Dermatology & Allergy · Full case

Acne Vulgaris

NICE NG198 / CKSTopical RetinoidsAntibiotics

12 weeks for topical treatment responseAcne treatments take 6–12 weeks to show benefit. Patients must be informed at the outset: seeing no improvement at 4 weeks does not mean failure. The minimum adequate trial of any topical or oral acne treatment before judging efficacy is 12 weeks (some references quote 6–8 weeks for topical retinoids; 12 weeks for antibiotics). Premature discontinuation due to impatience is the most common cause of treatment failure. Set expectations explicitly: “I want you to commit to this for 12 weeks before we judge whether it is working.”

Topical retinoid first-line for all gradesTopical retinoids (adapalene 0.1% gel/cream; tretinoin 0.025–0.1%; tazarotene) are first-line for all grades of acne from mild to moderate-severe. They work by normalising follicular keratinisation; reducing comedone formation; and have anti-inflammatory properties. Key messages: (1) apply at night only (photosensitising); (2) pea-sized amount to entire affected area (not spot treatment); (3) initial purging (worsening in first 2–4 weeks) is expected and does not mean failure; (4) start every other night to reduce irritation; (5) sunscreen daily. Adapalene 0.1% (Differin) has the best tolerability profile in the retinoid class.

Antibiotic + retinoid + BPO (not antibiotic alone)NICE NG198 and BAD guidelines: oral or topical antibiotics for acne must always be combined with a topical retinoid AND/OR benzoyl peroxide (BPO). Never prescribe antibiotics alone for acne. Rationale: (1) combination treatment is significantly more effective; (2) BPO reduces the risk of antibiotic resistance developing (BPO has direct bactericidal activity against P. acnes; does not generate resistance). Antibiotic stewardship: limit antibiotic courses to maximum 3–6 months; do not repeat courses without justification; do not prescribe topical and oral antibiotics simultaneously (cumulative resistance risk).

Isotretinoin: teratogenic — ABSOLUTE contraindication in pregnancyIsotretinoin (Roaccutane) is a systemic retinoid that is the only drug that can produce sustained remission of acne. It is a category X teratogen — causes severe and characteristic fetal abnormalities (craniofacial; cardiac; CNS; thymus). The UK Pregnancy Prevention Programme (PPP) is mandatory for all patients of childbearing potential: (1) two negative pregnancy tests before starting; (2) contraception (two methods for women of childbearing potential; at least one highly effective); (3) monthly pregnancy tests; (4) 4-week supply dispensed at each visit. The GPwER or dermatologist initiates and manages isotretinoin. The GP role: be aware of the PPP requirements; do not prescribe isotretinoin in primary care without specialist supervision; refer to dermatology.

Combined pill (COCP): acne indication in womenThe combined oral contraceptive pill (COCP) containing an anti-androgenic progestogen is an evidence-based treatment for acne in women. Options specifically licensed for acne in the UK: (1) co-cyprindiol (Dianette; ethinylestradiol 35mcg + cyproterone acetate 2mg) — stronger anti-androgenic effect; use is restricted to acne and hirsutism (should not be used purely as contraception); DVT risk higher than standard COCP (use for acne indication; review and step down once acne controlled). (2) Norgestimate-containing COCP (e.g. Cilest; Lizinna) or drospirenone-containing pill (e.g. Yasmin): lower-potency anti-androgenic options. COCP is first-line for women with acne who also require contraception. Contraindications: same as for COCP (migraines with aura; VTE risk; smoker >35; hypertension).

Acne scars: refer before scar formationAcne scarring occurs in 95% of patients with severe acne and is a major driver of psychological morbidity. Scarring is preventable with adequate early treatment but largely irreversible once established. NICE NG198: refer to dermatology before significant scarring occurs — the referral decision should be driven by psychological impact and risk of scarring, not just current severity. Scar types: icepick; boxcar; rolling (all atrophic); hypertrophic; keloid. Dermatology treatments: chemical peels; microneedling; fractional laser resurfacing; subcision; filler. Keloid scars: steroid injection (triamcinolone). GP must assess scarring at every acne consultation — any scarring = NICE trigger for dermatology referral discussion.

PHQ-9 in every acne consultationAcne has a profound psychological impact disproportionate to its physical severity. Studies show acne causes PHQ-9 scores equivalent to asthma and epilepsy. Psychological morbidity: depression; anxiety; social phobia; reduced quality of life (DLQI); suicidal ideation in severe cases. NICE NG198: assess psychological impact at every acne consultation. Tools: DLQI (Dermatology Life Quality Index) is validated for acne. PHQ-9 is practical in primary care. Key message: do not dismiss acne because it “looks mild.” The mildest acne on the cheeks of a teenager may be causing profound social anxiety and educational underachievement. The psychological severity, not the physical severity, drives urgency of treatment.

Benzoyl peroxide (BPO): no resistance; adjunct alwaysBenzoyl peroxide (BPO; 2.5–10%) is the only topical acne agent that generates zero antibiotic resistance. It is directly bactericidal to Cutibacterium acnes (formerly P. acnes) and oxidises bacterial lipid membranes — a mechanism that cannot generate resistance. Role: (1) monotherapy for mild inflammatory acne; (2) adjunct when antibiotics are prescribed (prevents resistance emergence); (3) maintenance after antibiotic course ends. Formulations: cream; gel; wash. Available OTC (Oxy; PanOxyl) at lower concentrations. GP prescription: 5% gel initially; build up to 10% if tolerated. Side effects: bleaches fabric and hair (warn); initial dryness; burning — build up gradually. Key rule: any antibiotic prescription for acne should be co-prescribed with BPO.

📋 Clinical Stem — Acne Vulgaris

Miss Priya Sharma, 19, university student, presenting with 18 months of worsening acne affecting her face; chest; and upper back, causing significant distress and social withdrawal, having tried OTC benzoyl peroxide without success

Miss Priya Sharma, 19, a first-year university student, attends with an 18-month history of acne on her face, chest, and upper back. She describes the acne as “getting worse since starting university.” She has tried over-the-counter benzoyl peroxide 5% gel for 3 months with partial improvement. She is not on any prescribed treatment. The acne is affecting her social life — she avoids going out; has been skipping lectures; and feels she cannot make friends because of her appearance. She is tearful and her PHQ-9 is 11 (moderate depression). She has no significant PMH. She is not on contraception. Her acne involves open and closed comedones; inflammatory papules; some nodules on the jaw and chin; and early superficial scarring on the cheeks. She asks: “Can I get the strong treatment — the tablet that clears it completely?” (referring to isotretinoin).

This stem tests: acne grading; correct stepped treatment (topical retinoid + BPO first; antibiotic stewardship; COCP consideration); managing expectations about isotretinoin (not a GP prescription; dermatology referral pathway; PPP; teratogenicity); addressing psychological impact (PHQ-9 11; social withdrawal; scarring); and the tension between giving the patient what she wants (isotretinoin) vs the correct pathway (topical treatment + referral for consideration of isotretinoin).

Scenario A — Miss Sharma (moderate-severe; isotretinoin request) 18 months; face; chest; back; nodules; early scarring; PHQ-9 11; social withdrawal. Treatment: topical adapalene 0.1% + BPO 5%; oral antibiotic (doxycycline 100mg OD) + retinoid + BPO; COCP discussion (she may want contraception); dermatology referral for isotretinoin consideration. Address psychological impact + social withdrawal urgently. Isotretinoin: not primary care prescription; PPP; teratogenicity; dermatology initiates.

Scenario B — Mild comedonal acne Blackheads and whiteheads only; no inflammatory papules; no scarring; mild PHQ-9 impact. First-line: topical adapalene 0.1% OD at night (retinoid; normalises follicular keratinisation). BPO 5% gel in the morning. 12-week review. No oral antibiotic needed. OTC advice (non-comedogenic moisturiser; SPF; avoid squeezing). No referral unless failing topical at 12 weeks.

Scenario C — Inflammatory papulo-pustular acne Papules; pustules; no nodules; no cysts; DLQI impact moderate. First-line: topical adapalene 0.1% + BPO 5%. If inadequate at 12 weeks: add oral antibiotic (doxycycline 100mg OD or lymecycline 408mg OD) + continue retinoid + BPO. NEVER antibiotic alone. Maximum 3–6 months antibiotic; do not repeat. COCP if female and wants contraception. Referral if fails two antibiotic courses or scarring developing.

Scenario D — Woman wanting COCP for acne Moderate acne; woman of childbearing age; wants combined oral contraceptive. Co-cyprindiol (Dianette): ethinylestradiol 35mcg + cyproterone acetate; licensed for acne; more anti-androgenic effect; higher DVT risk than standard COCP; use for acne indication only (not purely contraception); review and step down once acne controlled. UKMEC assessment before prescribing. Alternative: norgestimate or drospirenone COCP (lower anti-androgenic potency; better VTE profile).

Scenario E — Acne and isotretinoin monitoring (GPwER or shared care) Patient on isotretinoin; requiring monthly monitoring. GP role: pregnancy test (monthly; document in PPP); lipid profile (triglycerides — isotretinoin causes hypertriglyceridaemia); LFTs; FBC; depression monitoring (isotretinoin associated with mood changes — mechanism debated; monitor PHQ-9 monthly). Contraception: two methods confirmed monthly. Do not prescribe tetracyclines simultaneously (benign intracranial hypertension risk — pseudotumour cerebri).

Key variables to adapt for Age (teenagers vs adults — treatment threshold lower; hormonal acne in adults often perimenstrual); gender (COCP option for women; hormonal acne in women: polycystic ovary syndrome; check LH; FSH; testosterone; SHBG); severity (GAGS or Leeds score; NICE NG198 ladder); location (face vs back vs chest — back and chest may need oral treatment earlier); scarring (any scarring = dermatology referral discussion); psychological impact (PHQ-9; DLQI; social withdrawal; suicidality); contraception needs; antibiotic resistance stewardship

Steps:

Step 1

History — Grade · Duration · Psychological Impact · PHQ-9 · Prior Treatment · ICE

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The history in acne must establish severity (distribution; lesion types; scarring); the psychological impact (which drives urgency of treatment regardless of physical severity); prior treatment and why it failed; and the patient’s specific expectations (Priya wants isotretinoin — the expectation-management conversation is the core SCA challenge).

🎓 SCA opener — acknowledge the emotional impact before the clinical grading

"I can see this has been really getting you down — especially with everything that comes with starting university. Before I look at your skin, tell me in your own words what this has been like and how it has been affecting you."

Priya is tearful. She is skipping lectures; avoiding friends. The GP who launches immediately into grading the acne misses this — and misses the PHQ-9 11 that drives the clinical urgency. The emotional opener also surfaces the specific expectation: she wants the “strong tablet.”

