Acne Pathway (January 2015)
Key Points:
 Encourage patient self-care and check for aggravating factors.  Mild and moderate acne with low risk of scarring, prescribe a single topical treatment (either topical retinoid or benzoyl peroxide. Combined treatment is rarely necessary). For mild acne, benzoyl peroxide based treatments are available over the counter (OTC) from local community pharmacies.  Prescribe azelaic acid if other agents are poorly tolerated.  Moderate acne with risk of scarring; consider combined treatment with oral antibiotic and topical retinoid or benzoyl peroxide. o Do not prescribe an oral or topical antibiotic alone. Do not combine a topical and an oral antibiotic. o Oral antibiotics: limit to the shortest possible period (max. 6 months) Limit topical antibiotics to 12 weeks where possible, to reduce the risk of bacterial resistance developing o Minocycline is not recommended.
Oral isotretinoin should NOT be prescribed in primary care. Patients with severe acne requiring oral
isotretinoin should be referred to a Consultant Dermatologist. Monitor all patients on oral isotretinoin for severe psychiatric disorders as  For women patients, consider starting hormonal contraception: standard monophasic combined oral contraceptive (COC) with at least 30µg ethinylestradiol. For moderate and severe acne consider prescribing co-cyprindiol. Discontinue three to four menstrual cycles after the woman's acne has resolved. Mild Acne
Moderate Acne
Severe Acne

Step 1 Single Topical
Low scarring risk-
Moderate Scarring risk
as per Mild Acne
Papules/ pustules
Benzoyl Peroxide
Step 1: Combined topical treatment
Topical retinoid plus Topical antibiotic
Pure comedonal
Isotretinoin/adapalene plus clindamycin/
Topical Retinoid
(Topical isotretinoin)
Step 2: Oral antibiotic + topical retinoid or BP
Doxycycline 50-100mg OD
2nd line:
Pure comedonal
Lymecycline 408mg OD
Pregnancy and Breastfeeding: do not use tetracycline Azelaic acid.
antibiotic including doxycycline and lymecycline. Papules/ pustules
Consider erythromycin 500mg BD (if tetracyclines not
Azelaic acid
 Follow up: 6-12 weeks depending on initial severity. Review effectiveness, tolerability and compliance. If inadequate response- check adherence. If no response after 2–3 months, seek specialist advice particularly regarding changing antibiotics.  Other patients who may require referral include those who have severe psychosocial problems, including a morbid fear of deformity (body dysmorphic disorder). Patients who are developing scarring, or are at risk of developing it, despite primary care interventions, those with moderate acne that has failed to respond adequately to treatment over a period of at least 6 months, and patients with features that make the diagnosis uncertain. Refer routinely to endocrinology or gynaecology, those women suspected of having an underlying endocrinological cause of acne such as polycystic ovary syndrome. Consider BP or topical retinoid (isotretinoin or adapalene), azelaic acid or alternatively consider an oral antibiotic only in combination with a topical drug (avoid topical antibiotics) whilst waiting for appointment. Produced by the Medicines Management team, C&P CCG January 2015 (review 2018) with acknowledgment to, Ipswich and East Suffolk CCG Based on CCG Acne Guidance. December 2014. Available at

Topical retinoids
Isotretinoin 0.05%
Isotrex® Gel
Mild to moderate acne
Apply thinly OD or BD
Adapalene 0.1%
Differin® Gel or Cream
Mild to moderate acne
Apply OD in the evening
Benzoyl Peroxide and Azelaic acid
Benzoyl peroxide
Generic or Panoxyl® (if available), other
Mild to moderate acne
Apply OD or BD
brands include Acnecide®, Brevoxyl®.
Azelaic acid 20%
Skinoren® Cream
Mild to moderate acne
Azelaic acid 15%
Finacea® Gel
Mild to moderate acne
Topical antibiotics
Clindamycin 1%
Dalacin T® Solution or Lotion
Moderate acne
Apply thinly BD
Zindaclin® Gel
Moderate acne
Apply thinly OD
Erythromycin 2%
Stiemycin® Solution
Moderate acne
Apply thinly BD
Zineryt® Topical Solution
Moderate acne
Dual therapy options- only consider combination products if poor compliance with single constituent products
Benzoyl peroxide (strength variable) +

