Managing Acne in Primary Care

Nicholas Ashley

Objectives

• Classifying acne by severity

• Topical Management

• Systemic Management

• When referral is needed

Questions

• Name some dermatological findings present on the

skin of an acne sufferer

• Name some different treatments available

• At what point should a dermatology referral be

considered?

Severity• Mild

Comedones -Open/Closed

(Black/White heads)

No inflammation (erythema)

• Moderate

>Blackheads and Whiteheads

Papules and Pustules

Inflammation (erythema)

• Severe

Nodules and Cysts

Severe inflammation

Scarring

What conservative measures can be suggested?...

Conservative

• Empathy and Counselling

• Dietary advice

• Face washing (twice a day maximum)

• Sunlight

What topical treatments can be suggested?...

Topical Therapies• Benzoyl Peroxide

2.5% strength

• Antibiotics

Clindamycin/Erythro/Doxy

• Topical retinoids

Antiinflammatory

Ensure NO PREGNANCYDon’t use on same area as

Benzoyl Peroxide

What systemic treatments can be suggested?...

Systemic Therapies

• Antibiotics

Doxycycline (not in young – teeth S/E)

Erythromycin

(Not in combo with topical Abx)

• OCP

• Retinoids

(Double contraception)

Secondary Care ONLY

Treating Scarring• OTC topical treatments

• Laser Treatment

• Dermabrasion

Outpatient procedure. Abrasive substances blown onto the face and then vacuumed off. Limited role in treating acne scarring

• Chemical peels

• Subcision

Used to treat depressed acne scars. Uses a needle to breakdown subcuticular fibrotic strands, thus releasing the skin from the underlying connective tissue.

Specialty CareReferral

• People who have a severe variant of acne including acne fulminans or Gram-negative folliculitis should be referred urgently to be seen within two weeks.

• People who have severe acne such as painful, deep nodules or cysts (nodulocystic acne), or other people who could benefit from oral isotretinoin, should be referred as 'soon'.

• Milder cases with possible scarring or failure to get an adequate response require 'routine' referral.

Practical Prescribing• Case vignette:

Moderate acne non responsive to following regime

o PANOXYL Wash

o DUAC Daily (Benzoyl peroxide and Clindamycin) OD

o Isotrex 0.05% gel applied topically OD/BD

o Isotrex gel + Oral Erythromycin 250mg BD longterm (2 months)

Will need to strongly consider secondary care

referral

Conclusion

• Assess Severity

• Ask “does this need secondary referral?”

• Start at the appropriate level of treatment and

escalate as necessary

Topical or Systemic

• Always assess need for counselling/support

Answers• Name some dermatological findings of an acne sufferer

Comedones (open/closed)

Papules Nodules Scarring

Pustules Cysts

• Name some different treatments available

Antibiotic (cream/tablet)

Retinoids (cream/tablet)

Benzyl Peroxide

• At what point should a dermatology referral be considered?

Severe acne

Scarring potential

Refractory to treatment