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care</span></h1><div class="subtitle">Acne vulgaris: management</div><p><b>Evidence review D</b></p><p><i>NICE Guideline, No. 198</i></p><p class="contrib-group"><h4>Authors</h4><span itemprop="author">National Guideline Alliance (UK)</span>.</p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2021 Jun</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-4147-6</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div></div><div class="bkr_clear"></div></div><div id="niceng198er4.s1"><h2 id="_niceng198er4_s1_">Referral to specialist care</h2><div id="niceng198er4.s1.1"><h3>Review question</h3><p>When should people with acne vulgaris be referred to specialist care?</p><div id="niceng198er4.s1.1.1"><h4>Introduction</h4><p>Appropriate and timely referral for people with acne vulgaris from primary care to specialist care is important for both patient outcome and resource management. It may also play a role in the prevention of scarring. Finding criteria that indicate that referral is needed is therefore the aim of this review.</p></div><div id="niceng198er4.s1.1.2"><h4>Summary of the protocol</h4><p>See <a class="figpopup" href="/books/NBK573055/table/niceng198er4.tab1/?report=objectonly" target="object" rid-figpopup="figniceng198er4tab1" rid-ob="figobniceng198er4tab1">Table 1</a> for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng198er4tab1"><a href="/books/NBK573055/table/niceng198er4.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng198er4tab1" rid-ob="figobniceng198er4tab1"><img class="small-thumb" src="/books/NBK573055/table/niceng198er4.tab1/?report=thumb" src-large="/books/NBK573055/table/niceng198er4.tab1/?report=previmg" alt="Table 1. Summary of the protocol." /></a><div class="icnblk_cntnt"><h4 id="niceng198er4.tab1"><a href="/books/NBK573055/table/niceng198er4.tab1/?report=objectonly" target="object" rid-ob="figobniceng198er4tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Summary of the protocol. </p></div></div><p>For further details see the review protocol in <a href="#niceng198er4.appa">appendix A</a>.</p></div><div id="niceng198er4.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng198er4.appa">appendix A</a> and the <a href="/books/NBK573055/bin/niceng198er4_bm1.pdf">methods</a> document (supplementary document 1).</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/Media/Default/Get-involved/Fellows%20and%20scholars%20unsecure/Conflicts-of-interest-policy.pdf" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p></div><div id="niceng198er4.s1.1.4"><h4>Clinical evidence</h4><div id="niceng198er4.s1.1.4.1"><h5>Included studies</h5><p>A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.</p><p>See the literature search strategy in <a href="#niceng198er4.appb">appendix B</a> and study selection flow chart in <a href="#niceng198er4.appc">appendix C</a>.</p></div><div id="niceng198er4.s1.1.4.2"><h5>Excluded studies</h5><p>Studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng198er4.appk">appendix K</a>.</p></div></div><div id="niceng198er4.s1.1.5"><h4>Summary of studies included in the evidence review</h4><p>No studies were identified which were applicable to this review question (and so there are no evidence tables in <a href="#niceng198er4.appd">Appendix D</a>). No meta-analysis was undertaken for this review (and so there are no forest plots in <a href="#niceng198er4.appe">Appendix E</a>).</p></div><div id="niceng198er4.s1.1.6"><h4>Quality assessment of studies included in the evidence review</h4><p>No studies were identified which were applicable to this review question.</p></div><div id="niceng198er4.s1.1.7"><h4>Economic evidence</h4><div id="niceng198er4.s1.1.7.1"><h5>Included studies</h5><p>A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in <a href="#niceng198er4.appb">appendix B</a> and economic study selection flow chart in <a href="#niceng198er4.appg">appendix G</a>.</p></div><div id="niceng198er4.s1.1.7.2"><h5>Excluded studies</h5><p>Economic studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng198er4.appk">appendix K</a>.</p></div></div><div id="niceng198er4.s1.1.8"><h4>Economic model</h4><p>No economic modelling was conducted for this question because other topics were agreed as higher priorities for economic evaluation.</p></div><div id="niceng198er4.s1.1.9"><h4>The committee’s discussion of the evidence</h4><div id="niceng198er4.s1.1.9.1"><h5>Interpreting the evidence</h5><div id="niceng198er4.s1.1.9.1.1"><h5>The outcomes that matter most</h5><p>The committee agreed that participant reported and investigator-assessed improvement of acne, serious adverse events, and skin-related quality of life were critical outcomes. Effectiveness of any management strategy would depend on the reduction of acne lesions and therefore improvement of acne as judged by the person who has acne or by the relevant clinician or investigator are critical outcomes. Skin related quality of life would be an indication of whether any referral strategy would have an impact on the person’s wellbeing, for instance even when the improvement was not very large. Serious adverse events due to a lack of referral such as untreated skin reactions were also a critical indicator of effectiveness. The number of referrals was an important outcome due to its impact on resources.</p></div><div id="niceng198er4.s1.1.9.1.2"><h5>The quality of the evidence</h5><p>No evidence was identified for this review question.</p></div><div id="niceng198er4.s1.1.9.1.3"><h5>Benefits and harms</h5><p>No evidence was identified comparing different criteria of referral to specialist care. The committee therefore made recommendations based on their expertise and experience. They highlighted several distinct types of referral:
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<ul><li class="half_rhythm"><div>urgent referral because people with the most severe forms of acne would need to be seen within a day due to the seriousness of the condition</div></li><li class="half_rhythm"><div>standard referral criteria because there are groups of people who need to be seen by a member of a consultant dermatologist-led team, for example where the condition is uncertain, or the acne is severe enough for specialist review or acne which has already caused persistent pigmentary changes.</div></li><li class="half_rhythm"><div>referral to mental health services because people’s mental health can be affected by acne causing them psychosocial distress or contributing to a mental health disorder.</div></li><li class="half_rhythm"><div>referral to a relevant specialist who can treat an underlying medical cause for their acne because there are many medical conditions or medications that cause or contribute to the development of acne lesions. Amongst these are conditions or medications that impact on people’s hormone levels (such as polycystic ovary syndrome or use of anabolic steroids).</div></li></ul></p><p>The committee also discussed what would constitute ‘specialist care’ and who the referral would be made to. They agreed that, in line with <a href="https://www.gov.uk/government/publications/isotretinoin-for-severe-acne-uses-and-effects/isotretinoin-for-severe-acne-uses-and-effects" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">the MHRA safety advice on isotretinoin for severe acne: uses and effects</a> (which would relate to people with severe form of acne vulgaris) referrals should be made to a consultant dermatologist-led team to ensure the safety of the person in relation to possible mental health concerns and in relation to specific acne treatment options such as oral isotretinoin which can only be prescribed by members of such teams.</p><div id="niceng198er4.s1.1.9.1.3.1"><h5>Urgent referral</h5><p>When drafting recommendations, the committee decided that people with acne fulminans have to be referred on the same day in order to be assessed by the on-call hospital dermatology team within 24 hours because this condition could make people seriously unwell, potentially needing them to be admitted to hospital</p></div><div id="niceng198er4.s1.1.9.1.3.2"><h5>Standard referral criteria</h5><p>The committee agreed referral should always take place when people have any of a number of different characteristics, which can be interrelated, to make sure the person can then receive optimal management of their condition. The committee noted that it can sometimes be unclear whether or not the condition people present with is acne vulgaris or another skin condition and therefore people should be referred if there is diagnostic uncertainty. People with nodulo-cystic acne or acne conglobata need to be referred because these are severe forms of acne which can be painful, with deep nodules and cysts and the severe nature of these means that they could lead to scarring.</p><p>People who have acne vulgaris who tried a number of different treatments to no effect could also be referred to a consultant dermatologist-led team to establish whether there are other options for the management of their condition to help improve their symptoms. The committee agreed that currently people can remain on ineffective treatments too long and therefore decided that people with mild to moderate acne could be referred after 2 completed courses of treatment to explore further options. The committee noted that people with moderate to severe forms of acne may need treatment (such as oral isotretinoin) which can only be prescribed by members of a consultant dermatologist-led team and they therefore recommended that they should be referred. This should happen only if they had tried a treatment that included an oral antibiotic which is a prerequisite for oral isotretinoin treatment. The committee also recommended to that people with acne with persistent pigmentary changes associated with acne vulgaris (for example people with darker skin colour because post-inflammatory hyperpigmentation may occur as a result of acne) could be referred so that further changes in skin pigmentation can be prevented. People with acne with scarring can also be referred so that they receive optimal treatment to prevent further acne associated scarring.</p><p>The committee also agreed that there needs to be referral if acne or acne related scarring is causing or contributing to persistent psychological distress or a mental health disorder to ensure that their acne is treated promptly which may alleviate their distress.</p></div><div id="niceng198er4.s1.1.9.1.3.3"><h5>Referral to mental health services</h5><p>The committee recognised that acne vulgaris can have a psychological and social impact on people, causing anxiety or depression. It can also exacerbate pre-existing mental health conditions. They discussed that it is important to refer people to mental health services if they experience significant psychological distress or a mental health disorder to ensure people’s safety. In light of <a href="https://www.gov.uk/government/publications/isotretinoin-for-severe-acne-uses-and-effects/isotretinoin-for-severe-acne-uses-and-effects" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">the MHRA safety advice on isotretinoin for severe acne: uses and effects</a> related to, amongst other safety advice, adverse psychological events associated with oral isotretinoin treatment, referral to mental health services is particularly important when the use of this specific treatment is anticipated.