13.6 Acne and rosacea

(a) acne

Topical treatment
benzoyl peroxide
retinoids (adapalene)
Systemic treatment
First Choice:
Second Choice:
(an option in women is co-cyprindiol; see prescribing notes)
Under specialist supervision only
  • benzoyl peroxide 5% gel: apply 1–2 times daily.
  • topical antibiotics clindamycin 1% topical solution or lotion; apply twice daily.
  • topical retinoids: adapalene cream or gel 0.1%: see BNF for details.
  • oxytetracycline tablets 250mg: 250–500mg twice daily for 6 months initially.
  • erythromycin tablets 250mg, oral suspension 125mg/5mL, 250mg/5mL, 500mg/5mL: 250–500mg twice daily for 6 months initially.
  • lymecycline capsules 408mg (=tetracycline 300mg): 408mg daily for at least 8 weeks.
  • co-cyprindiol 2000/35 (cyproterone acetate 2mg, ethinylestradiol 35micrograms) 21–tab pack.
  • isotretinoin capsules 5mg, 10mg, 20mg: available only on specialist advice.
Prescribing Notes

See algorithm on following page

  • Topical treatment takes at least 30 days to become effective.
  • Topical antibiotics are as effective as oral antibiotics but encourage resistance and are more expensive.
  • Topical retinoids are recommended for comedonal acne; they may initially cause redness of the skin.
  • EpiDuo® gel (adapalene 0.1% and benzoyl peroxide 2.5% gel) is a combination product recommended first line in the treatment of mild acne that is mostly inflammatory in nature.
  • Duac® Once Daily gel (benzoyl peroxide 5% and clindamycin 1%) is a combination product suitable for use for the treatment of mild to moderate acne. It may enhance compliance compared to the two products individually.
  • Treclin® gel (clindamycin 1% and tretinoin 0.025%) is a combination product for the treatment of acne when comedones, papules and pustules are present.  It may be of use in patients for whom a topical combination of clindamycin and tretinoin is an appropriate choice of therapy.

  • Oxytetracycline may take up to 6 months of compliant use to achieve maximum benefit.
  • Co-cyprindiol 2000/35 is a treatment for severe acne and only in those patients may it also be used as an oral contraceptive (see section 7.3.1). In those who do not require contraception, co-cyprindiol 2000/35 should be withdrawn 3–4 cycles after the treated condition has completely resolved. If ongoing contraception is required, substitution with another COC is likely to maintain the improvement.
  • Some drugs, including enzyme–inducers and antibiotics, may impair the efficacy of oral contraceptives; see BNF for details.
  • Doxycycline can cause photosensitivity in some patients. Minocycline may be an alternative but prolonged use should be avoided due to the rare risk of liver damage; patients receiving minocycline for longer than 6 months should be monitored at least 3 monthly thereafter for signs and symptoms of hepatitis or SLE.
  • Tetracyclines and retinoids (systemic or topical) must be avoided in pregnancy.
  • Severe acne requires oral antibiotics and referral for consideration of isotretinoin for treatment failures. Oral isotretinoin (Roaccutane®) is a toxic and teratogenic drug which is only prescribable by a consultant dermatologist. Prescription of systemic isotretinoin for women is only possible if adequate contraception is undertaken (Pregnancy prevention programme).

(b) rosacea

First Choice:
azelaic acid gel
oroxytetracycline oral
Second Choice:
metronidazole topical
  • azelaic acid 15% gel (Finacea®); apply twice daily.
  • oxytetracycline tablets 250mg: 250–500mg twice daily according to disease activity for 3 months; repeated courses may be necessary.
  • metronidazole 0.75% gel or cream: apply twice daily for 3–4 months.
  • lymecycline capsules 408mg (=tetracycline 300mg): 408mg daily for 2-3 months.
Prescribing Notes
  • There is no effective treatment for redness of the skin due to rosacea; camouflage creams may be required (see section 13.8.2).
  • Mild rosacea is best treated with a topical agent.
  • Pustular rosacea is best treated with systemic antibiotics.
  • Azelaic acid gel is more cosmetically acceptable to patients, as moisturisers and make up can be applied on top of it.
  • Erythromycin should be used as an alternative to oxytetracycline or lymecycline in pregnancy.
  • Topical tetracyclines fluoresce under ultraviolet light.