NICE Acne Guideline: What's the Latest for Dermatologists?

Acne remains the commonest chronic inflammatory dermatosis, affecting up to 96% of adolescents.^[1] Prevalence data suggest acne is presenting earlier and persisting longer.^[2] The negative impact of acne can be profound, and it ranks globally as one of the most burdensome skin conditions.^[3] High-quality, evidence-based guidelines that are practical, relevant, easily accessible and understood by all stakeholders are key to sharing the latest knowledge and implementing effective management. Existing acne guidelines have been shown to have limitations.^[4] Acne guidelines are challenged both by a paucity of trials comparing treatments, and nonstandardized approaches for assessment.^[5]

Recently, the National Institute for Health and Care Excellence (NICE) launched a novel acne guideline informed by robust analyses of the evidence, addressing areas previously lacking from guideline quality appraisals.^[6] It provides practical considerations for clinicians, which should optimize management and guide primary care clinicians on when to refer to dermatologists. Further, it identifies important areas that lack evidence, to inform recommendations and future research. Many of these areas align with those identified in the James Lind Alliance Acne Priority Setting Partnership,^[7] emphasizing the need to invest in research for this common condition. A visual summary of the guideline is featured in Figure 1.

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Figure 1.

Visual summary of the National Institute for Health and Care Excellence (NICE) guideline NG198 (2021) for managing acne vulgaris. Prepared by Dr Jingyuan Xu (Dermatology registrar and clinical research fellow, University of Manchester, UK), on behalf of the NICE guideline committee. Available at: https://www.nice.org.uk/guidance/ng198 (last accessed 4 November 2021).

NICE recommends specific fixed-combination topicals as first-line therapy targeting more than one factor implicated in acne pathogenesis. Evidence confirms topical combination products achieve better efficacy than individual monotherapies, and improve treatment adherence. Benzoyl peroxide is suggested as an alternative if these fixed-combination products are contraindicated, or if a topical retinoid or antibiotic are not acceptable. Nonalkaline cleansing products are recommended twice daily in acne-prone skin and as part of any maintenance regimen. NICE did not find sufficient evidence to support dietary interventions.

For moderate-to-severe acne, second-generation oral tetracyclines (lymecycline, doxycycline) are recommended as first-line therapy alongside specific fixed-combination therapies or azelaic acid. If lymecycline or doxycycline are contraindicated or not tolerated, trimethoprim or an oral macrolide (e.g. erythromycin) should be considered.

Combinations of different topical and oral antibiotics should be avoided. To reduce antimicrobial resistance, oral antibiotics are recommended for 12 weeks. However, if the acne is improving but not clear, consideration should be given to continuing the oral and topical treatments for up to 12 more weeks. The guideline suggests only in exceptional circumstances should a treatment option that includes antibiotics (topical or oral) be continued for more than 6 months. Three-monthly reviews and stopping antibiotics as soon as possible are recommended. This is a potential challenge, particularly for male patients, as fewer systemic treatment options are available. However, future acne treatment developments, including topical antiandrogen and retinoid therapies, and alternative systemic treatments, may help.

The guideline aligns with the Medicines and Healthcare products Regulatory Agency recommendations on use of oral isotretinoin for severe acne, i.e. nodular/conglobate acne or acne at risk of permanent scarring resistant to adequate courses of standard therapy with systemic antibacterial and topical therapies; it also recommends isotretinoin for acne fulminans. NICE recommends that the duration and severity of acne should be considered when prescribing as this correlates with the risk of scarring. Cumulative isotretinoin dosing of 120–150 mg kg^–1 provides a guide to efficacy but if adequate response with no new acne lesions is evident for 4–8 weeks, discontinuing treatment could be considered.

The guideline confirms that 'evidence for the combined oral contraceptive pill did not show clear effectiveness'; however, based on clinical consensus, clinicians could consider it in addition to a first-line treatment option if hormonal contraception is required.

To date, evidence for oral spironolactone is not robust, and this has not been recommended. A study, supported by the National Institute for Health Research Health Technology Assessment, of acne in adult female patients may provide evidence in the future.^[8]

A novel introduction is the recommendation to consider photodynamic therapy for adults with moderate-to-severe acne if other treatments are ineffective, not tolerated or contraindicated.

NICE has identified evidence for three types of treatments for acne scars – glycolic acid peels, CO₂ laser monotherapy or CO₂ laser following punch elevation. They acknowledge these will not be feasible for all affected patients, and treatment will depend on the type of scarring and clinical judgement. NICE considers any impact on NHS resources will be limited, as the recommendation is for severe scarring persisting for 12 months following acne clearance. They also acknowledge these treatments will be limited to a few departments, with additional training and resources required to implement the service.

This guideline emphasizes the importance of assessing and supporting mental health issues resulting from acne, and provides a clear and practical update on management. Its adoption will support improved management in primary care. Novel areas for secondary care include the potential use of physical modalities and the management of acne scarring. Areas requiring further research have been identified to optimize care for people with acne.