1A — Open question, then structured acne history

Question	Why it matters	Changes what?
🏲 OPEN QUESTION"Tell me in your own words how your skin has been and how it has been affecting your life."	Priya’s primary concern is not the acne itself — it is what it is doing to her life: not making friends; skipping lectures; tearfulness. The open question surfaces the social withdrawal; the missed university experience; the self-consciousness; and the request for isotretinoin. Without the open question, the GP might grade the acne and prescribe a topical retinoid and miss the PHQ-9 11 and the social crisis — which changes both the urgency and the referral decision entirely.SCA: Global Skills; emotional acknowledgement; yellow flags for psychological urgency	Psychological severity; social impact; urgency; isotretinoin expectation; PHQ-9 urgency
PHQ-9 — psychological impact assessment"Over the last 2 weeks, how often have you felt down; had little interest in things you enjoy? Has the skin affected how you feel about yourself?"	PHQ-9 11 = moderate depression. This is the clinical urgency driver. NICE NG198: assess psychological impact at every acne consultation. Acne with PHQ-9 ≥10 = accelerate treatment; dermatology referral discussion; consider NHS Talking Therapies. PHQ-9 Q9: suicidal ideation must be assessed. Acne is associated with completed suicide in young adults — the severity of psychological impact does not always correlate with physical severity. A teenager with mild acne and PHQ-9 18 needs urgent help; a teenager with severe acne and PHQ-9 3 needs appropriate treatment but less psychiatric urgency.	PHQ-9 ≥10: accelerate treatment; dermatology referral discussion; NHS Talking Therapies; PHQ-9 Q9 suicidality; document
Duration and acne history"How long have you had acne? Is it getting worse? When did you first notice it?"	18 months of progressive acne with early scarring. Duration and progression rate inform treatment urgency. Acne starting or worsening at university: stress is a potent acne trigger (cortisol → increased sebum; androgen activity). In women: perimenstrual worsening (hormonal trigger; COCP is effective). Acne starting in adulthood for the first time: consider PCOS; hyperandrogenism (check LH; FSH; free testosterone; SHBG; DHEA-S).	Stress trigger (NHS Talking Therapies; stress management). Hormonal pattern (COCP; PCOS screen). Rapid progression (accelerate treatment; dermatology earlier)
Prior treatment and why it failed"What have you tried? How long did you use it? Did you apply it as directed — nightly; to the whole face?"	Priya has used BPO 5% OTC for 3 months with partial improvement. BPO as monotherapy is appropriate for mild inflammatory acne but insufficient for moderate-severe acne with nodules and scarring. Important questions: was the BPO applied correctly? (Many patients spot-treat rather than applying to the whole affected area — this produces poor results.) Was it used for long enough? Has she used any topical retinoid? Has she ever had prescribed treatment? Why did she stop (if applicable)?	BPO 3 months partial response: add topical retinoid + oral antibiotic; BPO continue as anti-resistance adjunct. No prior retinoid: add adapalene 0.1% tonight. No prior oral antibiotic: doxycycline 100mg OD indication present
Scarring"Have you noticed any marks or scars from the spots? Can you show me which areas you are most concerned about?"	Early superficial scarring on cheeks — this is a NICE NG198 trigger for dermatology referral discussion. Once scarring is established it is largely irreversible (atrophic scars) — preventing further scarring requires aggressive treatment. The presence of scarring moves Priya from “consider dermatology” to “strongly recommend dermatology referral.” Importantly: scarring also directly addresses her request for isotretinoin — isotretinoin is the most effective treatment for preventing further scarring.	Any scarring: NICE NG198 dermatology referral discussion; isotretinoin pathway accelerated; document type and location of scars
Hormonal factors; contraception"Are you on any contraception? Does the acne worsen before your period? Any hair growth on your face or chin? Any irregular periods?"	Priya is not on contraception — COCP (co-cyprindiol or norgestimate-containing pill) is a treatment option that should be discussed. Perimenstrual worsening (suggests androgenic trigger — COCP is most effective in this pattern). Irregular periods; hirsutism; male-pattern weight distribution: PCOS screen (LH; FSH; testosterone; SHBG; pelvic USS). PCOS with acne: co-cyprindiol is particularly effective (anti-androgenic mechanism). Any current contraception: isotretinoin PPP requirements — two methods of contraception needed.	Not on contraception + wants to be: COCP discussion (anti-androgenic options). PCOS features: hormonal screen. COCP already on: continue as treatment component

1B — Red flags and urgent concerns

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Red Flags — must screen at every acne consultation

Red flag	Concern	Action
Suicidal ideation (PHQ-9 Q9 ≥1)	Acne is a known risk factor for completed suicide in young adults. PHQ-9 11 (moderate depression) + social withdrawal + educational impact = high psychological burden. Q9 must be asked specifically. If suicidal ideation present: urgent mental health review regardless of acne treatment decision.	Same-day mental health review if PHQ-9 Q9 ≥1; emergency services if immediate risk
Acne fulminans — sudden severe cystic acne; fever; arthralgias	Rare but serious. Sudden eruption of severe nodular-cystic acne with systemic symptoms (fever; arthralgia; myalgia; elevated ESR; CRP). Can be triggered by starting isotretinoin. Requires urgent dermatology; systemic corticosteroids + antibiotics before low-dose isotretinoin.	Same-day dermatology; systemic corticosteroids; urgent bloods (ESR; CRP; FBC)
Features of hyperandrogenism — virilisation; rapid onset in adult	Sudden-onset severe acne in an adult woman with virilisation (hirsutism; clitoromegaly; voice change) may indicate androgen-secreting tumour (adrenal; ovarian). Require urgent endocrine workup.	Urgent endocrine bloods (testosterone; DHEA-S; LH; FSH); endocrinology referral
Gram-negative folliculitis — persistent acne worsening on antibiotics	Gram-negative folliculitis: superficial; pustular; perinasal/perimandibular acne that worsens on prolonged tetracycline use. Caused by Gram-negative organisms (Klebsiella; Proteus; Escherichia coli) replacing the flora eliminated by long-term antibiotics. Skin swab for MC&S; stop tetracycline; specialist treatment (isotretinoin is effective).	Skin swab; stop antibiotic; dermatology referral; isotretinoin may be needed

🛡️

Safeguarding — Acne and Psychological Vulnerability in Young People

Priya is 19; has moderate depression (PHQ-9 11); is socially withdrawing; and is missing lectures. Acne in young adults is associated with significant psychological morbidity including self-harm and suicidal ideation. The referral decision and urgency must be driven by psychological impact, not just physical severity.

💕 Suicidality and self-harm

PHQ-9 Q9: ask specifically about suicidal ideation at this consultation
Acne is a known risk factor for completed suicide — document screening
Social withdrawal and missing university: educational safeguarding concern
If any suicidal ideation: same-day mental health review; crisis team if immediate risk

📸 Isotretinoin and mental health

Isotretinoin: causal relationship with depression is debated but not excluded — PHQ-9 must be monitored monthly during isotretinoin treatment
Patient information: tell dermatologist about current mood before isotretinoin is started
Severe depression (PHQ-9 ≥15): discuss with dermatology whether isotretinoin is appropriate now

🏫 Educational and social safeguarding

Skipping lectures — this is an educational impact; university support services referral
Social withdrawal at university: isolation; potential for worsening depression
Refer to university mental health service; student union welfare; GP student health liaison where available

💋 Pregnancy and isotretinoin

Isotretinoin is an absolute teratogen — Pregnancy Prevention Programme (PPP) is mandatory
If isotretinoin is started: two methods of contraception; monthly pregnancy tests
Accidental pregnancy on isotretinoin: immediate referral to teratology service; termination counselling; MDT decision

Actions: PHQ-9 Q9 screened and result documented; university support services suggested; NHS Talking Therapies referral for PHQ-9 11; if suicidal ideation: same-day mental health; dermatolgy referral letter to include PHQ-9 score and social withdrawal context.

1C — PMH · Drug history · Social history

🥐 PMH · Hormonal history

Factor	Why it matters	Impact
PCOS or irregular periods	PCOS is associated with hyperandrogenism and acne. Screen: irregular periods; weight gain; hirsutism; acne; difficulty conceiving. LH; FSH; testosterone; SHBG; DHEA-S; fasting glucose; pelvic USS. Co-cyprindiol is particularly effective for PCOS-associated acne.	PCOS: co-cyprindiol first-line; metformin for metabolic features; endocrinology or gynaecology referral if complex
Family history of acne or scarring	Acne has a genetic component — family history of severe nodulocystic acne or significant scarring is a risk factor for similar severity and earlier consideration of isotretinoin. Also: family history of PCOS or hyperandrogenism in female relatives.	Strong family history of severe acne: lower threshold for dermatology referral and isotretinoin pathway

💊 Drug history · Social history · Lifestyle

Factor	Why it matters	Impact
Current medications	Lithium; phenytoin; anabolic steroids; progestogen-only pill (especially levonorgestrel-containing); high-dose vitamin B12 and B6; corticosteroids: all can cause or worsen acne. Iodide-containing preparations. POP (progestogen-only pill): may worsen acne — consider switching to COCP if no CI.	Drug-induced acne: treat primary cause if possible; dermatology if drug cannot be stopped
Diet	High-glycaemic index (GI) diet and dairy (particularly skimmed milk) are associated with acne in some studies. Evidence is moderate but dietary advice — reducing high-GI foods; reducing dairy — is low-risk and may complement pharmacological treatment. Chocolate and fried food: evidence is weak.	Diet advice: low-GI diet; reduce dairy; ensure adequate zinc and vitamin A from diet (not supplements)
Stress and university adjustment	Cortisol is directly pro-androgenic and stimulates sebum production. University transition stress is a recognised acne trigger — Priya explicitly links the worsening to starting university. Stress management; NHS Talking Therapies; university mental health services are therapeutic adjuncts — not alternatives to pharmacological treatment.	Stress management: NHS Talking Therapies referral; university mental health; mindfulness; exercise; social connection (not avoidance)
Skincare routine	Comedogenic products (certain sunscreens; foundations; hair products near forehead) can worsen acne. Ask specifically: what moisturiser; sunscreen; and make-up does she use? Non-comedogenic; oil-free products should replace any comedogenic products. Excessive washing or scrubbing: worsens barrier function; triggers more inflammation. Recommend: gentle non-comedogenic cleanser ×2/day; non-comedogenic SPF30 moisturiser.	Skincare review: switch to non-comedogenic products; stop oil-based products; gentle cleansing; SPF30

1D — ICE

💡 Ideas

"What do you think is causing your acne? Do you have any thoughts about what is making it worse since university?"

Priya may link the worsening to university stress (correct); to diet changes (possible); to not washing her face enough (incorrect — over-washing worsens acne). Understanding her illness model allows the GP to correct misconceptions (acne is not caused by poor hygiene) and build on what is accurate (stress is a real trigger). Correcting the hygiene myth is important — many acne patients scrub their skin aggressively, causing irritation and worsening the inflammatory component.

😟 Concerns

"What worries you most? Is it the scarring? Is it how long this is going to last? Are you worried it is going to be permanent?"

Priya’s most likely underlying concern is permanence — will she have acne forever? And scarring — will the marks be permanent? Both must be addressed specifically. “Acne is very treatable — most people get excellent improvement with the right treatment. The marks already on your cheeks will fade over time, though some may be permanent — that is why getting effective treatment started now, before more scarring happens, is important.”

🎯 Expectations

"You mentioned wanting the strong treatment — the tablet that clears it. Can you tell me more about what you have heard about that?"

Priya wants isotretinoin. This expectation must be explored and then managed with a specific evidence-based explanation: (1) isotretinoin is real and effective; (2) it is not prescribed in primary care — it is initiated by dermatologists; (3) the pathway to getting it involves trying first-line prescription treatment; (4) the referral she needs today includes dermatology; (5) PHQ-9 11 and scarring are strong arguments for that referral and for expediting the isotretinoin pathway. The GP who simply says “I can’t prescribe that” misses all of this.

