Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Stepwise management of acne in primary care:
- General advice: Acne is not caused by poor hygiene; avoid over-cleaning which may cause dryness and irritation. Use a non-alkaline synthetic detergent cleansing product twice daily on acne-prone skin. Avoid oil-based comedogenic skin care products, make-up, and sunscreens; remove make-up at the end of the day. Advise against persistent picking or scratching of lesions to reduce scarring risk. Treatments may irritate skin initially; start with alternate-day or short-contact application to reduce irritation. There is insufficient evidence to support specific diets for acne treatment, but advise maintaining a healthy diet 1,2.
- Mild to moderate acne: Offer a 12-week course of one of the following first-line topical treatments applied once daily in the evening: fixed combination of adapalene (0.1% or 0.3%) with benzoyl peroxide (2.5%), fixed combination of tretinoin (0.025%) with clindamycin (1%), or fixed combination of benzoyl peroxide (3% or 5%) with clindamycin (1%). Consider benzoyl peroxide monotherapy if these are contraindicated or if the patient wishes to avoid topical retinoids or antibiotics. Creams or lotions may be preferable for dry or sensitive skin; gels for oily skin. Adjust concentration or frequency if irritation occurs, gradually increasing application frequency if tolerated 1,2.
- Moderate to severe acne: Offer a 12-week course of one of the following: fixed combination of adapalene with benzoyl peroxide once daily plus oral lymecycline 408 mg or doxycycline 100 mg once daily; or topical azelaic acid (15% or 20%) twice daily plus oral lymecycline or doxycycline once daily. If oral tetracyclines are contraindicated or not tolerated, consider trimethoprim or an oral macrolide (e.g., erythromycin). Combined oral contraceptives (third or fourth generation) may be considered in women as an alternative to systemic antibiotics. Co-cyprindiol (Dianette®) may be considered if other treatments fail but requires careful risk-benefit discussion and discontinuation 3 months after acne control 1,2.
- Important treatment considerations: Do not use monotherapy with topical or oral antibiotics or combine topical and oral antibiotics. Oral tetracyclines can cause photosensitivity. Treatment effects may take 6–8 weeks to become noticeable; emphasize adherence. Topical agents should be applied to the entire affected area, not just visible lesions 1,2.
- Maintenance therapy: After successful treatment, maintenance therapy may not always be necessary. Consider maintenance with fixed combination of adapalene and benzoyl peroxide or monotherapy with adapalene, azelaic acid, or benzoyl peroxide in those with frequent relapse. Review maintenance treatment after 12 weeks 1,2.