July 2021: Treatment of acne in pregnancy and breastfeeding is currently under review, as is second line antibiotic treatment. In the meantime please contact the medicines management team if you have any queries.

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Related guidance: [NG198] Acne vulgaris: management *NEW* June 2021

See guidance for information on support, skin care advice, factors to take into account when choosing a treatment option, mental health, maintenance, relapse and referral to specialist care.

When discussing treatment choices with a person with childbearing potential, cover:
• that topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy and
• that they will need to use effective contraception, or choose an alternative treatment to these options.

If a person receiving treatment for acne wishes to use hormonal contraception, consider using the combined oral contraceptive pill in preference to the progestogen-only pill.


Many topical and oral medications listed are not suitable for children under 12. Seek further advice.

*To reduce the risk of skin irritation associated with topical treatments, such as benzoyl peroxide or retinoids, start with alternate-day or short-contact application (for example washing off after an hour). If tolerated, progress to using a standard application.
Treatment of acneOffer people with acne a 12-week course of 1 of the following first-line treatment options, taking account of the severity of their acne and the person's preferences, and after a discussion of the advantages and disadvantages of each option. See NICE recommendation 1.5.1 for more information.

Discuss the importance of completing the course of treatment, because positive effects can take 6 to 8 weeks to become noticeable.
First-line:
Any acne severity
A fixed combination of topical adapalene with topical benzoyl peroxideEpiduo®0.1%/2.5% gel: £19.53 (45g)

0.3%/2.5% gel: £19.53 (45g)
Apply once daily in the evening

Can cause skin irritation*, photosensitivity and bleaching of hair and fabrics
A fixed combination of topical tretinoin with topical clindamycin Treclin®0.025%/1% gel: £11.94 (30g)Apply once daily in the evening

Can cause skin irritation* and photosensitivity
Mild to moderate acne
Acne severity varies along a continuum. For mild to moderate acne, this includes people who have 1 or more of:
• any number of non-inflammatory lesions (comedones)
• up to 34 inflammatory lesions (with or without non-inflammatory lesions)
• up to 2 nodules.
A fixed combination of topical benzoyl peroxide with topical clindamycinDuac Once Daily®3%/1% gel:
£13.14 (30g)
£26.28 (60g)

5%/1% gel:
£13.14 (30g)
£26.28 (60g)
Apply once daily in the evening

Can cause skin irritation*, photosensitivity and bleaching of hair and fabrics
Moderate to severe acneAcne severity varies along a continuum. For moderate to severe acne this includes people who have either or both of:
• 35 or more inflammatory lesions (with or without non-inflammatory lesions)
• 3 or more nodules.
A fixed combination of topical adapalene with topical benzoyl peroxide, together with either oral lymecycline or oral doxycyclineEpiduo®0.1%/2.5% gel: £19.53 (45g)

0.3%/2.5% gel: £19.53 (45g)

Apply once daily in the evening

Can cause skin irritation*, photosensitivity and bleaching of hair and fabrics
Lymecycline408mg capsules: £6.34 (28)
£12.68 (56)
Lymecycline 408mg once daily

Can cause photosensitivity
orDoxycycline100mg capsules:
£1.19 (8)
Doxycycline 100mg once daily

Can cause photosensitivity
Topical azelaic acid with either oral lymecycline or oral doxycyclineSkinoren®

or

Finacea®
20% cream: £4.49 (30g)



15% gel: £7.48 (30g)
Apply twice daily
Lymecycline408mg capsules: £6.34 (28)
£12.68 (56)
Lymecycline 408mg once daily

Can cause photosensitivity
orDoxycycline100mg capsules:
£1.19 (8)
Doxycycline 100mg once daily

Can cause photosensitivity
Second-line:Consider topical benzoyl peroxide monotherapy as an alternative treatment to the first-line options, if:
-these treatments are contraindicated, or
-the person wishes to avoid using a topical retinoid, or an antibiotic (topical or oral).
Benzoyl peroxideAcnecide®5% gel:
£5.44 (30g)
£10.68 (60g)
Apply once or twice daily. Sensitive skin, apply once daily before bed.

Can cause skin irritation*, photosensitivity and bleaching of hair and fabrics

Acnecide is a P medicine and can be purchased in a pharmacy

Second line oral antibiotic:
For people with moderate to severe acne who cannot tolerate or have contraindications to oral lymecycline or oral doxycycline, consider replacing the medicines in the combination treatments with erythromycin
Erythromycin250mg tablets: £4.28 (28)250mg-500mg twice daily

(Second line due to resistance problems)
Review after 12 weeks as follows:- treatment failure – try another 12 week option
If oral plus topical treatment in combination, then at 12 weeks review as follows
- acne cleared up - consider stopping oral and treat 12 weeks with topical.
- acne improved but not clear – continue both for a further 12 weeks.
-second 12 week failure consider referral to dermatology team.
Only in exceptional circumstances continue treatment with oral or topical antibiotics beyond 6 months.
NICE recommends NOT using the following to treat acne:
• monotherapy with a topical antibiotic
• monotherapy with an oral antibiotic
• a combination of a topical antibiotic and an oral antibiotic.
Maintenance treatment of acne
First-line:
Consider maintenance treatment with a fixed combination of topical adapalene and topical benzoyl peroxide if a history of frequent relapse after treatment
Adapalene/benzoyl peroxide as
Epiduo®
0.1%/2.5% gel: £19.53 (45g)

