Ministry of Health Dermatological Society of Academy of

Malaysia Malaysia Medicine Malaysia

QUICK REFERENCE FOR HEALTH CARE PROVIDERS

QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF ACNE VULGARIS (SECOND EDITION)

KEY MESSAGES
1. Acne vulgaris is a chronic inflammatory skin disease of the pilosebaceous units,
commonly affecting adolescents & young adults.
2. Acne vulgaris affects the face & trunk. It is characterised by non-inflammatory lesions
(open & closed comedones) & inflammatory lesions (papules, pustules, nodules &
cysts).
3. Four pathogenic factors in acne vulgaris are increased sebum production, altered
follicular keratinisation, Cutibacterium acnes colonisation & inflammation of the
pilosebaceous unit.
4. Risk & aggravating factors for acne vulgaris include adolescence, positive family
history of acne vulgaris in first degree relatives, high glycaemic load diet, dairy
products, sweetened beverages & food, & unhealthy fat intake.
5. Acne vulgaris is diagnosed clinically but laboratory investigations may be indicated in
some cases.
6. Comprehensive Acne Severity Scale (CASS) may be used for grading of acne severity
in clinical practice.
7. Topical therapy is the mainstay of treatment in mild to moderate acne vulgaris.
8. Oral antibiotics may be used in moderate to severe acne vulgaris but should not be
used for more than 4 months.
9. Isotretinoin is indicated for severe nodulocystic acne & should only be prescribed by a
dermatologist.
10. Patients with moderate to severe acne vulgaris (e.g. nodulocystic acne) should be
referred early to a dermatologist. Patients with acne vulgaris who exhibit suicidal
behaviour should be referred urgently to a psychiatrist.

This Quick Reference provides key messages & summarises the main recommendations
in the Clinical Practice Guidelines (CPG) Management of Acne Vulgaris (Second Edition).

Details of the evidence supporting these recommendations can be found in the above
CPG, available on the following websites:
Ministry of Health Malaysia: www.moh.gov.my
Academy of Medicine Malaysia: www.acadmed.org.my
Dermatological Society of Malaysia: www.dermatology.org.my

CLINICAL PRACTICE GUIDELINES SECRETARIAT

Malaysian Health Technology Assessment Section (MaHTAS)
Medical Development Division, Ministry of Health Malaysia
Level 4, Block E1, Precinct 1,
Federal Government Administrative Centre
62590 Putrajaya, Malaysia
Tel: 603-88831229
E-mail: [email protected]

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QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF ACNE VULGARIS (SECOND EDITION)

DIAGNOSIS & INVESTIGATIONS

Acne vulgaris is diagnosed clinically based on the presence of:
• non-inflammatory lesions (NIL) – open (Figure 1) & closed comedones (Figure 2)
• inflammatory lesions (IL) – papules, pustules (Figure 3), nodules & cysts (Figure 4)

Investigations are only required to rule out other diseases which may be associated with acne
e.g. polycystic ovarian syndrome, Cushing’s syndrome or androgen-secreting tumour.

• Microbiological & endocrinological investigations may be performed to rule out other

conditions that may mimic acne vulgaris.

Figure 1: Open comedones Figure 2: Closed comedones

Figure 3: Papules & pustules Figure 4: Pustules, nodules and cyst

ASSESSMENT OF SEVERITY
CASS is a simple & validated tool to assess acne severity in clinical practice. Assessment is done
at a distance of 2.5 metres away for acne on the face, chest & back.

COMPREHENSIVE ACNE SEVERITY SCALE (CASS)

GRADE DESCRIPTION
No lesions to barely noticeable ones. Very few scattered comedones &
Clear 0
papules.
Hardly visible from 2.5 metres away. A few scattered comedones, few
Almost clear 1
small papules & very few pustules.
Easily recognisable; less than half of the affected area is involved.
Mild 2
Many comedones, papules & pustules.
More than half of the affected area is involved. Numerous comedones,
Moderate 3
papules & pustules.
Entire area is involved. Covered with comedones, numerous pustules &
Severe 4
papules, a few nodules & cyst.
5 Highly inflammatory acne covering the affected area, with nodules &
Very severe
cyst present.
[Refer to CPG Management of Acne Vulgaris (Second Edition) for photo illustrations of different
CASS severity]