</p><p>When discussing the psychological distress related to acne, the committee recognised that acne of any severity can cause psychological distress and mental health disorders. They agreed that this was an important principle that should be taken into account during consultation and decided to raise awareness of this so that psychological wellbeing of people with acne is considered when they are seen by a healthcare professional.</p></div><div id="niceng198er4.s1.1.9.1.3.4"><h5>Referral of people with an underlying medical cause for their acne vulgaris</h5><p>Based on their experience the committee noted that there are conditions (for example polycystic ovary syndrome) or people on medications (including self-taken anabolic steroids) which can be the cause of acne. The committee highlighted that people with such causal conditions or on such medications should be treated for their acne, but the healthcare professional should also consider whether they can provide specific management for the causal condition or whether a referral should be made to a relevant specialist (for example to a reproductive endocrinologist) so that the underlying condition is reviewed and managed. This is to ensure that not only the acne but also the condition itself is appropriately managed.</p><p>The committee discussed whether a research recommendation should be made for this topic, but decided that there are a multitude of reasons for referrals related to acne and also many different specialists to potentially refer to which means that it would be difficult to design such studies. They therefore decided not to prioritise this topic for a research recommendation.</p></div></div></div><div id="niceng198er4.s1.1.9.2"><h5>Cost effectiveness and resource use</h5><p>No economic evidence on the cost effectiveness of different criteria for referral of people with acne vulgaris to specialist services was identified. When drafting recommendations, the committee agreed that, for some groups of people with acne vulgaris (for example those with acne fulminans, nodulo-cystic acne, or where there is diagnostic uncertainty), specialist care is essential for people’s safety and symptom improvement. The committee expressed the opinion that referral to specialist care is also likely to be beneficial for other groups of people with acne, for example people with mild to moderate acne that has not responded to 2 completed courses of treatment and those with moderate to severe acne that has not responded to previous treatment which contains an oral antibiotic. These groups have more persistent forms of acne that are more likely to improve following more focused, specialist care, which may include (in the case of people with moderate to severe acne) treatment with isotretinoin that can only be provided in specialist dermatology settings. People with acne (or acne-related scarring) and psychological distress or a mental health disorder are also expected to benefit from specialist dermatology care that addresses their acne-related symptoms, which in turn is anticipated to alleviate psychological distress; they are also expected to benefit from specialist mental health care that can address any mental health concerns and reduce the risk of development of mental health problems. The committee was aware that referral to specialist care requires use of additional healthcare resources at extra costs, but decided to make recommendations based on their expertise because they expressed the view that benefits of referral to specialist care are likely to outweigh associated costs. Moreover, according to the committee’s opinion, timely referral to specialist services is expected to lead to health improvements before clinical symptoms of acne and other related conditions (for example mental health problems) become more severe and require more resource intensive, and thus costlier, management. The committee made strong recommendations (‘refer’) for groups of people for whom specialist care was considered to be essential for their safety and symptom improvement and weaker recommendations (‘consider referring’) for groups of people for whom specialist care was considered to be most likely beneficial.</p></div><div id="niceng198er4.s1.1.9.3"><h5>Other factors the committee took into account</h5><p>The committee cross referred to other NICE guidance relevant to the recognition of mental health disorders that may be associated with acne (such as NICE guidelines on <a href="https://www.nice.org.uk/guidance/ng134" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">depression in children and young people: identification and management</a>, <a href="https://www.nice.org.uk/guidance/cg90" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">depression in adults: recognition and management</a> and <a href="https://www.nice.org.uk/guidance/cg133" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">self-harm in over 8s: long-term management</a>).</p></div></div><div id="niceng198er4.s1.1.10"><h4>Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations 1.4.1 to 1.4.6 and 1.5.4 in the guideline.</p></div><div id="niceng198er4.s1.1.rl.r1"><h4>References</h4><ul class="simple-list"><p>There were no studies identified that were applicable to this review question.</p></ul></div></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng198er4.appa"><h3>Appendix A. Review protocol</h3><p id="niceng198er4.appa.et1"><a href="/books/NBK573055/bin/niceng198er4-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: When should people with acne vulgaris be referred to specialist care?</a><span class="small"> (PDF, 272K)</span></p></div><div id="niceng198er4.appb"><h3>Appendix B. Literature search strategies</h3><p id="niceng198er4.appb.et1"><a href="/books/NBK573055/bin/niceng198er4-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: When should people with acne vulgaris be referred to specialist care?