1E — Psychosocial context

Priya is missing lectures; avoiding making friends; feeling unable to participate in university life because of her appearance. This is not vanity — it is a recognised pattern of psychological morbidity in acne that includes social phobia; academic underachievement; reduced earning potential; and in some cases suicidal ideation. The PHQ-9 11 is the clinical number that should make this consultation urgent.

🏫 Educational Impact

Skipping lectures means Priya is at risk of failing her degree in the first year. This is not a trivial concern — it is a functional impairment driven by mental health comorbidity from acne. University support services; a letter supporting reasonable adjustment; and NHS Talking Therapies alongside skin treatment are all appropriate.

"I want to mention something — the skin is very treatable, but what worries me more right now is that you are missing lectures. I want to make sure you have some support at university for that too."

💔 Social Isolation

Avoiding going out; difficulty making friends at university — key developmental milestones for a 19-year-old. Social isolation at this life stage increases risk of persistent depression; anxiety; and relationship difficulties. NHS Talking Therapies; CBT for social anxiety; university peer support; and social prescribing are appropriate alongside dermatological treatment.

"Has the skin been making it hard to connect with people at university? I ask because social connection at this stage of life is really important for your mental health — and I want to make sure you have some support with that."

💔 Self-Image and Identity

Adolescent and young adult identity is heavily linked to appearance. Acne during this developmental stage can have lasting effects on self-image; self-efficacy; and relationship confidence that persist beyond the physical resolution of acne. Addressing self-image is not cosmetic — it is treating a clinically significant psychological condition.

"How is all of this affecting the way you feel about yourself? I know it can be hard to separate the acne from who you are — but I want you to know that this is treatable; and how your skin looks in 3 months can be very different from today."

💋 Relationships and Contraception

Priya is not on contraception. As part of the holistic consultation: the COCP discussion (anti-androgenic benefit for acne) may also address contraception needs. The isotretinoin PPP requirements (two forms of contraception) mean contraception must be established before isotretinoin starts. This consultation is an appropriate place to initiate this conversation.

"I want to ask about contraception — not just because it affects which treatment we choose for your acne, but because some of the acne treatments we might use require reliable contraception. Is contraception something you would like to discuss?"

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"I can see this has really been getting to you — especially with everything that comes with starting university. Before I look at your skin, tell me in your own words what this has been like and how it has been affecting you."

"Your mood score tells me the skin is having a real impact on how you are feeling about yourself and about university. Missing lectures — that worries me as much as the skin itself."

"You mentioned wanting the strong tablet — I do want to come back to that, because it is a real treatment and you may be a very good candidate for it. Let me explain the pathway."

Deductions

Not administering PHQ-9 or not responding to the tearfulness — the psychological impact is the clinical urgency; missing it misses the consultation
Refusing isotretinoin request without a full explanation of the pathway — “I can’t prescribe that” without context leaves Priya with no clear plan and damages rapport

🔴 Red

No emotional opener; PHQ-9 not administered; tearfulness not acknowledged; isotretinoin request dismissed without explanation; no scarring documented; no social withdrawal addressed; antibiotic prescribed alone (without retinoid + BPO)

🟠 Amber

Tearfulness acknowledged; PHQ-9 11 recognised; correct treatment prescribed; isotretinoin pathway explained; scarring documented; social withdrawal partially addressed; no NHS Talking Therapies; no dermatology referral despite scarring; contraception not discussed

🟩 Green

Emotional opener; PHQ-9 11 + Q9 screened; social withdrawal + missed lectures acknowledged; correct treatment (adapalene + BPO + doxycycline); antibiotic stewardship (not alone; 3–6 months; BPO adjunct); isotretinoin pathway explained + dermatology referral; scarring documented; COCP discussed; NHS Talking Therapies referral; 12-week review; contraception discussed; closing question

Step 2

Triage — Urgent Psychological Crisis · Acne Fulminans · GP-Managed Stepped Treatment

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Acne is a GP-managed condition in the vast majority of cases. The triage question is: urgent psychiatric crisis (suicidal ideation from acne); acne fulminans (emergency); or GP-managed stepped treatment? Priya is in the GP-managed-with-urgent-referral-elements category: the psychological impact (PHQ-9 11; social withdrawal; scarring) accelerates the dermatology referral decision.

🔴 Emergency

Same-Day Crisis

Immediate

Suicidal ideation (PHQ-9 Q9 ≥1)Same-day mental health; crisis team if immediate risk
Acne fulminans: fever + sudden severe cystic acneSame-day dermatology; systemic corticosteroids

🟠 Urgent

Accelerated Pathway

2–4 weeks

Severe acne with early scarring + PHQ-9 ≥10Expedited dermatology; start prescription treatment today while awaiting referral
Signs of virilisation (hyperandrogenism)Endocrinology; urgent hormone screen

🟩 GP-managed — Priya

Stepped Primary Care Treatment

NICE NG198 ladder

Moderate-severe acne (Priya): nodules; early scarring; PHQ-9 11Prescription today: adapalene + BPO + doxycycline; dermatology referral; NHS Talking Therapies; 12-week review
Mild inflammatory or comedonal acneTopical adapalene + BPO; 12-week review; no antibiotic needed initially

🎓 SCA Checkpoint — Step 2TasksGlobal Skills

Urgency framing

"I want to be honest with you — the acne on your face and the scarring I can already see means you are someone who would benefit from more than just a cream. I am going to start you on prescription treatment today — and I am also going to refer you to dermatology, because you may be a candidate for the strong tablet you asked about. But your PHQ-9 score worries me as much as the skin itself — and I want to make sure we address both today."

Deductions

Treating acne as a cosmetic issue and not assessing PHQ-9 Q9 suicidality — acne is associated with completed suicide; this is a patient safety issue

Step 3

Examination — Acne Grade · Lesion Types · Scarring · Distribution

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Acne examination establishes the grade (which determines treatment step); identifies lesion types; documents scarring (a referral trigger); and identifies features of PCOS or hyperandrogenism. Priya: face; chest; upper back; nodules; early scarring.

Feature	What it establishes	Management impact	Changes?
Lesion types and countComedones (open = blackheads; closed = whiteheads); papules; pustules; nodules; cysts	Lesion types determine grade and first-line treatment. Comedones alone: mild; topical retinoid first-line. Papules/pustules: mild-moderate; topical retinoid + BPO ± antibiotic. Nodules (≥5mm diameter; solid; non-fluctuant): moderate-severe; oral antibiotic + retinoid + BPO; dermatology if nodules + scarring. Cysts (fluctuant; pus-filled): severe; dermatology; isotretinoin pathway. Priya: nodules on jaw and chin + comedones + papules = moderate-severe.	Nodules + scarring: dermatology referral + oral antibiotic + retinoid + BPO. Cysts: urgent dermatology. Comedones only: topical retinoid + BPO; no antibiotic yet	YES — lesion type determines treatment step and referral decision
Distribution: face; chest; backDocument affected areas; photograph for baseline comparison	Chest and back involvement: often requires earlier oral treatment (topical agents harder to self-apply to back). Trunk acne responds well to oral antibiotics. Isotretinoin is particularly effective for truncal acne. Jawline; chin; perioral: classic androgenic distribution — perimenstrual worsening; COCP (anti-androgenic) is particularly effective. Forehead; nose: sebaceous gland rich areas; responds well to topical retinoid; BPO.	Trunk involvement: oral antibiotic earlier; isotretinoin consideration. Jawline: hormonal pattern; COCP. Face-only: topical first-line adequate for mild-moderate	YES — trunk involvement and distribution guide treatment choice
Scarring type and distributionAtrophic: icepick; boxcar; rolling. Hypertrophic; keloid. Active vs settled scars	Any acne scarring: NICE NG198 dermatology referral discussion. Scarring is largely irreversible once established — preventing further scarring requires aggressive treatment. For Priya: early superficial scarring on cheeks is documented. This directly supports the dermatology referral and the isotretinoin pathway discussion. Active scarring (occurring now despite treatment) = isotretinoin argument. Hypertrophic/keloid scars: triamcinolone injection; dermatology.	Any scarring: dermatology referral; isotretinoin pathway discussion. Active scarring: urgent referral. Keloid: specialist triamcinolone; silicon sheets	YES — scarring presence accelerates referral and treatment decisions
Signs of hyperandrogenismHirsutism; polycystic ovary features; androgenic alopecia; acanthosis nigricans	Signs of PCOS or hyperandrogenism in a young woman: facial and body hirsutism; acanthosis nigricans (insulin resistance); weight distribution. If present: LH; FSH; testosterone; SHBG; DHEA-S; fasting glucose; pelvic USS. PCOS with acne: co-cyprindiol is particularly effective. Androgen-secreting tumour (rare but must not be missed): rapid virilisation; urgently elevated testosterone.	PCOS features: hormone screen; co-cyprindiol; metformin; gynaecology/endocrinology referral. Rapid virilisation: urgent endocrinology	YES — PCOS changes first-line choice to co-cyprindiol specifically

🎓 SCA Checkpoint — Step 3Tasks

Examination communication

"I want to look carefully at your face; neck; and if you are comfortable, your chest and back — because the distribution of the acne helps me decide what treatment is most likely to work. I also want to look specifically at any marks or scars. Is that OK?"

Deductions

Not documenting scarring — the presence or absence of scarring is a key decision-point for dermatology referral and must be documented at every acne consultation

Step 4

Investigations — Hormone Screen · Isotretinoin Pre-Treatment · PHQ-9 Documentation

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Most acne does not require investigation. Investigations are triggered by: suspected PCOS or hyperandrogenism; isotretinoin pre-treatment baseline (by dermatology); or co-cyprindiol prescribing (UKMEC assessment; fasting lipids).

