SYMPOSIUM: DERMATOLOGY
A practical guide to the
assessment and
management of acne
vulgaris
Jane Ravenscroft
Damian Wood
Alison Layton
Abstract
Acne vulgaris (syn: acne) is very common and paediatricians are in an
ideal position to assess a young person and start first line treatment.
This article provides a practical guide to assessing a young person
with acne, giving accurate information about the condition, and start-
ing them on a treatment journey. The association between acne and
mental health is considered and advice offered regarding which treat-
ments to prescribe, for how long, when to review, and when to refer on
to dermatology. Indications for topical treatments, antibiotics, hor-
monal treatments and oral isotretinoin are discussed.
Keywords acne vulgaris; assessment; isotretinoin; management
Introduction
Acne is the commonest inflammatory dermatosis. The preva-
lence is increasing, and it appears to be presenting earlier and
lasting longer. The burden of acne is concentrated in adolescents
between 10 and 19 years, with a sharp drop off after the age of
20.1 However, some people will have persistent disease. The
visible nature of acne makes it a cosmetically unacceptable
problem for many young people and having acne may result in
significant impairment of psychosocial wellbeing and quality of
life.2 Around 20% of adolescents will have moderate to severe
acne. Acne is usually triggered by the hormonal changes of pu-
berty, resulting in increased sebum production, changes in the
pilosebaceous follicles, colonization with Cutibacterium acnes
(C. acnes, formerly known as Propionibacterium acnes) and
inflammation resulting from both innate and adaptive immune
Jane Ravenscroft MB ChB Hons MRCP Consultant Dermatologist,
Nottingham University Hospitals NHS Trust, UK. Conflicts of interest:
none declared.
Damian Wood MB ChB DCH FRCPCH Consultant Paediatrician,
Nottingham Children’s Hospital, UK. Conflicts of interest: none
declared.
Alison Layton MB ChB FRCP Consultant Dermatologist, Harrogate
Hospital and Clinical Lead, Skin Research Centre, York University,
UK. Conflicts of interest: Alison Layton has acted as a consultant for,
been chief investigator for research grants (funded to institution) and/
or received honoraria for unrestricted educational events from
Alliance, Almirall, GSK, Galderma, La Roche Posay, L’Oreal, Leo,
Mylan, Meda, Novartis, Proctor and Gamble, and Origimm.
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reactions. Genetic factors may influence both acne severity and
duration of the disease. Early and effective treatment of acne can
improve outcomes and prevent long term problems such as
scarring and hyperpigmentation.
Clinical presentation
Acne occurs most commonly on the face and may also involve
the back and chest. Greasy skin (seborrhoea), is accompanied by
primary non-inflammatory lesions or comedones (blackheads
and whiteheads), and inflammatory lesions (papules, pustules
and nodules). Acne can vary in severity from a few localized non
inflamed and/or superficial inflamed spots to a more severe
widespread condition with deep seated, inflamed, tender pus-
tules, nodules or cysts. Although acne often improves with age, it
can be associated with secondary changes including erythema-
tous macular lesions which can take time to fade and other
longer term sequelae including hyperpigmentation and scarring.
Approach to the young person with acne vulgaris
History
History should include age of onset, initial distribution of lesions,
menstrual/pubertal history, family history of acne, current and
previous treatment (over the counter/internet and prescribed),
and impact on self-esteem, mood and daily activities including
relationships/school/sport. Acne with onset between 2 and 7
years should raise concern about an endogenous hormonal
problem. Predisposing or exacerbating factors should be
considered (Table 1).
Underlying mental health disorders such as anxiety, depres-
sion, obsessive compulsive disorder (OCD), body dysmorphic
disorder (BDD) and eating disorders can be associated with acne.
Psychosocial risk assessment and mood screening should be car-
ried out for all patients presenting with acne. There is no
consensus on the most appropriate tools to assess mood but the
ideal approach should include using a structured adolescent psy-
chosocial framework of questions such as the HEEADSSS assess-
ment, and Patient Reported Outcome Measures e.g. Patient Health
Questionnaire (PHQ-9 or PHQ-Adolescent; www.corc.uk.net/
outcome-experience-measures/patient-health-questionnaire-phq/)
and the Cardiff Acne Disability Index. Information regarding
gender and sexual identity, history of soya allergy, migraines with
aura, heavy menstrual bleeding and venous thromboembolic risk
may all inform treatment options.
Examination
Examination should assess the severity of acne, pubertal stage
and presence of hyperandrogenism or other hormonal imbalance
e.g. virilization, hirsutism, galactorrhoea, obesity, acanthosis
nigricans. There are a number of scales for assessing acne
severity but there is no standardized validated or accepted tool
and most clinicians would consider acne as mild, moderate or
severe, depending on the following features:
 Extent of acne on the face, back, shoulders or chest.
 The degree of seborrhoea. Increased sebum can predispose
to more severe disease.
 Type and number of inflamed and non-inflamed lesions.
 Excoriations, which may indicate a background anxiety and
self-induced picking.
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 SYMPOSIUM: DERMATOLOGY