</a><span class="small"> (PDF, 194K)</span></p></div><div id="niceng198er4.appc"><h3>Appendix C. Clinical evidence study selection</h3><p id="niceng198er4.appc.et1"><a href="/books/NBK573055/bin/niceng198er4-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: When should people with acne vulgaris be referred to specialist care?</a><span class="small"> (PDF, 115K)</span></p></div><div id="niceng198er4.appd"><h3>Appendix D. Evidence tables</h3><div id="niceng198er4.appd.s1"><h4>Evidence tables for review question: When should people with acne vulgaris be referred to specialist care?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng198er4.appe"><h3>Appendix E. Forest plots</h3><div id="niceng198er4.appe.s1"><h4>Forest plots for review question: When should people with acne vulgaris be referred to specialist care?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng198er4.appf"><h3>Appendix F. GRADE tables</h3><div id="niceng198er4.appf.s1"><h4>GRADE tables for review question: When should people with acne vulgaris be referred to specialist care?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng198er4.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng198er4.appg.et1"><a href="/books/NBK573055/bin/niceng198er4-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Economic evidence study selection for review question: When should people with acne vulgaris be referred to specialist care?</a><span class="small"> (PDF, 232K)</span></p></div><div id="niceng198er4.apph"><h3>Appendix H. Economic evidence tables</h3><div id="niceng198er4.apph.s1"><h4>Economic evidence tables for review question: When should people with acne vulgaris be referred to specialist care?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng198er4.appi"><h3>Appendix I. Economic evidence profiles</h3><div id="niceng198er4.appi.s1"><h4>Economic evidence profiles for review question: When should people with acne vulgaris be referred to specialist care?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng198er4.appj"><h3>Appendix J. Economic analysis</h3><div id="niceng198er4.appj.s1"><h4>Economic analysis for review question: When should people with acne vulgaris be referred to specialist care?</h4><p>No economic analysis was conducted for this review question.</p></div></div><div id="niceng198er4.appk"><h3>Appendix K. Excluded studies</h3><div id="niceng198er4.appk.s1"><h4>Excluded studies for review question: When should people with acne vulgaris be referred to specialist care?</h4></div><div id="niceng198er4.appk.s2"><h4>Clinical studies</h4><p id="niceng198er4.appk.et1"><a href="/books/NBK573055/bin/niceng198er4-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (119K)</span></p></div><div id="niceng198er4.appk.s3"><h4>Economic studies</h4><p id="niceng198er4.appk.et2"><a href="/books/NBK573055/bin/niceng198er4-appk-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (117K)</span></p></div></div><div id="niceng198er4.appl"><h3>Appendix L. Research recommendations</h3><div id="niceng198er4.appl.s1"><h4>Research recommendations for review question: When should people with acne vulgaris be referred to specialist care?</h4><p>No research recommendations were made for this review question.</p></div></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Evidence review underpinning recommendations 1.4.1 to 1.4.6 and 1.5.4 in the NICE guideline</p><p>These evidence reviews were developed by the National Guideline Alliance which is a part of the Royal College of Obstetricians and Gynaecologists</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="https://gov.wales/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div><div class="small"><span class="label">Bookshelf ID: NBK573055</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/34424626" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">34424626</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng198er4tab1"><div id="niceng198er4.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the protocol</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK573055/table/niceng198er4.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng198er4.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng198er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng198er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with acne vulgaris</td></tr><tr><th id="hd_b_niceng198er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng198er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Referral based on pre-determined criteria to specialist care (e.g. to a GP with Extended Roles, secondary care, tertiary care, psychiatrist or psychologist)</td></tr><tr><th id="hd_b_niceng198er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng198er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Any other referral criteria or no referral</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng198er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng198er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>Critical</b>
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<ul><li class="half_rhythm"><div>Improvement of acne
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<ul class="circle"><li class="half_rhythm"><div>Participant reported</div></li><li class="half_rhythm"><div>Investigator-assessed</div></li></ul></div></li><li class="half_rhythm"><div>Serious adverse events</div></li><li class="half_rhythm"><div>Skin-related quality of life (validated tools only, e.g. Dermatology Life Quality Index)</div></li><li class="half_rhythm"><div>Scarring</div></li></ul>
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<b>Important</b>
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<ul><li class="half_rhythm"><div>Number of referrals</div></li></ul>
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</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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