their acne is leading to scarring . Referral for specialist treatment is also recommended for people who have or are at risk of scarring . Oral isotretinoin, a highly effective anti-acne therapy, is indicated in people with a tendency for acne-related scarring . If considering referral for isotretinoin, ensure urea and electrolytes, liver function tests, and fasting lipids are checked and documented .
  • Managing Ongoing Acne: Treatment of ongoing acne is crucial to prevent further scarring ,. For moderate to severe acne, first-line options typically include a 12-week course of a fixed combination of topical adapalene with topical benzoyl peroxide, or topical tretinoin with topical clindamycin . These topical combinations can be used with oral lymecycline or doxycycline . Topical azelaic acid with oral antibiotics is another option . Topical benzoyl peroxide monotherapy can be considered if other options are contraindicated . Avoid monotherapy with topical or oral antibiotics, or a combination of both . Combined oral contraceptives can be considered in women as an alternative to systemic antibiotics .
  • Addressing Psychological Distress: Discuss psychological distress related to acne and scarring ,. Consider referral to a consultant dermatologist-led team or GPwER if acne of any severity is causing or contributing to persistent psychological distress or a mental health disorder . Referral to mental health services should be considered if the patient experiences significant psychological distress or a mental health disorder, including suicidal ideation, self-harm, severe depressive or anxiety disorder, or body dysmorphic disorder .
  • Treatment for Scars (Specialist Setting): Specific treatments for severe, persistent acne-related scarring, such as CO2 laser treatment (alone or after punch elevation) or glycolic acid peel, are considered in a consultant dermatologist-led team setting after referral .

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