0.3%/2.5% gel: £19.53 (45g)
Apply once daily in the evening

Can cause skin irritation*, photosensitivity and bleaching of hair and fabrics
Second-line:
If first-line maintenance treatment not tolerated, or contraindicated, consider topical monotherapy with adapalene, azelaic acid, or benzoyl peroxide.
Adapalene as
Differin®

or

Azelaic acid as
Finacea® or
Skinoren®

or

Benzoyl peroxide as
Acnecide
0.1% gel: £16.43 (45g)
0.1% cream: £16.43 (45g)




15% gel: £7.48 (30g)
20% cream: £4.49 (30g)



5% gel:
£5.44 (30g)
£10.68 (60g)
Review maintenance treatments for acne after 12 weeks to decide if they should continue









Acnecide is a P medicine and can be purchased in a pharmacy

Treatment options for people with polycystic ovary syndromeFor people with polycystic ovary syndrome and acne:
-treat their acne using a first-line treatment option
-if the chosen first-line treatment is not effective, consider adding ethinylestradiol with cyproterone acetate (co-cyprindiol) or an alternative combined oral contraceptive pill to their treatment
-for those using co-cyprindiol, review at 6 months and discuss continuation or alternative treatment options.

Consider referring people with acne and polycystic ovary syndrome with additional features of hyperandrogenism to an appropriate specialist (for example, a reproductive endocrinologist).
Co-cyprindiol (Cyproterone acetate/ethinylestradiol)Dianette®2mg/35mcg tablets: £7.71 (63)The risk of VTE with Co-Cyprindiol is higher than with conventional low-dose COCPs and it is recommend that:
• it should only be used if the chosen first-line treatment is not effective
• it should only be used in licensed indication
• it should not be used solely for contraception
• for those using co-cyprindiol, review at 6 months and discuss continuation or alternative treatment options.
Oral isotretinoin is a

RED

drug
See MHRA Drug Safety Update and Safety Advice. If the person has the potential to become pregnant then they will need to follow the MHRA Pregnancy Prevention Programme.
Treatment of acne in pregnancySee CCG Medicines in Pregnancy, Children & Lactation webpage for more detailed information

Advise parent to ensure that topical treatments don't come into contact with child's skin if breastfeeding
First line
Benzoyl peroxide/clindamycin
Duac Once Daily®3%/1% gel:
£13.14 (30g)
£26.28 (60g)

5%/1% gel:
£13.14 (30g)
£26.28 (60g)
Can be used with caution during pregnancy and breastfeeding
Benzoyl peroxideQuinoderm® creamCurrently unavailableBenzoyl Peroxide, hydrous / Potassium Hydroxyquinoline Sulfate 5% / 0.5% cream

July 2021 - Currently unavailable

Can be used with caution during pregnancy and breastfeeding
Acnecide®Gel: £5.44 (30g)
£10.68 (60g)
Wash gel: £5.44 (50g)
Benzoyl peroxide 5%
Gel: once or twice daily.
Wash: twice daily.

Can be used with caution during pregnancy and breastfeeding
Second-line: Topical erythromycinZinerytLotion: £7.71 (30ml)
£16.68 (90ml)
Erythromycin 40mg/ml / Zinc acetate 12mg/ml
Twice daily for 10-12 weeks.

Can be used with caution during pregnancy and breastfeeding
13.6.3: Rosacea
First line: Topical Metronidazole or Azelaic Acid
1st – option Topical MetronidazoleRozex®Cream: £6.60 (30g)
£9.88 (40g)
Gel: £6.60 (30g)
£9.88 (40g)
Inflammatory papules, pustules and erythema of rosacea
Metronidazole 0.75% w/w, Propylene glycol 30 mg/g
Propyl parahydroxybenzoate (E216) 0.2 mg/g
Methyl parahydroxybenzoate (E218) 0.8 mg/g
Twice daily for up 3-4 months.
Acea®
Gel: £9.95 (40g)Metronidazole 0.75%
Acute inflammatory exacerbations of rosacea
Twice daily for 8 weeks.
Rosiced®Cream: £7.50 (30g)inflammatory papulo-pustules rosacea
metronidazole 0.75%
Twice daily for 6-12 weeks.
2nd option: Topical Azelaic acidFinacea®Gel: £7.48 (30g)Azelaic acid 15%
For the relief of mild to moderate papular-pustular acne of the facial area.
For the topical treatment of papulopustular rosacea.
Twice daily.
Second line: Topical IvermectinSoolantra®Cream: £18.29 (30g)One gram of cream contains 10 mg of Ivermectin
Licensed for the treatment of the inflammatory lesions of rosacea. NICE guidance due in December 15empag. More costly than topical metronidazole (roughly £14) but it may stop a cohort of patients progressing to oral antibiotics.
It has good evidence and, unlike other products, it is a parasiticidal and is thought to target mites that are associated with rosacea.
Apply once daily for up to 4 months. Discontinue if no improvement after 3 months
Third line: Topical BrimonidineMirvaso®
see MHRA alert
Gel: £33.69 (30g)One gram of gel contains 3.3 mg of brimonidine, equivalent to 5 mg of brimonidine tartrate.
Facial erythema of rosacea in adult patients provided that patients have tried all other alternatives and that redness is a significant problem.

AWMSG Clinical expert summary 27/08/15: It was highlighted by experts that the effect of topical brimonidine on erythema is short lasting. They felt that it should not be used daily since it has an extreme pallor effect and an extreme rebound reaction after 12 hours; generally patients would be advised to limit its use to special occasions where pallor is required temporarily. One exception however, might be when the patient’s occupation involves facing the public on a daily basis; then a regular treatment may be necessary.
MHRA ALERT
Brimonidine gel (Mirvaso): risk of systemic cardiovascular effects; not to be applied to damaged skin
Systemic cardiovascular effects including bradycardia, hypotension, and dizziness have been reported after application.
Link to MHRA alert