Executive summary
- Timeline: Manage expectations. Treatments take 8-12 weeks to work. Do not switch before then.
- Antibiotic Stewardship: Do NOT use oral antibiotics monotherapy (resistance risk). Always combine with topical Benzoyl Peroxide/Retinoid. Limit oral course to 3-6 months.
- Scarring: Any scarring risk = Upgrade urgency. Lower threshold for oral antibiotics or referral.
Treatment Ladder
- Step 1: Mild/Moderate (Topicals)
- Fixed Combo (First Line): Adapalene + Benzoyl Peroxide (e.g., Epiduo) od. Apply thin layer to whole area, not just spots.
- Alternative: Clindamycin + Benzoyl Peroxide (Duac). (Limit to 12 weeks to avoid resistance).
- Warning: Bleaches towels/sheets. Causes dryness/irritation (start alternate days if sensitive).
- Step 2: Moderate/Severe (Oral Antibiotics)
- Lymecycline: 408mg od for 3 months (review). Max 6 months.
- Doxycycline: 100mg od. (Risk of photosensitivity).
- Must combine with: Topical Adapalene or Benzoyl Peroxide (to prevent resistance).
- Step 3: Contraception (Females)
- Combined Oral Contraceptive Pill (COCP): Dianette (Co-cyprindiol) is licensed for severe acne. Use for 3-4 months after skin clears then switch to lower risk pill due to VTE risk.
- Step 4: Referral (Isotretinoin/Roaccutane)
- Refer if: Severe nodulo-cystic acne, scarring, or failure of 2x courses of antibiotics + topicals.
- Psychological: Refer early if significant distress, regardless of severity.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.