Acne

Question: Take a history from May Ling 15

years, examine her face ,outline the most likely

diagnosis and a management plan

Approach

Rapport

Concerns + expectations

Specific questions

Examination

Management

History

(1) Duration: months/years(2) Location : hormone or post adolescent acne(3) Previous treatments: how long and what

works best?(4) Triggers: What does she think causes the

acne?(5) Family history : scarring or isotretinoin (6) Impact: how do you feel about your skin ?

Does it stop you from doing anything?(7) Periods –regular?(8) Seek permission to examine

Examination

(1) Site: face chest , back(2) Severity of the acne: mild moderate and

severe(3) Inflammatory? Pink or red(4) Scarring evidence(5) Psychological impact

Differential diagnosis

(1) Rosacea(2) Perioral dermatitis(3) Acneiform drug eruptions(4) Folliculitis of the trunk

Classification of acne

Mild Moderate Severe

Open comedones ( blackheads)

++ + +

Closed comedones( white heads)

++ + +

Inflammatory Papules

occasional ++ ++

Pustules occasional ++ ++

Inflammatory Nodules + deeper lesions (cysts) + scarring

_ occasional ++

Mild Acne

Moderate Acne

Severe Acne

Hormonal or post-adolescent acne in women

(1) Mild, moderate or severe clinical form . (2) Postadolescent women + may continue into the

40s age group. (3) Often history of an acne flare premenstrually,

typically one week b4 the menses or during ovulation.

(4) Usually inflammatory and + deep; describe as ‘blind’ pimples lasting weeks.

(5) Characteristic distribution : lower third face, along the jawline + neck.

(6) Possible associations: hirsutism, menstrual irregularity and signs of polycystic ovary syndrome.

Infantile acne

(1) 6 months to 3 years of age

(2) Comedones and inflammatory lesions

(3) Cheeks, forehead and chin

(4) Usually settle after a few months

(5) Scarring can occur with inflammatoryand deeper lesions

Acne scarring

(1) Resulting from moderate or severe inflammatory acne lesions that heal with the formation of fibrous tissue

(2) As inflammatory lesions heal there are colour changes of purple, red and pink which gradually fade with time + hypo- + hyperpigmentation.

(3) Scars may be depressed + pit-like (termed ‘ice pick’) or flat, thin atrophic scars.

(4) Other scars are thick and lumpy + are hypertrophic or keloid in nature

Management

Explain medical understanding of cause of acne

Acne can be treated Diet is not proven to change acne Advise against picking or squeezing Regular washing soap: twice a day Avoid oily or greasy skin preparations Follow up

Evidence based practice

Strength of recommendation:(1) A: consistent + good quality patient

oriented evidence: topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics + oral contraceptives

(2) B: inconsistent or limited quality patient oriented evidence: herbal treatments + effect of diet

Mechanisms of action

Benzoyl peroxide

Topical retinoids

Antibiotics Oral isotretinoin

Decreased sebum

+ + ++ +++

Decreased abnormal kearatinisation

+ ++ ++ +++

Decreased P. acnes

+ + +++ +++

Decreased inflammation

+ ++ +++ ++++

Treatment

Acne Grading

Topical therapy

Oral antibiotics

Androgen blocker

Oral contraceptives(females)

Mild (1) Topical retinoids: nightly(2) Topical antibiotics( more inflammatory papules + pustules)

_ Indicated if failure topical therapy or inflammatory lesions increase or deeper

_ _

Moderate (1)Combination with topical antibiotic

(2)Pulse therapy:5-7 days

(1)Doxycycline 50-100 mg daily

(2)Bactrim

(1)Spironolactone 50 – 100 mg

(2)Cyproterone acetate 50 mg days 5-15 menstrual cycle

Oral contraceptive

Topical retinoids

(1) Preparations: adapalene ( differin gel or cream), adapalene + benzoyl peroxide ( epiduo gel) , isotretinoin ( isotex cream) , tretinoin ( retin – A, Retrieve cream, Stieva A) , tazarotene ( Zorac cream)

(2) Applied nightly to all areas of the face(3) Thin layer to a cool dry face(4) If sensitive face use every second night(5) Results 6-8 weeks(6) Maintenance therapy months

Oral contraceptives

Composition Brand names

Ethinyloestradiol + cyproterone acetate

Brenda -35 ED, Dianne -35 ED, Estelle -35 ED, Juliet -35 ED

Ethinyloestradiol + desogestrel Marvelon

Ethinyloestradiol + dienogest Valette

Ethinyloestradiol + drospirenone Yasmin, Yaz

Antibiotics therapy in acne

(1) Doxycycline : 50-100 mg daily ( some use 200 mg 1st 2 weeks + 100 mg thereafter)

(2) Bactrim(3) Do not use topical + oral antibiotics

at same time(4) Oral antibiotics for 6-12 weeks course(5) If longer course use benzoyl peroxide

for a week between courses(6) Side effects: photosensitivity with

doxycycline

Oral isotretinoin

(1) Severe acne, unresponsive conventional therapy + psychological therapy

(2) Common side effects: dry gritty eyes, dry skin, dry, chapped skin, headaches, muscle aches + secondary bacterial infections

(3) Contraindicated in pregnancy: start 2nd or 3rd day menstrual cycle + relatively contraindicated depression

(4) Starting dose 0.5 mg /kg/day (5) Stop when acne free 2-3 months(6) Stop all topical treatments + antibiotics