common dermatological condition that affects most people at some stage in life.

regarded as “normal” and OTC products available -> most people not seek treatment

14.1% of school aged students self-reporting “problem-acne”

• complex pathology:

• 1. sebum production

  2. increased follicular keratinisation

  3. Propionibacterium acnes follicular colonisation

  4. Release of inflammatory mediators

  5. Hormonal changes during puberty - increase sebum production

  6. Predisposition to hyperkeratinisation -> occlusion of hair follicles and sebaceous ducts -> open closed comedones

     • P.acnes in follicle

       breaks down sebum into fattu acids and peptides

     • rupture follicle wall

     • inflammatory response

     • formation of papules and pustules

  7. Deeper inflammation leads to nodules and cysts

  8. Scarring may then occur as deeper layers heal

History and exam

• >80% will develop some degree of acne b/w 11-30yo

• most mild and transitory

• can lead to complications

  • scarring

  • dyspigmentation

  • psychological issues

    • anxiety

    • depression

    • rarely, suicide

• History:

  • duration af symptoms

  • sites affected

  • typical appearance

  • possible aggravating factos:

    • use of cosmetics

    • skin products

    • sunscreens

  • use of medicines that may cause acne

    • antipsychotics

    • lithium

    • anabolic steroids (trunk)

  • menstrual history and oral contraception

  • Treatments that have been trailed

  • psychological and sociological effects of acne

• Examination:

  • Mild acne:

    • non inflammatory lesions - comedones

    • Some inflammatory lesions may be present but \<10-15

  • Moderate acne:

    • multiple comedones - 10-40

    • inflammatory lesions - 10-40

    • Nodules may be present

      • limited scarring

    • lesions may be present on trunk

  • Severe acne:

    • widespread presence of nodules and cysts

    • and/or large number of inflamed pustules and papules

    • scarring likely to be present

    • Nodulocystic acne = particularly severe form:

      • multiple inlfamed nodules and scarring

      • usually including trunk

      • young males

• discuss severity

• HEADSSS

• Take baseline photographs

Pharmacological treatment

All levels of severity:

• wash face gently with warm water dn mild soap or cleanser bd

• un-medicated face-wash = sufficient

• products containing benzoyl peroxide/salicylic acid = effective

• Rough scrubbing should be avoided - causes follicular rupture

  • increases inflammatory response

• Avoid soap if sensitive skin

• Acne products applied to all areas usually affected cf. individual lesions

• may take several months before significant results are seen

• should ensure current skin care products not contributing

  • look for label “non-comedogenic”

Mild acne:

topical benzoyl peroxide

• no subsidised - purchased OTC

• topical antimicrobial and keratolytic

• gel/cream/cleanser

  • 2.5-10%

• 2.5% sufficient for most

• higher concentrations = greater adverse effects

• gels more suited to oily skin

• rinse off more suitable if irritation occurs and for trunk

• washes applied 1-2 daily for 30sec

• gels applied OD removing after 2 hours for 3 days and then once daily at night

• adverse effects:

  • skin irritation

  • dryness

  • redness

  • avoid contact with eyes/mucous membranes

• oil free moisturiser can be used if skin peels/dry

• bleach linen, clothing or towels

• Salicyclic acid 0.1%-2% cream alternative

  • generally less effective and may cause skin dryness

  • softening and descaling skin -> reducing comedones

Topical retinoids

• inhibit keratinocyte differentiation and proliferation

• reduce comedones

• significant anti-inflammatory effects

• not suitable for patients with very inflammatory acne

• may not be tolerated by patients with sensitive skin

• must be applied at night:

  • UV radiation degrades retinoids

Adapalene

• available as 0.1% cream and gel

• applied thinly OD

• better tolerated cf. tretinoin

• gel suited for most people

Tretinoin

• 0.05% cream

• applied thinly OD

• Application built up to avoid adverse effects:

  • 1st night: 5min

  • 2nd night: 10min

  • inc. application time by 30min until 2 hour application achieved - then can be left overnight

• Topical reinoids should be trialled for at least 2 months before considering another treatment

• may cause mild acne flare

  • followed by significantly declining acne over 1-2 months

• Continued long-term use of retinoids safe and effective

• continue using topical retinoid even if acne initially appears slightly worse

Adverse effects:

• skin iririation, drness, erythema

• reduce time that product on skin before washed off and to apply a mild, oil-free moisturiser if there is obvious peeling