Dalacin T® + Generic BP or PanOxyl® (if
Moderate acne
Apply thinly OD or BD daily
clindamycin 1%
available); other brands of BP include
Acnecide®, Brevoxyl®

Isotretinoin 0.05% + erythromycin 2%
Mild to moderate acne
Apply thinly OD or BD
Benzoyl peroxide 3% + clindamycin 1%
Duac® Once Daily Gel
Moderate acne
Apply OD in the evening
Benzoyl peroxide 5% + clindamycin 1%
Duac® Once Daily Gel
Moderate acne
Apply OD in the evening
Adapalene 0.1% + benzoyl peroxide 2.5%
Epiduo® Gel
Moderate acne
Apply OD in the evening
Adherence adequate? Consider:
Increasing drug strength and/or frequency Oral A ntibiotics
BP=Benzoyl Peroxide Combine topical products: i.e  Duration of treatment is at Topical retinoids and tetracyclines, least 3 months. The daily dose including oral formulations are contra- may be reduced after 2–4 BD = Twice daily N.B. Topical retinoid with BP may be poorly indicated in pregnancy; females of tolerated. Apply separately at different times of day months, if adverse effects child-bearing age must use effective to minimise risk of adverse skin reactions. contraception (oral progestogen-only Adherence poor? Consider:
 Doxycycline is contraceptives are not considered Reducing strength of treatment (i.e. from 5% to recommended 1st line, Colour coded costs for
lymecycline 2nd line. topical agents
Switch to a less irritant alternative: topical Erythromycin can be used if antibiotic or azelaic acid). Adapalene may be tetracyclines are not Always consider contraceptive needs of better tolerated than topical isotretinoin or females of child bearing age and A treatment with a smaller discuss the pregnancy risks of oral £10.00- £14.99 Consider different formulation (i.e. cream dose over six months may result retinoids before referral. instead of alcoholic base gel or solution). in a better long term result than shorter treatments. Produced by the Medicines Management team, C&P CCG January 2015 (review 2018) with acknowledgment to, Ipswich and East Suffolk CCG Based on CCG Acne Guidance. December 2014. Available at


Russischer militärexperte: .

Russischer Militärexperte: H1N1-Grippe soll Überschuß. Russischer Militärexperte: H1N1-Grippe soll Überschuß an Menschen beseitigen In Abwesenheit von Rumpelstilz füllt das autarke „Leerer-Kollektiv"zwischenzeitlich die Leere ein wenig. Samstag, den 29. Mai 2009 geg. 21 Uhr ERINNERUNG AN EINEN IMMER NOCH NICHT AUFGEKLÄRTEN TODESFALL DERBRD-DIKTATUR 2004!

Microsoft word - sleep disorders.docx

Sleep Disorders 1. Primary hypersomnia 2. Primary insomnia 3. Narcolepsy 4. Breathing-related sleep disorder 5. Circadian rhythm sleep disorder 6. Nightmare disorder 7. Sleep terror disorder 8. Sleepwalking disorder 1. Primary hypersomnia The defining feature of primary hypersomnia (also cal ed idiopathic hypersomnia) is excessive sleepiness that has lasted for at least one month as manifested by prolonged sleep episodes at night or in the day. Excessive sleepiness during the day may result in long naps that fail to al eviate sleepiness, and other associated symptoms include prolonged sleep at night (which can last for 12 hours or more) as wel as sleep drunkenness. Sleep drunkenness describes a drawn out transition from sleep to waking, during which the person is apparently in a state of inebriation, exhibiting partial alertness, disorientation, drowsiness, poor coordination, and even agitated or violent behaviour. Because the person does not feel wel rested even after taking naps, they constantly struggle to stave off feelings of sleepiness. Hypnagogic hal ucinations and sleep paralysis are rare, but may be found among those with primary hypersomnia. The onset of this disorder typical y occurs before the age of 30 and continues on a chronic course unless treated.