13.6 Acne and rosacea

Topical Treatment

Step 1   Benzoyl peroxide    Start low and increase strength at night
Step 2   DUAC    (benzoyl peroxide 3%, clindamycin 1%)
Step 3   Retinoids    ADAPALINE ,  ISOTRETINOIN

Systemic Treatment

Step 1    LYMECYCLINE     for 6 months, failure of this seek specialist supervision for isotretinoin 

Under specialist supervision only : ISOTRETINOIN

Topical treatment takes at least 30 days to become effective.

Topical antibiotics are as effective as oral antibiotics but encourage resistance and are more expensive.

Topical retinoids are recommended for comedonal acne; they may initially cause redness of the skin.

Tetracyclines may take up to 6 months of compliant use to achieve maximum benefit.

CO-CYPRINDIOL  (cyproterone acetate with ethinylestradiol) is a treatment for severe acne and only in those patients may it also be used as an oral contraceptive (see section 7.3.1).  In those who do not require contraception, Co-cyprindiol should be withdrawn 3-4 cycles after the treated condition has completely resolved.  If ongoing contraception is required, substitution with another COC is likely to maintain the improvement.

Some drugs, including enzyme-inducers and antibiotics, may impair the efficacy of oral contraceptives; see BNF details.

Doxycycline can cause photosensitivity in some patients.  Minocycline may be an alternative but prolonged use should be avoided due to the rare risk of liver damage; liver function tests should be monitored 3 monthly.

Tetracyclines and retinoids (systemic or topical) must be avoided in pregnancy.

Severe acne requires oral antibiotics and referral for consideration of isotretinoin for treatment failures.  Oral isotretinoin (Roaccutane) is a toxic and teratogenic drug which is only prescribable by a consultant dermatologist.


1st        METRONIDAZOLE Topical  
2nd       LYMECYCLINE Oral  

There is no effective treatment for redness of the skin due to rosacea.

Mild rosacea is best treated with a topical agent.

Pustular rosacea is best treated with systemic antibiotics.

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