• Topical not associated with adverse effects as oral retinoids

  • should not be used in females that are pregnant or planning pregnancy

Topical antibiotics

• reducing number of P.acnes on surface of skin and in hair follicles and sebum ducts

• also antiinlammatory effects

erythromycin 4% gel or clinamycin 1% solution

• applied bd

• reviewed after 8-12 weeks

• should only be used alongside benzoyl peroxide or a topical retinoid

Moderate acne

Oral abx

Doxycycline

• 50-100mg daily for 4-6mo

• 50mg not subs

• tapered over 4 months if effective (to alternate day)

• if ineffective:

  • inc. to 100mg bd

  • CI in children \<12yo and women who are pregnant

• Minocycling:

  • effective for acne

  • greater risk of lupus erythematosus-like syndrome, hepatitis and pigmentation

  • not subsidised’

Adverse events

• oesophageal irritation

  • take with big glass of water and avoid lying down for 1 hour after dose taken

• photosensitivity

• Candida albicans vulvovaginitis

• N&V

Erythromycin

• 400mg bd

• less effective

  • increasing P.acnes resistance

Combined oral contraceptive

• effective mild-mod acne in females

• first for females (prior to abc)

• Standard COC should be tried initially

• Cyproterone (Ginet) more effective and suitable for women with PCOS

• slightly raise risk of VTE:

  • 40/100 000 cf. 20/100 000 for levonorgestrel-containing contraceptives

• POP and depot/implants: may worsen acne

• may take 6 cycles after initiating before effect seen

  • although reduction in seborrhoea usually apparent within 2-3 cycles

Severe acne

Isotretinoin

• severe, treatment resistant, older adults: may require oral isotretinoin

• associated with many adverse effects and is a major teratogen and requires monitoring

• Efficacy

  • affect all 4 pathogenic processes

    • results in sebaceous gland apoptosis and altered gene expression

  • highly effective clearing acne and reducing recurrence

  • single course:

    • significant improvement or complete remission of acne

  • Long-term:

    • depends on patient factos

  • if ineffective:

    • trigger investigation for endocrine cause - PCOS

Adverse effects

• range of serious adverse effects

• cheilitis:

  • so common = indicator of adherence

• may cause initial worsening of acne

  • severe flares = uncommon

• Females:

  • teratogenic and that exposure: particularly in first trimester:

    • spont. abortion

    • severe birth deformities

• should not donate blood during treatment or for one month after treatment stops

• Elevated lipid levels:

  • risk of pancreatitis if TAG >9

  • consider dose reduction or cessation if fasting TAG > 6mmol/L

  • likely to return to baseline one month after treatment finishes

• AbN LFT

  • >2.5 times ULN - stop

  • usually return to N within 2 weeks

• Depression

  • no clear evidence that isotretinoin causes depression

  • (acne associated with depression)

Initiating isotretinoin:

• use electronic decision support module

• discuss/provide in writing potential risks

• Baseline lab investigations

• contraception

• consent

  • understand adverse effects

  • importantance of not becoming pregnant

Dosing

• Low dose appears to be as effective as higher doses for resolving acne:

  • 0.1mg/kg == 1mg/kg

  • safer with regards to ADR

    • at 1mg/kg 98% report side effects

• Start @ 10-20mg/day continue until all lesions resolved (3-5months)

  • continue for further 2-4 months

• start at 0.5mg/kg/day

• 0.1-1mg/kg/day

• total dose over course of treatment 120-150mg/kg

• courses generally 3-4 months

• total doses of >150mg/kg = inc. adverse effects

• taken OD after main meal which should contain some fat - help increase absorption

• 10 and 20mg fully subs

Contraception

• Not pregnant prior to beginning

• strong advice against becoming pregnant during or within one month of completion of a course of isotretinoin

• 2 forms of reliable contraception

  • hormonal + barrier

• prescribed or know how to get ECP

Monitoriing

• significant adverse effects

• see above + cytopenias

• Baseline:

  • Lipid levels

  • LFT

  • Full blood test

  • Pregnancy testing

    • monthly during treatment and again 5 weeks post-treatment

Special authority

• Patient must have had trial of other available treatments with an inadequate response

• GP/NP/Dermatologist

• Up-to-date on knowledge of available acne treatments

• patient either:

  • female:

    • preg excluded

    • understand risk of teratogenicity

    • must not become pregnant during/one month after

  • male