[22] Acne Vulgaris

Question 1

What is acne vulgaris?

Answer 1

Acne vulgaris is a disorder of the pilosebaceous follicles found in the face and upper trunk

Question 2

When does acne typically present?

Answer 2

Just after puberty

Question 3

Why does acne typically present just after puberty?

Answer 3

Because at puberty, androgens increase the production of sebum from enlarged sebaceous glands that become blocked

Question 4

What bacteria is involved in lesion production in acne?

Answer 4

Propionobacterium acne

Question 5

What is the role of propionobacterium acne?

Answer 5

It’s exact role is unclear, but it’s a skin commensal that colonises the follicles in acne

Question 6

What are comedones?

Answer 6

Follicles impacted and distended by incompletely desquamated keratinocytes and sebum

Question 7

What are the types of comedones?

Answer 7

Open (blackheads) or closed (whiteheads)

Question 8

What can inflammation of comedones lead to?

Answer 8

Papules, pustules, and nodules

Question 9

How can acne cause problems mentally?

Answer 9

It can cause severe psychological problems, undermining self-assurance and self-esteem at a vulnerable time in life

Question 10

How does acne usually present?

Answer 10

Greasy skin with a mixture of comedones, papules, and pustules

Question 11

How long does acne last for?

Answer 11

It can continue for a variable number of years, usually stopping in the late teens or early 20’s

Question 12

In what respects is acne variable?

Answer 12

It runs a variable course with marked fluctuations, and the severity of the condition can vary enormously between individuals

Question 13

What are the differential diagnoses of acne vulgaris?

Answer 13

• Acne rosacea
• Folliculitis and boils
• Milia
• Perioral dermatitis

Question 14

What is the difference between acne rosacea and acne vulgaris?

Answer 14

Acne rosacea usually presents in middle age or later in life

Question 15

What is the difference between acne vulgaris and folliculitis/boils?

Answer 15

Folliculitis and boils may present with pustular lesions

Question 16

What are milia?

Answer 16

Small keratin cysts that tend to be whiter than acne whiteheads, and are most commonly seen around the eyes

Question 17

How is acne vulgaris investigated?

Answer 17

Usually, no investigations are required, however they are sometimes needed to explore a possible underlying cause

Question 18

How is mild acne managed?

Answer 18

• Reassure patient about natural course of condition, advising that it is very common, will usually clear up later in life without leaving significant scarring, and that treatments can be effective but take time to work and may irritate the skin.
• You should dispel common myths about acne
• Information about self care

Question 19

What common myths about acne should be dispelled?

Answer 19

• It is not caused by poor hygeine
• Excessive washing will not help - may actually aggrevate acne
• Diet has little or no effect on acne
• Acne is not infectious, and cannot be passed to other people

Question 20

What self care advise should be given to people with acne?

Answer 20

• Should not wash more than twice a day
• Use mild soap or cleanser and lukewarm water
• Avoid excessive use of makeup and cosmetics
• Use of OTC medications such as benoxyl peroxide

Question 21

Is prescription medication required in mild acne?

Answer 21

In mild acne, pharmacological treatment is not normally required, as the physical severity of the condition is limited, and scarring is unlikely. However, the psychological impact may be disproportionate, which is an indication for more aggressive treatment

Question 22

What is the first line pharmacological treatment for mild acne?

Answer 22

A topical retinoid, for example tretinoin or benzoyl peroxide

Question 23

What should be done if first-line pharmacological treatments for acne are poorly tolerated?

Answer 23

Azelaic acid should be prescribed

Question 24

Is combined treatment necessary for mild acne?

Answer 24

Rarely

Question 25

When should follow up be arranged for in pharmacological treatment for mild acne?

Answer 25

6-8 weeks

Question 26

What should be done at the 6-8 week follow up after pharmacological treatment for mild acne?

Answer 26

Review effectiveness, tolerability, and compliance with treatment

Question 27

How should moderate acne be managed?

Answer 27

• Same information regarding natural course of condition, popular myths about acne, and self-care advice as with mild acne
• Prescription medication

Question 28

Why is prescription medication required in moderate acne?

Answer 28

In moderate acne, inflammatory lesions (papules and pustules) predominate, and the acne may be widespread with a risk of scarring. There is also a considerable psychosocial morbidity, all of which are indications for aggressive treatment

Question 29

What pharmacological treatment should be considered in moderate acne that is limited and unlikely to scar?

Answer 29

A single topical drug, such as benozyl peroxide or topical retinoid, or azelaic acid if these are poorly tolerated

Question 30

What pharmacological treatment should be considered in patients with moderate acne which is at risk of scarring?

Answer 30

Combined topical treatment with a topical antibiotic and benozyl peroxide or a topical retinoid

Question 31

What is the advantage of a combination of topical antibiotic combined with benozyl peroxide or a topical retinoid in the management of moderate acne?

Answer 31

It is proven effective, and may limit the development of bacterial resistance

Question 32

When should an oral antibiotic be considered in the management of moderate acne?

Answer 32

• When there is acne on the back or shoulders that is particularly extensive or difficult to reach
• If the is significant risk of scarring or substantial pigment change

Question 33

What is the first-line oral antibiotic in the management of moderate acne?

Answer 33

Tetracycline or doxycycline

Question 34

What is an alternative if oral tetracycline or doxycycline are poorly tolerated or contraindicated in moderate acne?

Answer 34

Erythromycin

Question 35

What should not be done when prescribing an oral antibiotic in moderate acne?

Answer 35

• Prescribe oral antibiotic alone
• Combine oral and topical antibiotic
• Continue for any longer than shortest possible period

Question 36

When should a person with moderate acne be referred to dermatology?

Answer 36

• Development of, or risk of development of, scarring, despite primary care interventions
• Failed to respond adequately to treatment over a period of at least 6 months. Treatment failure should be judged on person’s perspective of their condition
• Features that make diagnosis uncertain

Question 37

How should severe acne be managed in primary care?

Answer 37

• Give patient same information regarding natural course of condition, popular myths about acne, and self-care as with mild and moderate acne
• Prescription medication
• Referral for specialist assessment and treatment

Question 38

Why is prescription medication required for severe acne?

Answer 38

In severe acne, there are nodules and cysts, as well as inflammatory papules and pustules. There is a high risk of scarring, and there is likely to be considerable psychosocial morbidity

Question 39

What pharmacological interventions can be given in primary care whilst the person awaits a specialist assessment?

Answer 39

Oral antibiotic in combination with topical drug

Question 40

What are the treatment options for severe acne in secondary care?

Answer 40

• Oral isotretinoin
• Laser treatment
• Surgical treatment

Question 41

What are the complications of acne?

Answer 41

• Significant psychosocial and social morbidity, with anxiety, severe depression, and suicidal ideaton
• Pernament scarring
• Post-inflammatory hyperpigmentation