Exacerbating factors for acne

Exacerbating factor for acne Comments

Hyperandrogenism May be exogenous from anabolic

Drugs
Pomades (greasy products used
on skin and hair)
Environmental factors
Picking and squeezing spots
steroids, or endogenous. See
Table 2 for investigations which
may be considered
Systemic steroids, cyclosporine,
anticonvulsants, chemotherapy
eg epidermal growth factor
receptor (EGFR) inhibitors
Should be avoided in acne prone
areas
Figure 1 Moderate facial acne with superficial papules, pustules and
Humid environment, excess comedones.
sweating, friction from clothes,
face masks
Can make scarring worse. Acne
excoriee is a particular type of
acne more common in females.
May be associated with
underlying anxiety.

Table 1

 Scarring, which may include depressed (atrophic) scars and

raised (hypertrophic or keloid) scars.
 Other sequelae: Hyperpigmentation and erythema.
The NICE guidelines3 propose a severity measure based on
lesion type and count to help distinguish between mild/moderate
and severe acne. (Box 1). Some examples of acne of varying
severity are shown in Figures 1 to 3.

Investigation
Investigations are rarely required to diagnose or assess acne.
Consider hormonal investigations if acne onset is between 2 and
7 years, acne pattern is atypical, refractory to treatment, or acne
is associated with features of hyperandrogenism (Table 2).

Management of adolescent acne

The aims of treatment are to improve psychosocial wellbeing, Figure 2 Severe facial acne with inflammatory lesions, comedones,
alleviate physical symptoms such as pain and discharge, and macular erythema, hyperpigmentation and early scarring.

Determining acne severity by lesion type and count as

per NICE guidance3
Mild to moderate acne
One or more of:

C any number of comedones

C up to 34 inflammatory lesions (with or without non-inflammatory
lesions)
C up to 2 nodules

Severe acne
C 35 or more inflammatory lesions (with or without non-
inflammatory lesions)
C 3 or more nodules

Box 1 Figure 3 Severe acne on the back with atrophic scarring.

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 SYMPOSIUM: DERMATOLOGY

irritation and will take several weeks to see full benefit. Factors
Investigations for acne when hormonal abnormality which influence choice of treatment include lifestyle factors,
suspected sensitivity of skin, gender and possible risk of pregnancy. The
most effective topical treatments contain a topical retinoid in
Investigation If suspect acne related to
combination with an antibiotic or benzoyl peroxide (BPO), but
these preparations are not always tolerated due to skin irritation.
Total and free testosterone Hyperandrogenism of Polycystic
Topical retinoid or BPO alone, or an azelaic acid preparation, can
ovarian syndrome (PCOS) or
be gentler alternatives. Topical and oral antibiotics should never
rarely, ovarian tumours
be used as monotherapy due to increased risk of developing
Lutenising hormone/follicular PCOS
antibiotic resistance; and topical and oral antibiotics should not
stimulating hormone (LH/FSH)
be used in combination for the same reason. Topical retinoids
ratio
and oral tetracyclines are contra-indicated in pregnancy, there-
Sex hormone binding globulin PCOS
fore pregnancy plans and contraception should always be
17-hydroxyprogesterone Congenital adrenal hyperplasia
considered.
(CAH)
Following discussion, adolescents should be offered a 12-
Urine steroid profile Adrenarche, CAH
week course of a first-line treatment option (Table 3), and a re-
Serum dehydroepiandrosterone Adrenarche, adrenal tumour or
view should be arranged, generally in general practice (GP). At
(DHEAS) CAH
the review a decision should be made regarding ongoing treat-
Prolactin Hyperprolactinaemia -
ment according to response. Oral antibiotics should be stopped
galactorrhoea
as soon as possible due to concerns about anti-microbial resis-
24 hour urinary free cortisol Cushing’s disease or syndrome
tance, and should not be continued for more than 6 months
Table 2 except in exceptional circumstances. Non antibiotic topical
treatment can be continued as long as required.
If the acne has failed to respond adequately to a 12-week course
of a first-line treatment option, treatments choices include a
prevent sequelae of acne. The latest NICE UK acne guidelines
different option from Table 3 or escalation to an oral antibiotic
NICE guideline NG198 (2021) https://www.nice.org.uk/
combination if not previously given. If acne fails to respond
guidance/ng198 published in June 20213 provide a comprehen-
sive evidence-based update for the management of acne in the
UK.