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QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF ACNE VULGARIS (SECOND EDITION)

TREATMENT
Treatment of acne vulgaris is based on the grade & severity of acne. Its goals include resolution
of lesions, reduction of psychological morbidity & prevention of scars. The treatment can be
divided into pharmacological & physical therapies.

a. Topical treatment
• Topical benzoyl peroxide (BPO) monotherapy or in combination with other topical therapy
should be given in mild to moderate acne vulgaris.
• Topical retinoids (e.g. tretinoin & adapalene) monotherapy should be used in
non-inflammatory acne vulgaris or in combination with other therapies in inflammatory acne.
• Topical antibiotics (e.g. clindamycin) should not be used as monotherapy in acne vulgaris to
prevent bacterial resistance.
• Topical azelaic acid (AA) may be used in acne vulgaris, especially in patients with
post-inflammatory hyperpigmentation.
• Combination topical therapy should be given in moderate acne vulgaris.

b. Systemic treatment
• Oral doxycycline, tetracycline or erythromycin should be used for moderate to severe acne
vulgaris.
 Response to these antibiotics should be evaluated at 6 - 8 weeks.

 Target duration of therapy should not exceed 3 - 4 months to reduce resistance.

• Isotretinoin should be prescribed for nodulocystic or severe acne vulgaris &

treatment-resistant moderate acne vulgaris.
 It should only be prescribed by dermatologists.

c. Physical treatment
• Chemical peels may be used as an adjunct in the treatment of acne vulgaris.
 The preferred choices are salicylic acid (SA) & glycolic acid (GA) peels.

Refer to the Medication Table & Algorithm on the Management of Acne Vulgaris for further
details.

• Practical advice on topical BPO:

 Start at a lower concentration of 2.5% & titrate gradually to 5 - 10% if no improvement
 Apply once a day on the affected areas only

 If skin irritation develops, withhold treatment & restart on alternate days once the adverse

event has subsided

 Concomitant use of moisturiser may improve tolerability

 Bleaching of clothes may occur & the patient should be advised accordingly

• Practical advice on topical retinoids:

 It can cause photosensitivity, thus should be applied at night
 Apply a thin layer on the affected areas or the entire face

 If skin irritation develops, withhold treatment & restart on alternate days once the adverse

event has subsided

 Concomitant use of moisturiser may improve tolerability

 Adequate sun protection (e.g. using broad-spectrum sunscreen, umbrella or hat) is

advisable

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 ALGORITHM ON THE MANAGEMENT OF ACNE VULGARIS
DIAGNOSIS & SEVERITY ASSESSMENT OF ACNE
[BASED ON COMPREHENSIVE ACNE SEVERITY SCALE (CASS)*]

MILD MODERATE SEVERE

PREDOMINANTLY PREDOMINANTLY
NON-INFLAMMATORY INFLAMMATORY
LESION LESION
QUICK REFERENCE FOR HEALTHCARE PROVIDERS

TOPICAL RETINOIDS** TOPICAL BENZOYL PEROXIDE COMBINATION OF ANY TWO TOPICAL AGENTS
i. Benzoyl peroxide (preferred)

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ii. Retinoids
iii. Topical antibiotics
iv. Azelaic acid
No improvement after 3 months v. Salicylic acid
*Severity assessment is based on CASS (mild
1 - 2, moderate 3, severe 4 - 5). Quality of life No improvement after 3 months
assessment should be taken into
consideration.
COMBINATION OF TWO TOPICAL AGENTS AS ABOVE# + ONE ORAL ANTIBIOTIC • Response to oral antibiotics should be
i. Doxycycline assessed at 6 - 8 weeks.
**Topical retinoids are to be avoided in
ii. Tetracycliine • Recommended duration of oral
pregnancy.
iii. Erythromycin antibiotics is 3 - 4 months.
In female patients with evidence of hyperandrogenism, consider hormonal therapy.
#
except topical antibiotics

No improvement after 3 months MAINTENANCE THERAPY

with topical retinoids or topical benzoyl
peroxide once acne under control
REFER DERMATOLOGIST for oral isotretinoin ± physical therapy )
MANAGEMENT OF ACNE VULGARIS (SECOND EDITION)
QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF ACNE VULGARIS (SECOND EDITION)

