How should I approach the management of acne vulgaris in a patient with significant scarring?

When managing acne vulgaris in a patient with significant scarring, the approach should primarily focus on preventing further scarring and addressing existing scars and their impact ¹,².

• Discussion and Information: Discuss the patient's concerns and provide information tailored to their needs ¹,². This should cover possible reasons for their scars, the importance of treating ongoing acne to help prevent further scarring, potential treatment options for acne-related scarring, how their scars may change over time, and any psychological distress ¹,². Advise the patient that persistent picking or scratching of lesions can increase the risk of scarring ¹,².
• Referral to Specialist Care: Refer the patient to a consultant dermatologist-led team with expertise in scarring management if acne-related scarring is severe and persists a year after their acne has cleared ¹,². Consider referral to a consultant dermatologist-led team or a nationally accredited GP with an Extended Role (GPwER) if their acne is leading to scarring ². Referral for specialist treatment is also recommended for people who have or are at risk of scarring ¹. Oral isotretinoin, a highly effective anti-acne therapy, is indicated in people with a tendency for acne-related scarring ¹. If considering referral for isotretinoin, ensure urea and electrolytes, liver function tests, and fasting lipids are checked and documented ¹.
• Managing Ongoing Acne: Treatment of ongoing acne is crucial to prevent further scarring ¹,². For moderate to severe acne, first-line options typically include a 12-week course of a fixed combination of topical adapalene with topical benzoyl peroxide, or topical tretinoin with topical clindamycin ¹. These topical combinations can be used with oral lymecycline or doxycycline ¹. Topical azelaic acid with oral antibiotics is another option ¹. Topical benzoyl peroxide monotherapy can be considered if other options are contraindicated ¹. Avoid monotherapy with topical or oral antibiotics, or a combination of both ¹. Combined oral contraceptives can be considered in women as an alternative to systemic antibiotics ¹.
• Addressing Psychological Distress: Discuss psychological distress related to acne and scarring ¹,². Consider referral to a consultant dermatologist-led team or GPwER if acne of any severity is causing or contributing to persistent psychological distress or a mental health disorder ². Referral to mental health services should be considered if the patient experiences significant psychological distress or a mental health disorder, including suicidal ideation, self-harm, severe depressive or anxiety disorder, or body dysmorphic disorder ².
• Treatment for Scars (Specialist Setting): Specific treatments for severe, persistent acne-related scarring, such as CO2 laser treatment (alone or after punch elevation) or glycolic acid peel, are considered in a consultant dermatologist-led team setting after referral ².