Questionnaire/history: Duration, type and distribution of lesions? Exacerbating factors? - Menstruation? - Contraception? - Cosmetics? - Face creams or hair pomades? Systemic features (eg fever, myalgia or arthralgia)? Psychosocial impact (eg anxiety, low mood)? Past medical history (eg hyperandrogenism (eg with irregular periods, androgenic alopecia or hirsutism in women))? Family history (eg endocrine disorders, polycystic ovarian syndrome, acne and other skin conditions)? Current medication (eg androgens, corticosteroids, lithium)? Previous treatment(s) and response? Drug allergies? Examination: Mild: predominantly non-inflamed lesions (open comedones (blackheads) and closed comedones (whiteheads)) and few inflammatory lesions (papules and pustules (< 5 mm in diameter))? Moderate: more widespread with an increased number of inflammatory papules and pustules? Severe: widespread inflammatory papules, pustules and nodules or cysts (> 5 mm in diameter), maybe sinuses (acne conglobata) and/or scarring (atropic/ice pick or hypertrophic/keloid scars)? Post-inflammatory depigmentation or hyperpigmentation? Seborrhoea? Conglobate acne with extensive inflammatory papules, suppurative nodules (which coalesce to form sinuses) and cysts on the trunk and upper limbs? Acne fulminans with severe inflammatory reaction, deep ulcerations and erosions, sometimes with systemic effects (such as fever and arthralgia)? Androgenic alopecia? Hirsutism? Images Differential diagnosis (rosacea, perioral dermatitis, folliculitis and boils, drug-induced acne, keratosis pilaris) Management: Advised: To avoid over-cleaning the skin To use non-alkaline (skin pH neutral or slightly acidic) synthetic detergent cleaning product twice daily To avoid oil-based comedogenic skin care products, make-up and sunscreens, and if make-up is used to remove it at the end of the day Not to pick or scratch the lesions to reduce the risk of scaring That treatment may irritate she skin, especially at the start of the treatment, to start with alternate-day or short-contact application (for example washing off after an hour) To read the NHS info 'Acne' and the info of the British Association of Dermatologists 'Acne' Mild-to-moderate acne: 12-week course to be applied once daily in the evening: Topical adapalene 0.1 or 0.3% + benzoyl peroxide 2.5% (eg Epiduo gel) Topical tretinoin 0.0.25% + clindamycin 1% (Duac Topical benzoyl peroxide 3% or 5% + clindamycin 1% (eg Dual Once Daily gel) Thinly in the evening, if sensitive skin initially lower frequency (eg 1-3x/week) and increase to daily use if tolerated Concomitant use of a noncomedogenic moisturizer and sunscreen may also help tolerability To avoid accumulation in angles of the nose, contact with mucous membranes, eczematous, broken or sunburned skin and exposure to UV light Moderate to severe acne: Topical adapalene 0.1 or 0.3% + benzoyl peroxide 2.5% (eg Epiduo gel) +/- lymecycline 408 mg or doxycycline 100 mg Topical tretinoin 0.0.25% + clindamycin 1% Topical azelaic acid (15% or 20%) twice daily + lymecycline 408 mg or doxycycline 100 mg (or trimethoprim or erythromycin) Combined oral contraceptives (3rd or 4th generation) (as an alternative to systemic antibiotics) + topical agent Cocyprindiol (Dianette) or other ethinylestradiol/cyproterone acetate-containing products in moderate to severe acne where other treatments have failed (1.5-2 fold increased incidence of VTE compared with levonorgestrel-containing combined pills, but absolute risk less than the risk associated with pregnancy) Referral if: Diagnostic uncertainty Acne conglobate Nodulo-cystic acne Referral considered if: Mild to moderate acne without response to two completed treatment courses Moderate to service acne without response to treatment that includes an oral antibiotic Scarring Persistent pigmentary changes Psychological distress Follow-up after 12 weeks Resource(s): NICE CKS: Acne vulgaris Information for patient/carer(s): British Associations of Dermatologists: Acne NHS Health A to Z: Acne