When to refer

Refer to GP, pharmacist independent prescriber or GP with extended role (GPwER) in dermatology:

• If the patient is under 12 years of age
• When one first-line treatment used for an appropriate length of time has not worked and the acne is mild to moderate
• When the acne is moderate to severe with a large number of inflammatory lesions (especially if there are nodules or cysts present)
• When oral acne therapies previously used
• When medication (e.g. anabolic steroids, lithium and some anti-epileptic drugs) may be contributing to the acne
• With acne of any severity (or acne-related scarring) associated with psychological distress or a mental health disorder
• If there is diagnostic uncertainty.

Patient support

All acne treatments need to be used for eight to 12 weeks for the maximum effect to be apparent (although some effects will be visible sooner). This can be dispiriting for patients, especially if advertising claims have led them to expect instant effects. Manage expectations by explaining and supporting.

Acne treatment should be applied to the whole of the acne-prone area and not just dabbed onto spots since comedones are not palpable in the early stages but could be forming in the skin.

Both benzoyl peroxide and retinoids can have drying and irritant effects on the skin. These can be minimised by starting with alternate day or short-contact application (e.g. washing off after an hour). Treatment should be started with the lowest concentration of BPO (2.5%) and may be increased if tolerated. Alternatively, a BPO wash product could be used. 

Treatment should be reviewed both in the early stages (two to four weeks) to check for tolerability and adherence, and at 12 weeks to assess response and consider the need for alternative or maintenance treatment.

Mild wash products should be recommended for skin cleansing. These have neutral to slightly acidic pH value, similar to the skin, in contrast to soap, which is strongly alkaline. As such, they cause less disruption of the skin barrier and less drying of the skin. Containing a blend of synthetic surfactants (detergents) – often described as ‘syndets’ – wash products are widely available in both solid and liquid forms as skin cleansing products.

Examples include (liquids) Sebamed liquid, Purifide pH Control Face Wash, Lipikar Syndet AP+ Cream Wash, and (bars) Sebamed cleansing bar, Cerave Hydrating Cleanser Bar, Eucerin Ph5 Syndet For Sensitive Skin.

Acne patients may need facial moisturisers to balance the effects of drying treatments such as BPO – oil-free, non-comedogenic products are suitable. Avoid using meaningless terms such ‘water-based’. Oil-free moisturisers use dimethicone (or similar) in place of conventional oils for the lipid component.

Acne can have profound psychological effects – watch for changes and refer if necessary. Consider signposting patients to support groups for additional support. Keep a supply of acne information leaflets (e.g. the Self Care Forum acne factsheet: selfcareforum.org/wp-content/uploads/2024/10/8-Acne-202410-V5.pdf), ideally as QR codes for easy patient access.