Investigation	When and why	Result and action
PHQ-9 (mandatory at every acne consultation)Score and document; Q9 suicidality specifically	NICE NG198: assess psychological impact at every acne consultation. PHQ-9 11 = moderate depression requiring action: NHS Talking Therapies referral; dermatology referral acceleration; PHQ-9 Q9 suicidality screening. Not a “nice to do” — it changes clinical urgency and referral decision. Document the score in the notes alongside treatment decision. If isotretinoin is planned: PHQ-9 monthly during treatment.	PHQ-9 0–9: watchful waiting; reassure. PHQ-9 10–19: NHS Talking Therapies; accelerate treatment; dermatology referral. PHQ-9 ≥20: urgent mental health input; dermatology discussion about treatment timing. Q9 ≥1: same-day mental health.
Hormone screen — if PCOS or hyperandrogenism suspectedLH; FSH; testosterone; SHBG; DHEA-S; fasting glucose; androstenedione	Indicated if: irregular periods; hirsutism; adult-onset acne; signs of virilisation; acne not responding to standard treatment. Timing: day 2–5 of cycle for LH; FSH; day 7–10 for testosterone. Free androgen index (FAI) = (testosterone × 100) / SHBG — elevated in PCOS and hyperandrogenism. Elevated DHEA-S: adrenal androgen excess (adrenal tumour; congenital adrenal hyperplasia — late-onset).	PCOS biochemistry: polycystic ovaries on USS + irregular cycles + hyperandrogenism. Treatment: co-cyprindiol; metformin; lifestyle. Adrenal: endocrinology referral. Priya: no PCOS features — hormone screen not indicated today.
Pre-isotretinoin bloods — dermatology baselineLFTs; fasting lipids; FBC; pregnancy test (urine)	Performed by dermatology before isotretinoin is started. GP should be aware: isotretinoin causes hypertriglyceridaemia (can be dramatic) — fasting triglycerides and cholesterol at baseline and monthly. LFTs (isotretinoin is hepatotoxic at high doses). FBC. Pregnancy test: two negative tests before starting; monthly during treatment. This is the dermatologist’s responsibility — the GP role is to refer with relevant information and know what monitoring is required for shared care.	Elevated fasting triglycerides (>8 mmol/L): significant risk of pancreatitis; discuss with dermatologist before starting. Pregnancy: isotretinoin absolutely contraindicated. LFTs >2×ULN: delay treatment.
UKMEC assessment — before co-cyprindiol (Dianette)Thrombotic risk; BP; BMI; smoking; migraine with aura; liver disease	Co-cyprindiol (ethinylestradiol + cyproterone acetate) is a COCP with higher VTE risk than standard COCP. UKMEC assessment before prescribing: UKMEC 4 (contraindication) if: migraine with aura; current DVT/PE; prolonged immobilisation; smoking + age >35; severe hypertension; known thrombophilia; personal history of VTE. UKMEC 3 (relative contraindication): BMI >35; hypertension; certain medications. Also: Dianette should not be used purely as contraception — it is indicated for acne and hirsutism and should be stepped down to a standard COCP once acne is controlled.	UKMEC 4: do not prescribe co-cyprindiol; use alternative COCP (norgestimate; drospirenone-containing). BP >160/100: address before COCP. Migraine with aura: absolute CI for any COCP — use POP or non-hormonal method.

🎓 SCA Checkpoint — Step 4TasksGlobal Skills

Investigations communication

"For most acne, I do not need to do blood tests. But because you are asking about whether you would be suitable for the stronger tablet — the dermatologist will do some baseline blood tests when they see you, including checking your liver function and your triglycerides, and a pregnancy test. That is part of the monitoring programme for that treatment. I will include all of this in your referral."

Deductions

Not administering or documenting PHQ-9 despite the patient being tearful and describing social withdrawal — NICE NG198 mandates psychological impact assessment at every consultation

Step 5

Diagnosis — Acne Grading · Plain Language · Isotretinoin Expectations · Scarring Impact

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The diagnosis communication must: explain the grade in plain language; address the isotretinoin request with the pathway; discuss scarring honestly; and set realistic 12-week expectations.

🗣️ Explaining acne and addressing the isotretinoin request

"You have moderate-to-severe acne. The way acne works is that your pores become blocked by dead skin cells; the oil inside gets infected with a bacterium that lives on the skin; and that produces the inflammation and the spots. The marks on your cheeks are early scars — and preventing more from forming is now one of the main goals. About isotretinoin — it is a completely real treatment and for someone like you, with the severity you have and the impact on your life, it is absolutely something we should pursue. I cannot prescribe it here — it is started by dermatologists because it requires careful monitoring including regular pregnancy tests. I am referring you to dermatology today, and while you wait I am giving you prescription treatment that will start working immediately."

💬 Key concern responses

"Will I always have acne?"
"About 80% of people who complete isotretinoin get sustained remission. The prescription I am starting today will make a real difference while you wait. Give it 12 weeks — acne treatments take time."

"Will the scars go away?"
"The dark marks are post-inflammatory hyperpigmentation — those fade over months. Some of the deeper ones may be early atrophic scars — those are harder to reverse once established, which is exactly why getting effective treatment started today matters — to stop more forming."

Priya’s Diagnosis

GP treatment + dermatology referral today

Moderate-severe acne; 18 months; face/chest/back; comedones; papules; nodules (jaw/chin); early superficial scarring (cheeks); PHQ-9 11; social withdrawal; missed lectures. Treatment: adapalene 0.1% + BPO 5% + doxycycline 100mg OD. Dermatology referral. NHS Talking Therapies. COCP discussed.

Differential — Consider

Rosacea

Central face; flushing; telangiectasia; no comedones; heat/food/alcohol triggers. Treat: metronidazole; azelaic acid; doxycycline 40mg MR. NOT retinoids.

Perioral dermatitis

Perioral/perinasal papules; often steroid-triggered. Stop steroids; treat with metronidazole or tetracycline.

Do Not Miss

Acne fulminans

Sudden severe cystic acne + fever + arthralgia = emergency. Same-day dermatology.

Androgen-secreting tumour

Rapid virilisation + severe acne. Urgent hormone screen.

📊 NICE NG198 acne severity and treatment step

Grade	Lesions	First-line	Referral?
Mild	Comedones; few papules; no nodules; no scarring	Adapalene 0.1% + BPO 5%; review 12 weeks	No — unless fails 2 topical regimens or scarring develops
Moderate	Papules/pustules ± few nodules; possible superficial scarring	Adapalene + BPO + doxycycline 100mg OD; COCP for women	Consider if failing antibiotics; scarring; PHQ-9 significant
Moderate-severe (Priya)	Nodules; early scarring; PHQ-9 11; social withdrawal	Adapalene + BPO + doxycycline; COCP; dermatology referral; NHS Talking Therapies	YES — today; scarring + PHQ-9 ≥10 both drive decision
Severe / cystic	Widespread nodules; cysts; significant scarring	As above; urgent dermatology; isotretinoin likely	Urgent dermatology; systemic steroid if acne fulminans

🎓 SCA Checkpoint — Step 5TasksRelating to Others

Isotretinoin pathway explanation

"I want to be direct — isotretinoin is real; it works; and you are genuinely someone who should be on the path to getting it. I cannot start it here because it requires specialist monitoring: monthly blood tests; two forms of contraception; monthly pregnancy tests. I am referring you to dermatology today. While you wait, I am starting prescription treatments. You should not have to wait and do nothing."

Deductions

"I can't prescribe that" without pathway explanation — fails Relating to Others and Tasks
Promising isotretinoin when you cannot prescribe it — inaccurate and builds false expectations

Step 6

Referral — Dermatology (Isotretinoin) · NHS Talking Therapies · Always Start Treatment Now

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Two referrals today — dermatology (isotretinoin pathway; scarring; PHQ-9 11 + nodules) and NHS Talking Therapies (PHQ-9 11; social withdrawal; missed lectures). Start prescription treatment simultaneously — never “wait for the referral.”

Referral	Urgency	GP actions first	Must NOT do
Dermatology — isotretinoin pathway + scarring + PHQ-9 11	Routine — accelerated; PHQ-9 11 + scarring	Referral includes: grade (moderate-severe); lesion types; scarring (early superficial; cheeks); PHQ-9 11; social impact (missing lectures; social withdrawal); duration (18 months); prior treatment (BPO 5% OTC; now starting doxycycline + adapalene + BPO); isotretinoin request; contraception status. Start prescription treatment today — never "wait for the referral." Dermatology will: assess for isotretinoin; initiate PPP; advise on scarring treatment options.	Do NOT refuse dermatology referral as “cosmetic.” Do NOT withhold prescription treatment while awaiting referral. Do NOT prescribe isotretinoin in primary care.
NHS Talking Therapies — PHQ-9 11; social withdrawal; missed lectures	Routine — PHQ-9 11 + functional impairment	PHQ-9 11 with missed lectures and social withdrawal. NHS Talking Therapies for CBT: social anxiety; body image; habit reversal for skin-picking. University mental health service: counselling for skin-related anxiety. Social prescribing: university clubs; activities rebuilding confidence. Explicit framing: NHS Talking Therapies is alongside acne treatment, not instead of it.	Do NOT prescribe antidepressants as first-line for PHQ-9 11 driven by acne — treating acne is the primary intervention. Do NOT start SSRIs without NHS Talking Therapies trial first.

🎓 SCA Checkpoint — Step 6Tasks

Dual referral framing

"I am referring you to dermatology today — I am going to tell them about the severity of your acne, the scarring I can see, and how much it has been affecting your mental health and your ability to be at university. I am also referring you to the talking therapy service — because your mood score tells me you need support with the anxiety now, while the skin is being treated. Both referrals go today."

Deductions

Not referring to NHS Talking Therapies despite PHQ-9 11 with functional impairment — incomplete management

Step 7

Management — Topical Retinoid · BPO · Oral Antibiotic · COCP · Isotretinoin Pathway · Stewardship

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7A — Address the isotretinoin expectation

🤝

Priya wants isotretinoin — validate; explain the pathway; offer a plan for now

Validate — isotretinoin is appropriate for Priya

Never dismiss the isotretinoin request. Nodules; scarring; PHQ-9 11 = isotretinoin is clinically indicated.

"You are right — isotretinoin is a very effective treatment, and given your acne severity and the impact on your life, you are genuinely someone who should be considered for it."

Explain the pathway — specific PPP reason

Specific explanation of why isotretinoin is not a GP prescription: PPP; specialist monitoring.

"I cannot start it from this surgery — not because I don’t think you need it, but because it requires a specialist monitoring programme: monthly blood tests; two forms of contraception; monthly pregnancy tests. That monitoring has to be set up by a dermatologist."

Offer a complete plan — referral now + treatment now

Never send a patient away with only a referral and no treatment.

"I am referring you to dermatology today. While you wait I am giving you prescription treatments that will start working on the acne now. You should not have to choose between waiting and doing nothing."

7B — Treatment goals

Treatment goals

≥50% lesion reduction at 12 weeksPrevent further scarring PHQ-9 improvement — target <10 at 12 weeksReturn to attending lectures Dermatology seen; isotretinoin pathway initiatedCOCP in place; contraception before isotretinoin 12-week review; antibiotic max 6 months; BPO maintenance12-week timeline understood; stewardship understood

Motivational language

"You have managed this on your own for 18 months. Now you have prescription treatment and a specialist referral. The next 3 months should look very different."

"Getting the skin treated is actually getting the university situation treated too — the missed lectures are a symptom of what the acne is doing to your confidence."

7C — Non-medication management

💧

Skincare Routine

Gentle cleanser ×2/day; non-comedogenic SPF30; no scrubbing; no picking

What to use

Gentle non-comedogenic cleanser twice daily (CeraVe Foaming; La Roche-Posay Effaclar). Non-comedogenic SPF30 moisturiser daily — essential with retinoid and doxycycline (both photosensitising). Fragrance-free; oil-free; non-comedogenic make-up.

What NOT to do

Never pick or squeeze — causes scarring. No scrubs; toners; astringents — worsen barrier function. Do not over-wash (twice daily maximum). Acne is NOT caused by poor hygiene — over-washing worsens inflammation.

Non-comedogenic skincare reduces comedone formation; SPF protects during retinoid and antibiotic use

🔥

The Purge — Weeks 2–4

Expected worsening — do not stop; reduce frequency if severe

Why it happens

Topical retinoids accelerate cell turnover — existing microcomedones are pushed to the surface faster, causing a temporary worsening. This is expected and does not mean treatment failure. It is the most common reason patients stop retinoids prematurely. Must be warned explicitly at the prescribing consultation.

