13.6 Acne and rosacea

General Guidance

• In very mild acne the exfoliating action of regular cleansing of the affected skin may be adequate. The choice of topical preparation depends on whether the acne is inflammatory or comedonal.
• - significant comedonal acne responds well to topical retinoids, whereas both comedonal and inflamed lesions respond well to benzoyl peroxide.
  - topical antibiotics should generally be avoided due to concerns of antimicrobial resistance, if one is required clindamycin may be a reasonable option since it is rarely used systemically nowadays.
• In moderate acne oral antibiotics are effective. Most treatment failures with tetracyclines are due to inadequate dose over too short a time or poor patient compliance. Treatment for at least 3-6 months is required.
• Co-cyprindiol (Dianette®) is no more effective than oral antibiotics but is useful in women who also wish contraception.
• Systemic therapy with isotretinoin can be very effective for resistant acne. However, it should only be used under the supervision of a specialist.
• There are a variety of washes available, these should be avoided they are of uncertain efficacy compared to other available treatments.

Recommended drugs

Mild/moderate inflammatory acne

Benzoyl peroxide gel

Mild/moderate comedonal acne

Tretinoin gel/cream/lotion

Moderate acne (topical antibiotic)

Clindamycin lotion

Clindamycin 1% and benzyl peroxide 3%, 30g in an aqueous basis (Duac® Once Daily)

Erythromycin 40 mg, zinc acetate 12 mg/mL when reconstituted with solvent containing ethanol (Zineryt®, used twice daily) [Topical solution, powder for reconstitution and solvent to provide 30 mL, or 90 mL]

Moderate acne (oral contraceptive)

Co-cyprindiol 2000/35

Moderate acne (systemic antibiotics)

1st line: Oxytetracycline 500mg bd

2nd line: Doxycycline

3rd line: Minocycline

 

Rosacea

General Guidance

• Mild to moderate disease should be treated with topical metronidazole for at least 9-12 weeks.
• In more severe cases (or those not responding to the trial of topical therapy), topical antibiotics should be combined with systemic antibiotics.
• Potent topical corticosteroids are contra-indications in rosacea.
• Systemic tetracyclines are especially effective in inflammatory lesions but are less effective against erythema and telangiectasia.

​Recommended drugs

1st line: Metronidazole gel 0.75%

2nd line: Oxytetracycline systemic or Erythromycin systemic

3rd line: Doxycycline systemic

 

Drug Traffic Light Key:

Green – On Formulary

Amber – Restricted use, see local guidelines      

Purple – Specialist use/initiation

Red – Non Formulary

 

Relative Costs Key (where indicated):

£££££ - high

£££ - moderate

£ - low