Dermatology specialist nurse Julie Van Onselen offers her top tips for management of acne in primary care
Acne is a very common skin condition in the UK. While mainly seen in young people, it can also affect adults. Males tend to have more severe acne as young people, but women are more likely to continue to have acne into adulthood, with 45% of women aged 21-30 years affected, and 26% aged 31-40 years.1 Acne is associated with psychological problems and if not treated can cause scarring. This article offers some tips to help nurses manage acne in primary care.
- Always examine the face, back and chest
Acne assessment needs to include patient history, family history and clinical examination of the face, chest and back. It is important to always examine all these areas to ensure a full assessment of the location and severity of the acne. Remember to record visible acne lesions (comedones, papules, pustules and nodules) and any evidence of scarring. Acne is seen on the face (99% of all cases), the back (60% of all cases) and the chest (15% of all cases).2
- Ask the patient how much their acne bothers then
A psychological assessment of acne is vitally important. A simple way to assess this is the ask the patient to rate on a score of 1 to 10, ‘how much does your acne bother you?’ (10 being the worst). The psychological effects of acne should never be underestimated, and psycho-social effects can be seen in all severities of acne, including mood disturbance, and not thriving at school.3 Severe acne is particularly associated with social and psychological problems, including suicidal ideation and depression.3 If a patient does report being bothered by their acne or has a low mood, the Patient Health Questionnaire (PHQ)-9 is also recommended – this has reliability and validity for preliminary screening of depression in acne.4
- Match treatment to severity – and review every 12 weeks
NICE acne management guidelines recommend mild to moderate acne (defined as any number of comedones or 1-34 inflammatory lesions, or 1-2 nodules) is treated topically, either with over-the counter or prescribed products.5 Moderate to severe acne (defined as either or both 35 inflammatory lesions and 3 or more nodules) usually requires a prescribed topical non antibiotic preparation (for example, Epiduo, a combined retinoid/benzoyl peroxide preparation) combined with oral antibiotics (lymecycline or doxycycline; or erythromycin in pregnancy). Each treatment course should be 12 weeks, and a review date should be booked. NICE recommends no more than 6 months treatment with oral antibiotics.
- Consider contraception choices carefully
If a female patient with acne wishes to use hormonal contraception, NICE advises offering the combined oral contraceptive (COC) pill in preference to progesterone-only (POP) pill. Note that both POP and long-acting reversible contraceptives (LARCs) can make acne worse.6
In terms of contraception as a treatment, NICE recommends COC (co-cyprindiol or an alternative) as a second line option for acne, but only in the context of PCOS.
The Primary Care Dermatology Society (PCDS) supports contraception as a treatment option for acne, alone or in combination with topical/oral treatments as above, and recommends second/third generation COC with a lower oestrogen level (20 mcg), for example Eloine or Mercilon. Co-cyprindiol (Dianette) is now reserved for moderate or severe acne, when other COC pills have not helped, due to being associated with an increased risk of venous thrombosis.7 The PCDS web page on acne and acne treatment pathway gives practical guidance on COC and acne.6
- Always advise on how to apply topical treatments
Acne topical treatments need to be applied to the whole area (face, back and/or chest) not just the individual lesions. The most common patient application error is applying to the ‘spots’ only, so do explain that treatment is anti-acne, hence applying to the whole area affected.
Also advise patients to wash hands before applying a thin film of once daily treatment, best applied at night.
Benzoyl peroxide products can bleach, so advise patients to use old pillowcases and towels; it can also be very drying, so advise use of an emollient lotion or light cream labelled oil-free (non-comedogenic) and fragrance-free for washing, make-up removal and moisturising.
The PCDS web page on acne is a helpful resource including practical advice for patients on managing acne, as is the British Association of Dermatologists (BAD) patient information web page.6
- Include general skin care advice
NICE provides guidance for skin care and recommends syndets (synthetic detergents) that are non-alkaline (neutral pH or slightly acidic [pH 5.5]) for washing, which helps to maintain the skin barrier properties.5 Emollients containing nicotinamide may be helpful for their anti-inflammatory effects (eg, Adex Gel or Effaclar Duo).
Patients should be advised to wash the acne areas twice a day in lukewarm water with either an antimicrobial emollient or acne cosmetic wash, then pat dry. All make-up should be removed prior to washing. Advise not to scrub when washing or use harsh facial scrubs.
Encourage non-comedogenic (labelled on the product, meaning formulated not to block skin pores) make up and light foundation, but advise patients to try to have some foundation-free periods.
- Know when to refer to dermatology
NICE recommends urgent referral to dermatology for acne fulminans.5
Routine referral is recommended for:5,7
- Acne conglobata, nodulocystic acne, or where there is diagnostic uncertainty.
- Mild to moderate acne that has not responded to two completed courses of treatment.
- Moderate to severe acne that has not responded to previous treatment that includes an oral antibiotic.
- Acne with scarring.
- Acne with persistent pigmentary changes.
- Acne of any severity, or acne-related scarring, which is causing or contributing to persistent psychological distress or a mental health disorder. Consider direct referral to mental health services if a patient expresses suicidal ideation, has body dysmorphia, or severe anxiety and depression.
A referral to secondary care will often be for consideration of isotretinoin. NICE recommends fully informing the patient (and family as appropriate) about the potential risks of isotretinoin treatment (including pregnancy prevention) as well as the expected benefits before referral to the consultant-dermatologist-led team. It is helpful to direct patients to the BAD isotretinoin patient information and Acne Support website written by dermatologists, to provide impartial information.
Note current NICE guidelines recommend referral for scarring which persists a year after the acne has cleared. Recommended acne scar treatments are CO2 laser treatment (alone or after a session of punch elevation) or glycolic acid peel.
NICE also advises that condition-specific management or referral to a specialist (for example a reproductive endocrinologist) should be considered, if a medical disorder or medication (including self-administered anabolic steroids) is likely to be contributing to a person’s acne.5
Julie Van Onselen is a Dermatology Lecturer Practitioner at Dermatology Education Partnership Ltd and clinical advisor for the National Eczema Society and Check4Cancer
References
- Perkins A, Maglione J, Greg H et al. Acne vulgaris in women: prevalence across the life span. J Women’s Health 2012; 21(2): 223-230
- Picardo M, Eichenfield LF, Tan J. Acne and Rosacea. Dermatol Ther2017; 7 (Suppl 1):43-52
- Halvorsen JA, Stern RS, Dalgard F et al. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study. J Invest Dermatol 2011 Feb;131(2):363-70
- Peng T, Li ZM, Liu J, Zhang Y. Evaluation of reliability and validity of the Patient Health Questionnaire-9 in patients with acne. Dermatol Ther2020; 33(4):e13584
- NICE. Acne vulgaris management. [NG198] 2021
- PCDS. Acne vulgaris. Last updated 2024
- Arowojolu A, Gallo M, Lopez L et al. Combined oral contraceptive pills for treatment of acne. 2012; Issue 7: CD004425