MEDICATION TABLE
a. Topical treatments
Drug Recommended Common Adverse Events Contraindications
Dosage
Benzoyl Apply once to Increased sensitivity to sunlight, Hypersensitivity to BPO
peroxide twice daily skin peeling, erythema, swelling,
(2.5 - 10%) dryness, mild burning sensation,
contact dermatitis
Tretinoin Apply once at Initial exacerbation of acne vulgaris, Hypersensitivity to tretinoin, eczema,
(0.025 - night or before skin irritation, stinging, oedema, broken or sunburned skin, personal
0.05%) bedtime blistering, crusting, erythema, scaling, or family history of cutaneous
photosensitivity, transient hypo/ epithelioma, pregnancy
hyperpigmentation
Adapalene Apply once at night Mild skin irritation, scaling, erythema, Hypersensitivity to adapalene,
(0.1%) or before bedtime dryness, stinging, burning, pruritus pregnancy
Clindamycin Apply twice daily Skin irritation, dryness, stinging, Hypersensitivity to clindamycin or
(1%) erythema, contact dermatitis lincomycin, ulcerative colitis,
antibiotic-related colitis
Azelaic acid Apply twice daily Skin irritation, mostly burning or Hypersensitivity to propylene
(20%) pruritus, occasionally erythema & glycol
scaling, photosensitivity
Sulphur & its Apply once to Skin irritation, contact dermatitis Hypersensitivity to sulphur,
combinations twice daily infant <2 months
(1 - 8%)

b. Systemic treatments
Drug Recommended Common Adverse Events Contraindications
Dosage & Duration
Tetracycline 500 - 1000 mg daily GI disturbances, discolouration of Hypersensitivity to tetracyclines,
in 2 divided doses teeth & nails, photosensitivity, children ≤8 years old, pregnancy,
for 3 - 4 months visual disturbances lactation, severe renal impairment

Doxycycline 100 - 200 mg daily GI disturbances, photosensitivity, Hypersensitivity to

in 1 - 2 divided hypersensitivity, permanent tetracyclines, children ≤8 years old,
doses for 3 - 4 staining of teeth, rash pregnancy, lactation
months

Erythromycin Erythromycin Ethyl GI disturbances, rash, urticaria, Hypersensitivity to erythromycin,

Succinate (EES): headache, dizziness prolonged QT interval,
400 - 800 mg twice uncorrected hypokalaemia or
daily for 3 - 4 months hypomagnesaemia, clinically
significant bradycardia
Erythromycin Stearate:
250 - 500 mg twice
daily for 3 - 4 months
Isotretinoin 0.1 - 1 mg/kg/day Dryness of skin or mucosa, Hypersensitivity to isotretinoin or
Suggested starting exanthema, pruritus, facial any of its components, pregnancy
dose of 10 - 20 mg/day erythema/ dermatitis, hair thinning, due to teratogenicity, lactation,
photosensitivity, muscle & joint pain, hypervitaminosis A,
Treatment should be
headache, dyslipidaemia hyperlipidaemia, co-administration
given until acne
with tetracyclines & vitamin A
clearance & continued
Potentially serious AEs - Stevens- (including dietary supplements)
for another 4 - 8 weeks
Johnson syndrome, toxic epidermal
(estimated duration
necrolysis, suicide ideation
up to 6 months)

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QUICK
QUICKREFERENCE
REFERENCEFOR
FOR
HEALTHCARE
HEALTHCARE
PROVIDERS
PROVIDERS MANAGEMENT
MANAGEMENTOF
OFACNE
ACNEVULGARIS
VULGARIS(SECOND
(SECONDEDITION)
EDITION)

DIAGNOSIS
TREATMENT OPTIONS & INVESTIGATIONS
IN PREGNANT & LACTATING WOMEN
Acne
Type vulgaris is diagnosed
of treatment clinically based on the presence of:
Medication
• non-inflammatory lesions (NIL) – open (Figure 1) & closed comedones (Figure 2)
• inflammatory lesions Benzoyl peroxide pustules (Figure 3), nodules & cysts (Figure 4)
(IL) – papules,
Topical antibiotics (clindamycin)
Topical treatment
Investigations are onlyAzelaic acid
required to rule out other diseases which may be associated with acne
e.g. polycystic ovarianSalicylic
syndrome,acidCushing’s syndrome or androgen-secreting tumour.
Systemic treatment Macrolides (erythromycin, azithromycin)
• Microbiological & Chemical peel (Glycolic
endocrinological acid, lacticmay
investigations acid)be performed to rule out other
Physical that mayLight-based
treatment
conditions therapy (intense pulsed light, blue- or red-light
mimic acne vulgaris.
phototherapy)

