Table 1.

Treatment choices for mild-to-moderate and moderate-to-severe acne vulgaris

Acne severityTreatmentAdvantagesDisadvantages
Any severityFixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening
  • Topical

  • Does not contain antibiotics

  • Not for use during pregnancy and with caution during breastfeeding (see recommendation 1.5.8)

  • Can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics

Any severityFixed combination of topical tretinoin with topical clindamycin, applied once daily in the evening
  • Topical

  • Not for use during pregnancy or breastfeeding (see recommendation 1.5.8)

  • Can cause skin irritation (see recommendation 1.5.7) and photosensitivity

Mild to moderateFixed combination of topical benzoyl peroxide with topical clindamycin, applied once daily in the evening
  • Topical

  • Can be used with caution during pregnancy

  • Can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics

Moderate to severeFixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening, plus either oral lymecycline or oral doxycycline taken once daily
  • Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back)

  • Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin (see recommendation 1.5.8 and the MHRA alert on Isotretinoin for Severe Acne: Uses and Effects)4

  • Not for use in pregnancy, during breastfeeding or under the age of 12 (see recommendation 1.5.8)

  • Topical adapalene and topical benzoyl peroxide can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics

  • Oral antibiotics may cause systemic side effects and antimicrobial resistance

  • Oral tetracyclines can cause photosensitivity

Moderate to severeTopical azelaic acid applied twice daily, plus either oral lymecycline or oral doxycycline taken once daily
  • Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back)

  • Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin (see recommendation 1.5.8 and the MHRA alert on Isotretinoin for Severe Acne: Uses and Effects)4

  • Not for use in pregnancy, during breastfeeding, or under the age of 12 (see recommendation 1.5.8)

  • Oral antibiotics may cause systemic side effects and resistance

  • Oral tetracyclines can cause photosensitivity

  • ¬©NICE 2021. Acne vulgaris: management. NG198. Available from https://www.nice.org.uk/guidance/ng198. All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. MHRA = Medicines and Healthcare products Regulatory Agency. NICE = National Institute for Health and Care Excellence.