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Referral to specialist care
Evidence review D
NICE Guideline, No. 198
National Guideline Alliance (UK).
Referral to specialist care
Review question
When should people with acne vulgaris be referred to specialist care?
Introduction
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.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol.
For further details see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Clinical evidence
Included studies
A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.
Summary of studies included in the evidence review
No studies were identified which were applicable to this review question (and so there are no evidence tables in Appendix D). No meta-analysis was undertaken for this review (and so there are no forest plots in Appendix E).
Quality assessment of studies included in the evidence review
No studies were identified which were applicable to this review question.
Economic evidence
Included studies
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 appendix B and economic study selection flow chart in appendix G.
Excluded studies
Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.
Economic model
No economic modelling was conducted for this question because other topics were agreed as higher priorities for economic evaluation.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
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.
The quality of the evidence
No evidence was identified for this review question.
Benefits and harms
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:
- 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
- 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.
- 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.
- 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).
The committee also discussed what would constitute ‘specialist care’ and who the referral would be made to. They agreed that, in line with the MHRA safety advice on isotretinoin for severe acne: uses and effects (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.
Urgent referral
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
Standard referral criteria
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.
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.
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.
Referral to mental health services
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 the MHRA safety advice on isotretinoin for severe acne: uses and effects 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.
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.
Referral of people with an underlying medical cause for their acne vulgaris
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.
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.
Cost effectiveness and resource use
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.
Other factors the committee took into account
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 depression in children and young people: identification and management, depression in adults: recognition and management and self-harm in over 8s: long-term management).
Recommendations supported by this evidence review
This evidence review supports recommendations 1.4.1 to 1.4.6 and 1.5.4 in the guideline.
References
There were no studies identified that were applicable to this review question.
Appendices
Appendix A. Review protocol
Review protocol for review question: When should people with acne vulgaris be referred to specialist care? (PDF, 272K)
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Study selection for: When should people with acne vulgaris be referred to specialist care? (PDF, 115K)
Appendix D. Evidence tables
Evidence tables for review question: When should people with acne vulgaris be referred to specialist care?
No evidence was identified which was applicable to this review question.
Appendix E. Forest plots
Forest plots for review question: When should people with acne vulgaris be referred to specialist care?
No evidence was identified which was applicable to this review question.
Appendix F. GRADE tables
GRADE tables for review question: When should people with acne vulgaris be referred to specialist care?
No evidence was identified which was applicable to this review question.
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: When should people with acne vulgaris be referred to specialist care?
No economic evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: When should people with acne vulgaris be referred to specialist care?
No economic evidence was identified which was applicable to this review question.
Appendix J. Economic analysis
Economic analysis for review question: When should people with acne vulgaris be referred to specialist care?
No economic analysis was conducted for this review question.
Appendix K. Excluded studies
Excluded studies for review question: When should people with acne vulgaris be referred to specialist care?
Clinical studies
Download PDF (119K)
Economic studies
Download PDF (117K)
Appendix L. Research recommendations
Research recommendations for review question: When should people with acne vulgaris be referred to specialist care?
No research recommendations were made for this review question.
Final
Evidence review underpinning recommendations 1.4.1 to 1.4.6 and 1.5.4 in the NICE guideline
These evidence reviews were developed by the National Guideline Alliance which is a part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: 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.
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.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Review Optimal management of acne to prevent scarring and psychological sequelae.[Am J Clin Dermatol. 2001]Review Optimal management of acne to prevent scarring and psychological sequelae.Layton AM. Am J Clin Dermatol. 2001; 2(3):135-41.
- Pilot study for the evaluation and adaptation of a Four Item-Acne-Scar Risk Assessment Tool (4-ASRAT): a resource to estimate the risk of acne-induced scars.[F1000Res. 2020]Pilot study for the evaluation and adaptation of a Four Item-Acne-Scar Risk Assessment Tool (4-ASRAT): a resource to estimate the risk of acne-induced scars.Estrella Porter J, Camacho M, Viteri MI, Aguilar K, Belhadi D, Bettoli V, Buestán ADR, Dréno B, Endara P, Layton A, et al. F1000Res. 2020; 9:651. Epub 2020 Jun 26.
- Evaluation, Prevention, and Management of Acne Scars: Issues, Strategies, and Enhanced Outcomes.[J Drugs Dermatol. 2018]Evaluation, Prevention, and Management of Acne Scars: Issues, Strategies, and Enhanced Outcomes.Fabbrocini G, Cacciapuoti S. J Drugs Dermatol. 2018 Dec 1; 17(12):s44-48.
- Review Treatment of acne vulgaris. Guidelines for primary care physicians.[Postgrad Med. 1991]Review Treatment of acne vulgaris. Guidelines for primary care physicians.Taylor MB. Postgrad Med. 1991 Jun; 89(8):40-2, 45-7.
- A clinical evaluation of acne scarring and its incidence.[Clin Exp Dermatol. 1994]A clinical evaluation of acne scarring and its incidence.Layton AM, Henderson CA, Cunliffe WJ. Clin Exp Dermatol. 1994 Jul; 19(4):303-8.
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