Management

Start adapalene every other night for 2 weeks; increase to nightly. If purge severe: reduce to every third night; build up slowly. Pea-sized amount to entire face (not spot-treatment). Apply to dry skin after washing. BPO in the morning; retinoid at night (BPO can inactivate retinoid if applied simultaneously).

Knowing about the purge prevents premature discontinuation — the most common retinoid adherence failure

🧠

NHS Talking Therapies and Stress Management

NHS Talking Therapies referral today; CBT for social anxiety; university support

Why

Stress worsens acne (cortisol → sebum); acne worsens mood (PHQ-9 11). CBT breaks the cycle: social anxiety; body image; catastrophising about appearance; social avoidance. University mental health services address the specific context. Habit reversal: CBT addresses skin-picking compulsion that worsens scarring.

Resources

NHS Talking Therapies: self-referral or GP. University counselling. Acne Support (UK): acnesupport.org.uk. Exercise: reduces cortisol; improves mood. Sleep: reduces cortisol; improves immune regulation. Letter to university tutor (with consent) for missed lectures.

CBT for acne-related anxiety: RCT evidence; reduces avoidance; improves QoL independently of skin

☀

Sun Protection

SPF30 daily — essential during retinoid and doxycycline use

Why critical

Both adapalene and doxycycline cause photosensitivity. Unprotected sun on retinoid-treated skin: irritation; redness; peeling; risk of PIH darkening. Apply adapalene at night only (UV inactivates the drug). SPF30 non-comedogenic moisturiser every morning — even in winter; even in overcast weather. No sunbeds ever during treatment.

PIH and SPF

Post-inflammatory hyperpigmentation (dark marks after acne) is dramatically worsened by UV. SPF is not cosmetic during acne treatment — it protects against PIH darkening. Mineral SPF options (Altruist SPF50; La Roche-Posay Anthelios) are non-comedogenic and well-tolerated.

SPF: prevents retinoid irritation; prevents PIH worsening; mandatory during dual photosensitising treatment

🍱

Diet and Lifestyle

Low-GI diet; reduce skimmed milk; zinc from diet; adequate sleep

Evidence

Moderate evidence: high-GI diet (white bread; sugary drinks; processed carbohydrates) worsens acne through insulin and IGF-1 stimulation of sebum. Skimmed milk (specifically) is associated with acne. Low-GI diet: whole grains; vegetables; legumes; lean protein. Chocolate and fried foods: evidence weak. Zinc: some evidence for dietary zinc (pumpkin seeds; seafood; wholegrains).

Practical

Reduce: white bread; sugary drinks; skimmed milk; ultra-processed foods. Increase: low-GI foods; oily fish (omega-3 anti-inflammatory). Adequate sleep and hydration. Diet is an adjunct — not a replacement for pharmacological treatment.

Low-GI diet: modest but real adjunctive benefit alongside pharmacological treatment

👓

Antibiotic Stewardship Advice

Maximum 6 months; BPO always; no repeat without review

Rules

Never antibiotic without BPO co-prescription (prevents resistance; NICE NG198 requirement). Maximum 6 months per course. Do not repeat back-to-back without clinical review. Never co-prescribe topical and oral antibiotics simultaneously. If no response at 3 months: reassess; switch class; refer to dermatology. After antibiotics stop: maintain with retinoid + BPO.

For Priya

Doxycycline 100mg OD: maximum 6 months. BPO 5% throughout and after. At 12-week review: if adequate response, plan antibiotic discontinuation at 6 months. If inadequate: switch to lymecycline 408mg OD or refer. Never restart doxycycline without review.

BPO co-prescription: prevents C. acnes resistance; maintains antibiotic efficacy throughout course

7D — Prescribing guide

NICE NG198 stepwise: Priya (moderate-severe): doxycycline 100mg OD + adapalene 0.1% gel (at night) + BPO 5% gel (morning). NEVER antibiotic alone. COCP discussed. Dermatology referral for isotretinoin. Max 6 months antibiotic.

Topical: for all grades (foundation)

Adapalene 0.1% gel (Differin): at night; pea-sized; entire face; every other night start; purge weeks 2–4; SPF30 daily
BPO 5% gel: morning; bactericidal; no resistance; bleaches fabric — warn; continue after antibiotics stop
Azelaic acid 15–20% (Finacea; Skinoren): alternative to retinoid; safe in pregnancy; treats PIH; ×2/day

12-week review for all topical treatments. Purge warning essential at prescribing.

Oral antibiotics: add for moderate-severe

Doxycycline 100mg OD: first-line; take with food; photosensitising; dairy interaction (30 min before or 2h after); max 6 months
Lymecycline 408mg OD: alternative; better GI tolerability; once-daily
Erythromycin: pregnancy/<12 years only; higher resistance rate
NEVER alone; NEVER + topical antibiotic; NEVER >6 months without review

Stop at 6 months; continue retinoid + BPO maintenance. Never restart without review.

COCP for women (anti-androgenic)

Co-cyprindiol (Dianette; EE35+CPA2): licensed for acne; most anti-androgenic; UKMEC before prescribing; higher DVT; step down when acne controlled
Drospirenone COCP (Yasmin): moderately anti-androgenic; lower DVT than co-cyprindiol
Norgestimate COCP (Cilest): mildly anti-androgenic; lowest DVT of anti-androgenic options
NOT desogestrel POP — may worsen acne

COCP takes 3–6 months for acne effect. Can combine with topical treatment simultaneously.

Isotretinoin — dermatology only; PPP mandatory

0.5–1mg/kg/day; 4–6 months; cumulative dose 120–150mg/kg
Only treatment producing sustained remission (70–80% one course; 80–90% two)
PPP: two pregnancy tests before start; two contraception methods; monthly pregnancy tests; 4-week supply max
Monthly: triglycerides; LFTs; FBC; PHQ-9
NEVER co-prescribed with tetracyclines (BIH/pseudotumour cerebri)
Absolute teratogen: craniofacial; cardiac; CNS defects

What NOT to prescribe

Antibiotic alone — always + retinoid AND BPO (NICE NG198; stewardship)
Topical + oral antibiotic simultaneously — resistance without added benefit
Isotretinoin in primary care — specialist initiation only; PPP required
Co-cyprindiol without UKMEC assessment — higher DVT risk
Repeated antibiotic courses without review — escalating resistance; gram-negative folliculitis

7E — Medication selector

Select severity and patient characteristics

Mild (comedonal; few papules) Moderate-severe (nodules; scarring — Priya) Female; COCP consideration Pregnant or planning pregnancy Requesting isotretinoin pathway PCOS / hormonal acne

Acne treatment guidance

Moderate-severe (Priya): doxycycline 100mg OD + adapalene 0.1% gel (night; pea-sized; entire face; every other night start; purge warning; SPF30) + BPO 5% gel (morning; bleaches fabric — warn). Never antibiotic alone. Maximum 6 months antibiotic; BPO throughout and after. Dermatology referral (isotretinoin; scarring; PHQ-9 11). NHS Talking Therapies referral. COCP discussed. Mild: adapalene 0.1% + BPO 5% only; no antibiotic. Pregnant: azelaic acid 15% (Finacea) or BPO only — no retinoids; no tetracyclines; no isotretinoin. Isotretinoin: refer to dermatology; PPP mandatory (two pregnancy tests; two contraception; monthly pregnancy tests; 4-week supply; monthly bloods); not co-prescribed with tetracyclines (BIH). COCP: co-cyprindiol (Dianette; EE35+CPA2) — UKMEC first; acne indication only; step down when controlled. PCOS: co-cyprindiol first-line; consider endocrinology/gynaecology.

7F — Drug reference cards

Adapalene 0.1% (Topical Retinoid)

Differin gel/cream · Epiduo (adapalene + BPO) · Apply at night · Pea-sized · Entire affected area · Start every other night · Purge warning

✓ First-line all grades — night; pea-sized; entire face; SPF30 daily; purge warning weeks 2–4

First-line topical — all acne gradesPea-sized every other night weeks 1–2; then nightly; apply to entire face not spots; SPF30 daily

✓ Mechanism and correct application

Adapalene normalises follicular keratinisation — the fundamental defect in acne. Reduces microcomedone formation; has anti-inflammatory properties; best-tolerated topical retinoid. Apply at night (photosensitising; UV inactivates the drug). Pea-sized amount to entire affected area (NOT spot treatment). Start every other night ×2 weeks then nightly. The “purge” (worsening in weeks 2–4) is expected as accelerated cell turnover pushes existing microcomedones to the surface — warn explicitly. Full benefit at 12 weeks. BPO in morning; adapalene at night (BPO can inactivate retinoid if applied simultaneously).

✗ Contraindications

PREGNANCY: all topical retinoids contraindicated (teratogenic concern — precautionary avoidance despite limited systemic absorption evidence). Breastfeeding: avoid. Rosacea: topical retinoids worsen rosacea — contraindicated. Eczema-prone skin: cautious use; reduce frequency if worsening.

⚠ Side effects

Dryness; redness; peeling; initial purge (weeks 2–4 — expected; warn). Photosensitivity (SPF30 mandatory). Irritation: reduce to every other night; non-comedogenic moisturiser. BPO applied at same time increases irritation — separate morning/night application.

🔬 Monitor

PHQ-9 at 12 weeks; acne grade comparison; scarring stable or worsening?; SPF adherence. If no improvement at 12 weeks: confirm technique; confirm purge passed; add oral antibiotic if not already; consider dermatology.

💬 For Priya

"This is a vitamin A cream that goes on at night. Use a pea-sized amount — genuinely tiny — and spread it over your whole face, not just the spots. In the first 2–4 weeks your skin may get worse before it gets better — that is completely normal and means the treatment is working. Do not stop it. Use sunscreen every morning because the cream makes your skin more sensitive to sunlight. Give it 12 weeks."

Adapalene: first-line retinoid; at night; pea-sized; entire face; SPF30 daily; purge warning weeks 2–4 (critical — prevents premature discontinuation). CI: pregnancy; rosacea. SCA: no purge warning = Tasks deduction (patient stops at week 2; treatment fails; most common retinoid adherence failure).

Benzoyl Peroxide (BPO) 5–10%

PanOxyl gel · Duac (BPO + clindamycin) · Epiduo (BPO + adapalene) · Morning application · BLEACHES FABRIC — WARN · No resistance generated

✓ Co-prescribe always with antibiotic — prevents resistance; only acne agent that generates zero resistance

All grades — essential adjunct with antibiotics; maintenance after antibiotics stopBPO 5% gel morning; build to 10% if tolerated; entire affected area; bleaches fabric — warn

✓ The only acne agent with zero resistance risk

BPO destroys C. acnes by oxidative mechanism — this mechanism cannot generate resistance. Co-prescription with oral antibiotics: better efficacy AND prevents resistance emerging. BPO alone: effective for mild inflammatory acne. Maintenance after antibiotic course: continue BPO to prevent relapse without resistance risk. Apply in morning; adapalene at night (BPO inactivates retinoid if applied simultaneously). Start 5%; build to 10% if tolerated.

✗ Bleaching warning — mandatory at prescribing

BPO BLEACHES FABRIC AND HAIR — must be told at prescribing. Pillowcases; towels; clothing. Many patients stop BPO because clothing is ruined — preventable with advance warning. Use white or old pillowcase. Keep away from hair.

