NATIONAL INSTITUTE FOR HEALTH AND CLINICAL
Optimal Practice Review (OPR)
Tetracyclines for acne vulgaris
The Chief Executive is asked to consider the following
does not proceed as a technology appraisal
does not proceed as an OPR developed using short clinical guideline
is referred back through the topic selection process for development
as a clinical guideline. If referred, the OPR aspect would be dealt with
by an economic section focussing on the cost effectiveness of
tetracyclines in the treatment of acne vulgaris.
Tetracyclines are antibiotics that are commonly used for acne vulgaris.
A number of systematic reviews have failed to find any difference in
efficacy between the tetracyclines despite differences in acquisition
cost. There is potential for a different adverse effect profile but this has
not been fully explored. Similarly, although there are differences in the
recommended regimens, the implications have not been evaluated.
The original OPR paper to the Department of Health considered the
tetracyclines for acne to be a potential candidate for the OPR work
stream. The purpose of considering it would not be to stop the
prescription of tetracyclines, but to consider their most cost effective
A draft scope and evidence table were consulted on and a workshop
held in 2007 to discuss the issues raised from consultation and to
decide which programme of work would be the most appropriate to
Issues discussed at scoping workshop
All stakeholders agreed that this topic was important and should
proceed through the Institute’s work programmes.
The focus should be on the use of tetracyclines in general, rather than
Comparisons between tetracyclines would be a valid approach.
However because there are many treatment options, including the use
of oral and topical treatments in combination, a technology appraisal
approach would not be able to take into account the existing
complexities and uncertainties surrounding treatment.
The impact of the different treatment regimens were considered to be
important (e.g. treatment dosage, adherence and duration of
treatment) and it was felt they could only be fully explored within a
The scope should not include acne rosacea.
Teenagers should be considered as a separate sub-group.
Gram negative folliculitis patients should be excluded as a sub-group.
There are other important subgroups that could only be fully explored
in a guideline (i.e. patients who have previously failed to respond to
other treatments, patients for whom acne vulgaris is either chronic or
Options for progress
Consultees considered that a technology appraisal would answer an
important question. However key parameters that needed to be taken
into account were safety, dosage, treatment regimens and adherence
to treatment. However, due to the many treatment pathways and sub-
groups it would be very complex project that would not easily be able
to accommodate the many parameters that ultimately impact on the
clinical and cost-effectiveness. There were also restricted options for
recommendations and the original OPR remit might not be fulfilled.
Initially, Consultees had only been give a choice between the OPR
being carried out as either a technology appraisal or as a “short
clinical guideline” and consultation responses favoured a “short clinical
guideline”. During the workshop, it became apparent that it would be
difficult to limit the scope to just 3 or 4 questions and many of the
uncertainties surrounding the management of acne would not be
resolved. It was, therefore, considered not appropriate to use the short
There are no existing UK guidelines on the management of acne,
although a guideline from the British Association of Dermatologists is
anticipated in 2008. A clinical guideline would be able to consider the
full care pathway for this important disease, address appropriate
questions for health economic assessment and also take into account
the chronic nature of acne and the complexity around its treatment.
Consultees, however, acknowledged that such a guideline would be
larger and longer in development than either a technology appraisal or
an OPR developed using the short clinical guideline process. It
should also be noted that although a clinical guideline on the
management of acne vulgaris has been considered for referral to
Issues for consideration
There is widespread variation in the management of acne and
guidance from NICE would optimise current practice and explore the
The proposed topic is not suitable for development as a technology
appraisal due to the complexities and uncertainties surrounding the
It is unlikely that a short clinical guideline (i.e. limited to 3 or 4
questions) would be able to take all of the necessary issues into
account. It is also unlikely that this topic would meet the criteria for
referral by the DH as a ‘short clinical guideline’.
It is not clear what the costs associated with the comparators are and
therefore whether the outcome will result in increased costs, be cost-
The Short Clinical Guideline process is currently committed and
further discussion is required as to whether this topic should be
prioritised or further resources committed.
Following consultation it is considered by both the Appraisals and
Guidelines teams that a standard guideline is necessary and should
Dr Sarah Garner, Associate Director, R&D, CPHD
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