TREATMENT OPTIONS IN ADOLESCENTS

• Topical BPO & topical retinoids (tretinoin & adapalene) may be used safely in adolescents
with acne vulgaris.
• Oral tetracycline derivatives (e.g. tetracycline, doxycycline & minocycline) should not be used
in patients aged <8 years with acne vulgaris.
Figure 1: Open comedones Figure 2: Closed comedones
• Oral isotretinoin can be used safely in patients aged ≥12 years with severe acne vulgaris.

COMPLICATIONS OF ACNE VULGARIS

Acne vulgaris should be treated early to prevent complications. The complications that can arise
from acne vulgaris are shown below.

Figure 3: Papules & pustules Figure 4: Pustules, nodules and cyst

ASSESSMENT OF SEVERITY
CASS is a simple & validated tool to assess acne severity in clinical practice. Assessment is done
at a distance of 2.5 metres away for acne on the face, chest & back.

COMPREHENSIVE ACNE SEVERITY SCALE (CASS)

GRADE DESCRIPTION
Post-acne erythema Post-inflammatory Hypertrophic &
No lesions to barely noticeable ones. Very few scattered comedones &
Clear 0 hyperpigmentation keloid scars
papules.
Hardly visible from 2.5 metres away. A few scattered comedones, few
Almost clear 1
small papules & very few pustules.
Easily recognisable; less than half of the affected area is involved.
Mild 2
Many comedones, papules & pustules.
More than half of the affected area is involved. Numerous comedones,
Moderate 3
papules & pustules.
Entire area is involved. Covered with comedones, numerous pustules &
Severe 4
papules, a few nodules & cyst.
5 Highly inflammatory acne covering the affected area, with nodules &
Very severe
cyst present.
[Refer toIcepick scar
CPG Management Rolling
of Acne Vulgaris scar Edition) for photo Boxcar
(Second scarof different
illustrations
CASS severity]

6 2
QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF ACNE VULGARIS (SECOND EDITION)

QUALITY OF LIFE
Acne vulgaris may affect the quality of life of the patients. A simple assessment tool which can
be used is Cardiff Acne Disability Index (CADI).

The Cardiff Acne Disability Index

1. As a result of having acne, during the  (a) Very much indeed
last month have you been aggressive,  (b) A lot
frustrated or embarrassed?  (c) A little
 (d) Not at all
2. Do you think that having acne during  (a) Severely, affecting all activities
the last month interfered with your daily  (b) Moderately, in most activities
social life, social events or intimate  (c) Occasionally or in only some activities
personal relationships?  (d) Not at all
3. During the last month have you avoided  (a) All of the time
public changing facilities or wearing  (b) Most of the time
swimming costumes because of your  (c) Occasionally
acne?  (d) Not at all
4. How would you describe your feelings  (a) Very depressed and miserable
about the appearance of your skin over  (b) Usually concerned
the last month?  (c) Occasionally concerned
 (d) Not bothered
5. Please indicate how bad you think your  (a) The worst it could possibly be
acne is now:  (b) A major problem
 (c) A minor problem
 (d) Not a problem
© Cardiff Acne Disability Index. R J Motley, A Y Finlay 1992 (2021 Updated Version)

CADI score Severity

0-5 Mild
6 - 10 Moderate
11 - 15 Severe

REFERRAL
The urgency for referral of patients with acne vulgaris can be divided into urgent (within 24 hours),
seen early (within 2 weeks) & non-urgent (based on the availability of the appointment).

Refer patients urgently:

• to a dermatologist: patient suspected to have acne fulminans
• to a psychiatrist: patient has major depression or exhibits suicidal behaviour

Refer patients to be seen early by dermatologists in:

• moderate to severe acne (e.g. nodulocystic acne)
• severe social or psychological problems including a morbid fear of deformity
(dysmorphophobia)