⚠ Side effects

Dryness; peeling; burning especially at 10%. Initial irritation settles after 1–2 weeks. Sensitisation (rare contact allergy — if erythema/itch worsens rather than settles: stop; review). Avoid eye area; mouth; nostrils.

🔬 Monitor

Acne improvement at 12 weeks. Check BPO is being used correctly (whole face not spot-treatment). Confirm BPO will continue as maintenance after antibiotics stop — document this plan at antibiotic review.

💬 Bleaching warning — mandatory

"One important thing: this gel bleaches fabric. Your pillowcase; your towels; any clothing it touches will be bleached. Use an old or white pillowcase. I tell everyone this because it comes as a shock if you are not warned."

BPO: zero resistance; must co-prescribe with ALL antibiotic prescriptions (NICE NG198 stewardship requirement). Bleaches fabric — mandatory warning; most common reason patients stop BPO. Apply morning; adapalene night. Continue as maintenance after antibiotics stop. SCA: doxycycline without BPO = antibiotic stewardship fail = Tasks deduction.

Doxycycline 100mg OD

Vibramycin · 100mg OD · With food · Max 6 months · Never alone · Always + retinoid + BPO · Photosensitising · Dairy interaction

✓ Moderate-severe acne — always + retinoid + BPO; max 6 months; never repeat without review

Moderate-severe — NEVER oral antibiotic alone100mg OD with food; max 6 months; dairy/antacid 30 min before or 2h after; SPF30 daily

✓ Role and stewardship rules

Doxycycline reduces C. acnes colonisation and inhibits inflammatory metalloproteinases. OD dosing improves adherence. Takes 6–8 weeks for measurable improvement; 12 weeks for full assessment. Stewardship rules: (1) NEVER without retinoid AND BPO; (2) max 6 months; (3) do not repeat without review; (4) never co-prescribe with topical antibiotics (cumulative resistance without added benefit). Take with food; drink full glass of water; do not lie down for 30 minutes after (oesophageal irritation).

✗ Absolute contraindications

Pregnancy (fetal bone/tooth staining — erythromycin instead). Age <12 years (dental staining). Concurrent isotretinoin (benign intracranial hypertension — NEVER co-prescribe). Breastfeeding: avoid. SLE (photosensitivity worsening). Dairy/calcium/antacids/iron: reduce absorption — take 30 min before or 2h after.

⚠ Side effects

GI: nausea; oesophageal irritation (take with food; full glass water; no lie down 30 min). Photosensitivity (SPF30 daily). Vaginal candidiasis (warn; prescribe fluconazole if symptomatic). Rarely: benign intracranial hypertension (headache; visual changes — stop immediately; ophthalmology — absolute CI concurrent isotretinoin).

🔬 Monitor

12-week review: significant improvement? Plan stop at 6 months. Scarring: stable or progressive? If no improvement at 3 months: switch to lymecycline 408mg OD or refer. BPO: document will continue as maintenance after stopping.

💬 For Priya

"Take this once a day with food — always with food, full glass of water. Don’t lie down for 30 minutes after taking it. It is photosensitising — so sunscreen every day. If you have dairy around the same time, leave at least 30 minutes between them. Maximum 6 months — we will review at 12 weeks."

Doxycycline: NEVER alone (always + adapalene + BPO; NICE NG198); max 6 months; dairy interaction (30 min before or 2h after); photosensitising (SPF30); CI: pregnancy; age <12; concurrent isotretinoin (BIH). SCA: prescribing doxycycline alone = antibiotic stewardship fail.

Co-cyprindiol (Dianette) / Anti-androgenic COCP

Dianette (EE35+CPA2) · Yasmin (EE30+drospirenone) · Cilest (EE35+norgestimate) · UKMEC assessment first · Acne indication only

✓ Women with acne — UKMEC; co-cyprindiol for acne only (not purely contraception); step down when controlled

Women with moderate-severe or hormonal acne; UKMEC assessment requiredCo-cyprindiol 1 tablet daily; 21+7 or 28-day pill; 3–6 months for acne effect

✓ Mechanism and selection

Anti-androgenic COCPs reduce free testosterone (via raised SHBG) and directly compete with androgen receptors, reducing sebum. Most anti-androgenic: co-cyprindiol (Dianette; EE35mcg + cyproterone acetate 2mg). Licensed for acne and hirsutism only — not purely contraception. Step down to standard COCP once acne controlled (typically 6–12 months). Takes 3–6 months for full acne effect; combine with topical treatment initially. Drospirenone COCP (Yasmin): moderately anti-androgenic; lower DVT than co-cyprindiol. Norgestimate COCP (Cilest): mildly anti-androgenic; lowest DVT.

✗ UKMEC contraindications

UKMEC 4 (absolute CI): migraine with aura; current/past VTE/DVT/PE; age ≥35 + smoking >15/day; severe hypertension (>160/100); known thrombophilia; active liver disease; oestrogen-dependent cancer. Co-cyprindiol has higher VTE risk than standard COCP. Do NOT use for contraception alone — acne or hirsutism indication required. Step down to standard COCP at 6–12 months once controlled.

⚠ Side effects

Nausea; breast tenderness; mood changes; libido reduction (anti-androgenic effect). VTE: 2–3× background risk (co-cyprindiol higher than lowest-risk COCP). BP monitoring at 3 months. Acne may worsen initially before improving. Breakthrough bleeding initially.

🔬 Monitor

BP at 6 weeks and 3 months. PHQ-9 (mood changes). Acne response at 3–6 months. Step down to standard COCP when acne controlled. UKMEC reassessment annually.

💬 Counselling

"This pill reduces the male hormones that drive oil production. Takes 3–6 months for full acne effect. Also provides effective contraception. Main thing: small risk of blood clots — which is why I asked about migraines and family history of clots. Overall risk is small but worth knowing about."

Co-cyprindiol: acne indication only (not purely contraception); UKMEC assessment before prescribing; higher DVT; step down when controlled. 3–6 months for acne effect. SCA: prescribing without UKMEC = Tasks deduction. Alternatives: drospirenone (Yasmin); norgestimate (Cilest).

Isotretinoin (Roaccutane) — Dermatology Only

Roaccutane · 0.5–1mg/kg/day · 4–6 months · PPP mandatory · Absolute teratogen · NOT primary care · NEVER + tetracyclines

✓ Severe/nodular/scarring — dermatology ONLY; PPP mandatory; refer today + start interim treatment

Specialist only — failed antibiotics; nodular/cystic; scarring; severe psychological impact0.5–1mg/kg/day; 4–6 months; cumulative 120–150mg/kg; PPP; monthly monitoring

✓ Why isotretinoin is unique

The only acne treatment addressing all four pathological mechanisms simultaneously: sebum; follicular keratinisation; C. acnes; inflammation. 70–80% sustained remission after one course; 80–90% after two. Indications: severe/nodular/cystic acne; failed 2 antibiotic courses; active scarring; significant psychological morbidity (PHQ-9 ≥10); isotretinoin request with appropriate grade. All four apply to Priya — dermatology referral today is strongly indicated.

✗ Pregnancy Prevention Programme — mandatory

ABSOLUTE TERATOGEN: craniofacial; cardiac; CNS; thymic defects. PPP mandatory: (1) two negative pregnancy tests before starting (one by specialist; one within 3 days of prescribing); (2) two forms of contraception (one highly effective — IUD; implant; COCP; injectable; plus barrier); (3) monthly pregnancy test during treatment; (4) 4-week supply maximum per prescription; (5) pregnancy test after stopping; (6) contraception for 1 month after course ends. If pregnancy on isotretinoin: immediate teratology referral; MDT; termination counselling. NEVER co-prescribe with tetracyclines: benign intracranial hypertension (pseudotumour cerebri).

⚠ Side effects — monitoring required

Cheilitis (almost universal; Vaseline/Blistex). Facial dryness; conjunctival dryness (lubricant drops). Myalgia; arthralgia. Hypertriglyceridaemia (fasting triglycerides monthly; if >8mmol/L: pancreatitis risk; discuss with dermatology). LFTs monthly. FBC monthly. PHQ-9 monthly (mood changes; causal link debated but monitored). Night vision: rarely impaired (warn drivers). No waxing during treatment (skin fragility). No tetracyclines (BIH).

🔬 GP monitoring in shared care

Monthly: fasting triglycerides; LFTs; FBC; PHQ-9; pregnancy test (if female of childbearing potential); confirm contraception (two methods). 4-week prescription max. Refer immediately: triglycerides >8mmol/L; LFTs >3×ULN; significant mood change; positive pregnancy test; visual disturbance.

💬 What to tell Priya today

"Isotretinoin genuinely works — 80% of people get sustained clearance. I am referring you to dermatology today and I am going to highlight in that letter that you have scarring and that this is significantly affecting your life and your mental health. Before they can prescribe it: monthly blood tests; two forms of contraception; monthly pregnancy tests throughout. It cannot be taken in pregnancy because it causes very serious birth defects. The dermatologist will set all of this up."

Isotretinoin: not GP prescription; PPP mandatory; absolute teratogen; monthly monitoring (triglycerides; LFTs; FBC; PHQ-9; pregnancy test). NEVER + tetracyclines (BIH). 70–80% remission after one course. SCA: explain pathway specifically (not just “I can’t prescribe that”) + interim prescription + dermatology referral = Tasks + Relating to Others marks.

Azelaic Acid 15–20%

Finacea 15% gel · Skinoren 20% cream · Alternative to retinoid · Safe in pregnancy · Treats PIH · Less irritating

✓ Alternative to retinoid; safe in pregnancy; treats PIH — particularly Fitzpatrick III–VI skin

Alternative topical — retinoid-intolerant; pregnancy; PIHAzelaic acid 15% gel (Finacea) or 20% cream (Skinoren) ×2/day; 12-week assessment

✓ When to choose azelaic acid

Preferred over retinoid in: (1) PREGNANCY — safe alternative (unlike retinoids and tetracyclines); (2) retinoid-intolerant skin; (3) rosacea (azelaic acid is a licensed rosacea treatment); (4) Fitzpatrick skin types III–VI where PIH is a major concern — azelaic acid inhibits tyrosinase and directly depigments PIH. Mechanism: antimicrobial; anti-inflammatory; comedolytic; keratolytic. Apply twice daily to entire affected area. Less potent than adapalene for severe inflammatory acne — combine with BPO and oral antibiotic if grade 3–4.

✗ Limitations

Less potent than adapalene for severe comedonal acne. May cause temporary hypopigmentation (usually reversible; monitor in darker skin types). Initial burning and stinging (settles after 1–2 weeks). Not first-line for severe inflammatory acne as monotherapy.

⚠ Side effects

Burning; stinging; itching on application (usually settles). Mild bleaching effect (usually beneficial — treats PIH). Rare contact allergy. SAFE in pregnancy and breastfeeding.

🔬 Monitor

Acne response at 12 weeks. PIH improving? Skin pigmentation at application sites. If inadequate acne response: add BPO ± oral erythromycin (if pregnancy: erythromycin is safe oral option). SPF essential to prevent PIH darkening.