Provision of information
First line acne management (adapted from NICE acne
Patient education and provision of information is important to
guidelines June 20213)
improve understanding and aid successful management of acne. First line treatment options Acne severity
Topics to cover include possible reasons for acne, treatment
options, the benefits and drawbacks associated with treatments, Topical fixed combination All severities
the importance of adhering to treatment, the long term nature of 0.1 adapalene plus 2.5% benzoyl peroxide
acne and required treatment, and what to do if acne relapses after (EpiduoÒ ) once daily
treatment. See Appendix 1 for further information resources for Topical fixed combination All severities
young people and their families. 0.025% Tretinoin plus 1% clindamycin
(TreclinÒ ) once daily
Skin care and dietary advice Topical fixed combination benzoyl peroxide Mild to moderate
Exacerbating factors (Table 1) should be minimized, and skin plus clindamycin (DuacÒ ) once daily
care products, including make up, should be non-oil based. Topical fixed combination Moderate to severe
Mild, non-alkaline (skin pH neutral or slightly acidic) syn- 0.1% adapalene plus 2.5% benzoyl peroxide
thetic detergent (syndet) cleansing products should be (EpiduoÒ ) once daily, in combination with oral
advised, in preference to harsh soaps which can add to skin lymecycline 408 mg daily or doxycycline
irritation. In most cases diet plays no role in acne, and there is 100 mg daily
currently not enough evidence to support specific diets for Topical azelaic acid 10% (SkinorenÒ ) twice daily Moderate to severe
treating acne. in combination with oral lymecycline 408md
daily or doxycycline 100 mg daily
Selection of medical treatment If the above antibiotics not working, not
When selecting treatment for acne, the treatment should be tolerated or contraindicated, consider oral
tailored to the individual to improve treatment satisfaction and macrolide or trimethoprim
benefit. Topical treatments are recommended for all patients, Topical Benzoyl peroxide once daily if above All severities
with the addition of oral antibiotics in those with more severe treatments are contraindicated and there is a
acne. Table 3 summarises the recommendations from the NICE need to avoid topical retinoid or topical
acne guidance regarding first line treatment options. All topical antibiotics
treatments should be applied daily to the whole acne prone area,
and patients should be advised that the treatments can cause Table 3

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 SYMPOSIUM: DERMATOLOGY

adequately to two 12 weeks courses of treatment or the acne is Appendix 1. Further information for Young People and
deteriorating or is at risk of permanent scarring, referral to a Families
consultant dermatology led team is recommended.

Combined oral contraceptive (COC) treatment for British Association of Dermatologists

acne Advice from experts in managing acne
The NICE acne guidance suggests the evidence for the combined www.acnesupport.org.uk
oral contraceptive (COC) pill for acne did not show clear effec- HealthTalk e Acne
tiveness, therefore a COC was not recommended as a treatment Experience of young people with acne
option for patients with a normal hormone profile. If a young www.healthtalk.org/acne
person with acne requires contraception or menstrual control, it Dermatologically Tested Podcast
is, however, preferable to use a COC rather than a progesterone Young people quiz an acne expert
only preparation (POP), as POP may exacerbate acne. The anti- https://www.skinhealthinfo.org.uk/13-adolescent-skin-with-dr-tess-
androgenic COC (Yasmin and Dianette) have an increased as- mcpherson/
sociation with venous thromboembolic risk, thus are only National Institute for Health and Care Excellence Acne Guidance
recommended in patients with polycystic ovary syndrome. Guidance on best practice in acne management
https://www.nice.org.uk/guidance/ng198
Oral isotretinoin treatment
Isotretinoin is an extremely effective drug and the benefits of a 6
e12 month course can be life changing for many patients. Con-
cerns regarding teratogenicity and reports of mood deterioration
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Indications for dermatology referral
Children and young people with severe inflammatory acne
including nodular cystic acne or acne with evidence of scarring
should be referred to a dermatologist. Acne which is very inflamed
or painful should be referred urgently. Patients with acne onset Practice points
under 8 years should be assessed for hormonal abnormalities C Acne is a common problem for children and young people
before referring on for treatment of acne. In other situations the
affecting more than 1 in 5 adolescents. Even with avoidance of
paediatrician may wish to ask the GP to monitor and continue
known exacerbating factors and use of over the counter acne
treatment and refer on to dermatology if acne is not responding.
products a significant proportion will benefit from prescribed
therapy.
Conclusion C Topical treatments are recommended for management, the choice
Acne is a common condition which causes significant impair- will depend upon severity and the degree to which these are
ment of psychosocial well-being and quality of life in young tolerated.
people, which can be independent of the clinical severity of the C The most effective topical treatments contain a topical retinoid in
disease. Paediatricians should consider acne in their assessment combination with an antibiotic or benzoyl peroxide (BPO), but
of adolescents in clinic and initiate first line treatment if these preparations are not always tolerated due to skin irritation.
requested. Prompt, effective treatment for acne can improve long C If oral antibiotics are required for moderate to severe acne, these
term outcomes and prevent disfiguring and permanent sequelae should always be used in combination with a topical product, and
including hyperpigmentation and scarring. Referral to a derma- for no longer than 3e6 months, in order to reduce the risk of
tologist is required for severe acne or acne which has not antibiotic resistance.
responded to adequate courses of first line treatments. A

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