💬 Counselling

"This treatment works on the bacteria and inflammation in your acne, and also helps with the dark marks the spots leave behind. Apply it twice a day. It can sting a bit at first — that settles. Keep using sunscreen — sun makes the marks worse."

Azelaic acid: safe in pregnancy (unlike retinoids and tetracyclines); treats PIH; Fitzpatrick III–VI; rosacea. Skinoren 20% cream; Finacea 15% gel; ×2/day. SCA: the candidate who chooses azelaic acid for a pregnant acne patient (instead of contraindicated adapalene and doxycycline) demonstrates prescribing safety knowledge.

7G — Psychological impact of acne

🧑️

Acne’s impact on Priya is disproportionate to its physical severity — PHQ-9 11 and missed lectures are the clinical urgency

Studies measuring DLQI in severe acne show impairment equivalent to psoriasis; renal failure on dialysis; and ischaemic heart disease. A 19-year-old missing lectures and unable to make friends is experiencing a medical emergency of quality of life — even if the acne “only looks moderate.”

🏫

Education and Career

Missed lectures = missed content; poor grades; potential first-year failure. A letter to the university (with consent) may access reasonable adjustments; extended deadlines; mental health support tied to a medical condition.

"Would it help if I wrote a letter to your university? Medical acknowledgement helps access support and reasonable adjustments."

💔

Social Development

University social withdrawal has long-term consequences: reduced social confidence; smaller professional network; worsened depression. NHS Talking Therapies + CBT for social anxiety re-engagement is as clinically important as the prescription.

"The talking therapy I am referring you to will help you get back into social situations even while the treatment is still working."

📸

Body Image and Social Media

Filtered and edited social media skin creates unrealistic comparison. CBT addresses body image distortion; catastrophising; social comparison. Body dysmorphic disorder (BDD) must be screened if distress is grossly disproportionate to objective acne severity.

"Social media makes this feel worse — what you see online is almost never real skin. The therapy I am referring you to will also help with the comparison and anxiety."

💕

Suicidality

Acne is a known risk factor for completed suicide in young adults. PHQ-9 Q9 screening is mandatory and must be documented. Crisis safety-net given and documented. Any suicidal ideation: same-day mental health review.

"I want to ask you directly — have you had any thoughts of hurting yourself? If you ever do — please ring us; go to A&E; or Samaritans 116 123. That is not overdramatic."

📈

Prognosis and Hope

Priya needs specific, evidence-based optimism: "The prescription treatment starts working in 6–8 weeks. With isotretinoin — which is what I am pushing for you to get — 80% of people get sustained clearance. By this time next year, your skin can look completely different."

"This is not a life sentence. Acne is one of the most treatable skin conditions we have."

🚘

Isotretinoin and Mood

The causal relationship between isotretinoin and depression is debated but not excluded. PHQ-9 11 should be included in the dermatology referral letter so the dermatologist can factor it in. PHQ-9 monitored monthly during isotretinoin. The depression concern is a reason for close monitoring — not necessarily a reason to withhold isotretinoin.

"The link between isotretinoin and depression is debated — I am going to include your PHQ-9 score in the referral so the dermatologist can consider this specifically."

7H — Follow-up

Today — Adapalene + BPO + doxycycline; dermatology referral; NHS Talking Therapies; COCP discussed

Adapalene 0.1% gel (night; pea-sized; entire face; every other night start; purge warning; SPF30 daily). BPO 5% gel (morning; bleaches fabric — warn). Doxycycline 100mg OD (with food; max 6 months; dairy 30 min; photosensitising). Dermatology referral (isotretinoin; scarring; PHQ-9 11; social withdrawal). NHS Talking Therapies referral (PHQ-9 11). COCP discussed (not yet decided). PHQ-9 Q9 documented. Crisis safety-net (Samaritans 116 123). 12-week review booked.

12-week review booked today

12 Weeks — Acne grade; PHQ-9; antibiotic plan; dermatology update

Acne grade: ≥50% lesion reduction? PHQ-9: improving? Missed lectures: returned? NHS Talking Therapies engaged? Dermatology appointment received? Scarring: stable or progressive? If improving: plan doxycycline stop at 6 months; continue retinoid + BPO. If inadequate: switch to lymecycline 408mg OD; accelerate dermatology. BPO: confirm maintenance plan after antibiotics stop. COCP: review decision.

Acne grade; PHQ-9; antibiotic plan; dermatology update

6 Months — Antibiotic stop; maintenance; dermatology update

Doxycycline stop at 6 months. Maintenance: adapalene 0.1% 2–3×/week + BPO alternate days. PHQ-9. Dermatology: has she been seen? Isotretinoin started? If isotretinoin started: monthly GP monitoring (bloods; PHQ-9; pregnancy test). University: lectures attended?

Antibiotic stop; maintenance; dermatology; isotretinoin monitoring if started

Monthly (if on isotretinoin) — Shared care monitoring

Fasting triglycerides; LFTs; FBC; PHQ-9; pregnancy test. 4-week prescription max. Contraception confirmed (two methods). Cheilitis management. Stop if: triglycerides >8mmol/L; LFTs >3×ULN; significant mood change; positive pregnancy test; visual disturbance.

Monthly isotretinoin: triglycerides; LFTs; FBC; PHQ-9; pregnancy test

Post-isotretinoin — Remission assessment; scarring; annual review

6–12 months post-isotretinoin: PHQ-9; acne status; scarring assessment; dermatology follow-up. If remission: no maintenance needed. If relapse: topical maintenance; second course (dermatology). PIH: reassure; SPF; azelaic acid. Scarring: dermatology for scar treatment (fractional laser; microneedling; subcision).

Remission; scarring; PHQ-9; dermatology scar treatment

7I — Monitoring — PARTS mnemonic

PARTS monitoring mnemonic for acne

PHQ-9: at every review — psychological impact drives urgency; Q9 suicidality documented. Acne grade: lesion count; scarring; compare to baseline. Resistance: has BPO been co-prescribed? Antibiotic stewardship documented? Treatment response at 12 weeks: ≥50% improvement? If not: switch; step up; refer. Scarring: stable or progressive? Progressive = urgent dermatology.

Treatment	Monitor	Timing	Action
Adapalene 0.1%	Acne grade; purge passed; SPF adherence	12 weeks	Purge: reassure; continue. No response at 12 weeks: add oral antibiotic; consider dermatology. Pregnancy: stop immediately.
Doxycycline 100mg OD	Acne response; GI tolerability; PHQ-9; scarring	12 weeks; stop at 6 months	No response at 3 months: switch to lymecycline; refer. Stop at 6 months. BPO maintenance confirmed.
Co-cyprindiol	BP; PHQ-9; acne response; VTE symptoms	6 weeks; 3 months; annually	BP >160/100: stop. Step down to standard COCP at 6–12 months when acne controlled.
Isotretinoin (dermatology)	Triglycerides; LFTs; FBC; PHQ-9; pregnancy test; lips	Monthly	Triglycerides >8: stop; specialist. LFTs >3×: stop. Pregnancy: emergency teratology. Mood worsening: dermatology.

Milestone	Action
12 weeks	Acne grade; PHQ-9; antibiotic plan; NHS Talking Therapies progress; dermatology received?
6 months	Doxycycline stop; maintenance adapalene + BPO; dermatology update; isotretinoin monitoring if started
Monthly (isotretinoin)	Triglycerides; LFTs; FBC; PHQ-9; pregnancy test; 4-week prescription; contraception confirmed
Annually	PHQ-9; acne relapse; COCP step-down; scarring; dermatology for scar treatment

7J — Safety-netting

⚠ Three critical safety-nets for Priya

Documentation requirements

PHQ-9 score 11 documented; Q9 specifically screened and result documented; Samaritans number given

Acne grade: moderate-severe; nodules jaw/chin; early scarring cheeks; face/chest/back distribution documented

Antibiotic stewardship: "doxycycline prescribed with adapalene 0.1% AND BPO 5% — not as monotherapy; max 6 months"

Isotretinoin pathway explained; PPP requirements discussed; cannot prescribe in primary care — documented

Purge warning documented; BPO bleaching warning documented; SPF counselling; dairy interaction documented

Dermatology referral sent; NHS Talking Therapies referral sent; 12-week review booked before patient leaves

999/A&E/SamaritansSuicidal ideation — 999; A&E; or Samaritans 116 123 (24h)

12 weeksAcne grade; PHQ-9; antibiotic plan; dermatology update; purge resolved?

6 monthsDoxycycline stop; maintenance; dermatology seen; isotretinoin monitoring if started

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing the consultation

"Let me pull together what we have agreed. I am prescribing three things — a retinoid cream at night; a benzoyl peroxide gel in the morning; and doxycycline tablets. Most important: the cream may get worse in the first 2–4 weeks — do not stop. And the benzoyl peroxide bleaches fabric — use an old pillowcase."

"I am referring you to dermatology today. In the letter I am going to specifically mention the scarring and how much this has been affecting your university life and your mental health — because those are strong arguments for the treatment you asked about."

"I am also referring you to the talking therapy service — because your mood score tells me you need support now, while the treatment is working."

"And I want to ask — the skin aside — have you had any thoughts of hurting yourself? If you ever do: ring us; A&E; or Samaritans 116 123. Before you go — is there anything we haven’t covered?"

Deductions

Doxycycline alone without retinoid + BPO — antibiotic stewardship fail; NICE NG198; most common acne prescribing error
"I can't prescribe isotretinoin" without pathway explanation — Relating to Others fail
PHQ-9 Q9 not screened — patient safety fail
No purge warning for adapalene — most common reason patients stop retinoids
No BPO bleaching warning — most common reason patients stop BPO
No NHS Talking Therapies referral despite PHQ-9 11 and social withdrawal

Tasks summary

PHQ-9 11 + Q9 documented; crisis safety-net
Acne graded; scarring documented
Adapalene + BPO + doxycycline (never alone)
Purge + bleaching warnings
Isotretinoin: PPP explained; dermatology referred
NHS Talking Therapies referred; COCP discussed; 12-week review

Relating to Others

PHQ-9 11 + missed lectures = urgency driver
Isotretinoin validated + pathway specific
80% remission statistic + 12-week timeline
Crisis safety-net: Samaritans named

🔴 Red

Antibiotic alone; isotretinoin refused without explanation; PHQ-9 not administered; Q9 not screened; purge warning absent; bleaching warning absent; no dermatology referral; no NHS Talking Therapies

🟠 Amber

PHQ-9 scored; correct combination; purge warning; isotretinoin pathway explained; dermatology referred; no bleaching warning; NHS Talking Therapies not referred; COCP not discussed; Q9 not documented

🟩 Green

Emotional opener; PHQ-9 11 + Q9 + crisis safety-net; adapalene + BPO + doxycycline; purge + bleaching warnings; isotretinoin pathway + PPP + dermatology; NHS Talking Therapies; COCP discussed; 12-week review; closing question; university support

"I’ve had acne for about 18 months and it keeps getting worse since I started university. I’ve tried a gel from the chemist but it hasn’t really worked. I want the proper treatment — the one that clears it completely. I think it’s called Roaccutane?"

Who you are

Priya Sharma, 19, first-year university student (English Literature). Acne since 17 but much worse since starting university. Face (forehead; cheeks; chin; jawline); chest; upper back. BPO 5% gel OTC for 3 months — partial improvement only. Not on any prescribed treatment. Not on contraception. PHQ-9 11 (moderate depression). Tearful. Avoiding going out; not made friends; missing lectures. “I can’t face people.”

Hidden agenda — disclose if GP creates space

Fear of permanence (disclose if asked about concerns): “I’m scared these marks on my cheeks are permanent. My mum had acne at my age and hers never really went away. I don’t want that.”

Missed lectures (volunteer if asked about impact): “I’ve missed about half my lectures this term. I can’t face walking in late when everyone looks at me.”

Passive dark thoughts (answer honestly if Q9 specifically asked): “I haven’t thought about hurting myself but I have thought ‘what’s the point’ a few times. It does go quite dark sometimes.” [Q9 = 1; requires safety-net.]

Responses to key conversations

On "I can't prescribe isotretinoin" without explanation: Upset: “But I really need something that will actually work. I’ve been dealing with this for 18 months.”
On pathway explanation: “So I can get it — I just need to see a dermatologist first? That’s fine, I didn’t know that was the route.”
On purge warning: “So it might get worse first? You’re sure I shouldn’t stop? OK — that’s really useful. I would definitely have stopped.”
On NHS Talking Therapies: Initially: “I don’t think talking therapy will help with my skin?” If GP links the two: “Oh — it’s not to replace the skin treatment; it’s for the anxiety while the treatment is working. That makes sense.”

Clinical details

Comedones; papules; nodules (jaw; chin; 4–6); early superficial scarring (bilateral cheeks; 2–3 areas each side)
No fever; no arthralgia; no systemic illness; no fulminans features
Regular menstrual cycle; perimenstrual worsening; no hirsutism
PHQ-9 11; Q9 = 1 (passive dark thoughts; not active suicidal planning)

"I read online that Roaccutane can cause depression — and I’m already feeling pretty low. Does that mean I can’t get it? I’m worried that by the time I see a dermatologist I’ll have even more scars."

Ideal GP response to challenge: “The link between isotretinoin and depression is debated — not proven, not excluded. I am going to include your PHQ-9 score in the referral letter so the dermatologist can factor it in and monitor your mood monthly. Your concern about scarring is exactly why I am referring you now, not waiting — and starting treatment today.” Priya leaves: “I didn’t know there was so much I could do right now. I thought I just had to wait. Thank you for actually listening.”

🏥

Clinic Quick Reference

Acne Vulgaris — Clinical Decision Framework

NICE NG198 · PHQ-9 every consultation · Antibiotic + retinoid + BPO · Never antibiotic alone · Isotretinoin = dermatology · PPP · Purge warning · BPO bleaches

▼expand

💊 1 — Severity and Treatment Step (NICE NG198)

Acne → Grade (lesions; distribution; scarring) + PHQ-9 → Treatment step → Referral?

🔴 Urgent / Emergency

PHQ-9 Q9 ≥1 → same-day mental health; crisis safety-net
Acne fulminans (fever + sudden cystic) → same-day dermatology
Rapid virilisation → urgent endocrinology

Same-day crisis / dermatology

🟠 Dermatology Referral

Nodular/cystic; active scarring
Failed 2 antibiotic courses
PHQ-9 ≥10 + scarring (Priya)
Isotretinoin request with appropriate grade

Routine/accelerated dermatology + start treatment now

🟩 GP-managed

Mild: adapalene 0.1% + BPO 5%; review 12 weeks
Moderate-severe: + doxycycline 100mg OD; COCP for women; dermatology if scarring

NICE NG198 stepwise; 12-week review

📊 2 — Key Clinical Numbers

12 weeks minimum

Minimum trial for ALL acne treatments. Warn about purge (weeks 2–4). Never judge at 4 weeks.

Antibiotic + retinoid + BPO

Never antibiotic alone (NICE NG198). BPO prevents resistance. Max 6 months; never repeat without review.

PHQ-9 every consultation

NICE NG198. Score ≥10 = NHS Talking Therapies + accelerate referral + Q9 crisis screen. Acne severity ≠ psychological impact.

Isotretinoin = dermatology

Never primary care. PPP mandatory. Absolute teratogen. 70–80% remission one course.

Purge warning

Adapalene: worse weeks 2–4. Expected. Do not stop. Most common retinoid failure.

BPO bleaches fabric

Mandatory warning. Pillowcase; towels; clothing. Most common reason patients stop BPO.

Co-cyprindiol: acne only

Not purely contraception. UKMEC before prescribing. Higher DVT. Step down when acne controlled.

Scarring = refer

Any scarring: dermatology referral discussion (NICE NG198). Largely irreversible once established.

Azelaic acid in pregnancy

Safe alternative. Finacea 15%; Skinoren 20%; ×2/day. Also treats PIH.

Doxycycline-dairy

Calcium chelation reduces absorption. 30 min before or 2h after. Also photosensitising.

No tetracycline + isotretinoin

Benign intracranial hypertension (BIH). Absolute contraindication. Never co-prescribe.

80%: isotretinoin remission

70–80% sustained clearance after one course; 80–90% after two. Only treatment producing sustained remission.

⚠ 3 — PARTS Monitoring

PARTS	Parameter	Timing	Action
PHQ-9	PHQ-9 total; Q9 suicidality	Every consultation	≥10: NHS Talking Therapies; dermatology accelerated. Q9 ≥1: crisis safety-net; same-day MH if acute.
Acne grade	Lesion count; scarring; distribution	12 weeks	Not improving at 12 weeks: switch; step up; dermatology. Scarring progressive: urgent referral.
Resistance	BPO co-prescribed with antibiotic?	At every antibiotic Rx	BPO absent: add it. Antibiotic alone = stewardship fail.
Treatment response	≥50% lesion reduction at 12 weeks	12-week review	<50%: switch antibiotic class; or dermatology. At 6 months: stop antibiotic; maintain retinoid + BPO.
Scarring	Type; extent; active scarring?	Every consultation	Any scarring: dermatology discussion. Active scarring despite treatment: urgent referral; isotretinoin.

🎓

SCA Exam Quick Reference

Acne SCA — PHQ-9 Q9 · Adapalene + BPO + doxycycline · Never antibiotic alone · Purge warning · BPO bleaches · Isotretinoin pathway · PPP · NHS Talking Therapies

NICE NG198 · Priya: moderate-severe + scarring + PHQ-9 11 · Dermatology + NHS Talking Therapies referral · COCP discussion

▼expand

💬 Opening & ICE

Opener: “I can see this has really been getting to you — the missed lectures; finding it hard to meet people. Tell me in your own words what this has been like.”

ICE — Ideas: “What do you think is causing it?” Validate stress; correct hygiene myth.

ICE — Concerns: “Is it the permanence? The scarring?” Then: “80% get sustained clearance with isotretinoin. Treatment now prevents more scars.”

ICE — Expectations: “Tell me more about the treatment you’ve heard about.” Validate; pathway; PPP; interim Rx today.

Isotretinoin request: “You are right — it’s very effective; you are a candidate. I cannot start it here — PPP: two contraception methods; monthly pregnancy tests; monthly bloods. Dermatologist initiates. Referring today. Prescriptions starting now.”

Isotretinoin + depression challenge: “The link is debated — not proven; not excluded. I am including your PHQ-9 11 in the referral. Monitored monthly throughout.”

✅ Key SCA Tasks (15pt)

Acne graded + scarring documented (2pt): Moderate-severe; nodules; early scarring cheeks; face/chest/back. Drives dermatology referral today.

Antibiotic stewardship (2pt): Doxycycline + adapalene + BPO (all three). NEVER alone. Max 6 months; BPO prevents resistance. Most common SCA error: doxycycline alone.

PHQ-9 11 + Q9 + crisis safety-net (2pt): PHQ-9 11 administered; Q9 documented; Samaritans 116 123; NHS Talking Therapies referred.

Isotretinoin pathway + dermatology (2pt): PPP explained; cannot prescribe in GP (specific reason); referral today includes PHQ-9 + scarring; interim Rx started now.

Purge + bleaching + SPF + dairy (2pt): Four counselling points all documented. Most commonly missed in SCA acne prescribing.

NHS Talking Therapies (1pt): PHQ-9 11 + social withdrawal; alongside acne treatment; not instead of.

COCP discussed (1pt): Anti-androgenic; contraception; UKMEC; options explained.

Scarring prognosis (1pt): PIH vs atrophic distinction; prevention priority.

12-week review + antibiotic plan (1pt): Review booked; stop at 6 months; BPO maintenance.

PPP explained (1pt): Two contraception; monthly pregnancy tests; monthly bloods; absolute teratogen; documented.

🔴 Doxycycline alone = automatic Tasks fail

🔴 Q9 not screened with PHQ-9 11 = patient safety fail

👥 Relating to Others (11pt)

Tearfulness + missed lectures (1pt): Emotional opener; specific acknowledgement

ICE: Ideas (1pt): Stress validated; hygiene myth corrected

ICE: Concerns (1pt): Permanence; 80% remission; treatment prevents more scars

ICE: Expectations (1pt): Isotretinoin validated; pathway specific; plan offered

PHQ-9 urgency (1pt): “Mood and missed lectures worry me as much as the skin.”

NHS Talking Therapies concurrent (1pt): Alongside; not instead of; for anxiety now

Specific optimism (1pt): 12 weeks + 80% remission + “not a life sentence”

Medication conversational (1pt): Purge; bleaching; SPF; dairy — human; practical

University support (1pt): Letter offered; reasonable adjustments; student services

Crisis safety-net (1pt): Samaritans 116 123; A&E; named; specific; compassionate

Closing question + pause (1pt): Genuine pause; Priya’s additional questions answered

🟩 Priya leaves: “I didn’t know there was so much I could do right now. Thank you for actually listening.”

💊 Treatment Quick-Pick

Acne Vulgaris

Red Flags — must screen at every acne consultation

Safeguarding — Acne and Psychological Vulnerability in Young People

💕 Suicidality and self-harm

📸 Isotretinoin and mental health

🏫 Educational and social safeguarding

💋 Pregnancy and isotretinoin

🏫 Educational Impact

💔 Social Isolation

💔 Self-Image and Identity

💋 Relationships and Contraception

Same-Day Crisis

Accelerated Pathway

Stepped Primary Care Treatment

Rosacea

Perioral dermatitis

Acne fulminans

Androgen-secreting tumour

Validate — isotretinoin is appropriate for Priya

Explain the pathway — specific PPP reason

Offer a complete plan — referral now + treatment now

Select severity and patient characteristics

Education and Career

Social Development

Body Image and Social Media

Suicidality

Prognosis and Hope

Isotretinoin and Mood

Today — Adapalene + BPO + doxycycline; dermatology referral; NHS Talking Therapies; COCP discussed

12 Weeks — Acne grade; PHQ-9; antibiotic plan; dermatology update

6 Months — Antibiotic stop; maintenance; dermatology update

Monthly (if on isotretinoin) — Shared care monitoring

Post-isotretinoin — Remission assessment; scarring; annual review

PARTS monitoring mnemonic for acne

⚠ Three critical safety-nets for Priya

Documentation requirements

🎭 Patient actor brief — Miss Priya Sharma, 19

Who you are

Hidden agenda — disclose if GP creates space

Responses to key conversations

Clinical details