Acne

Question 1

History

Answer 1

Age of onset of acne and its duration.

In females:

• menstruation and contraceptive history.
• PCOS - ask about hirsutism, period irregularity.

Skin sensitivity and dryness, especially if atopic.

Use of topically applied products e.g., cosmetics, cleansers, sunscreens, hair products, and moisturisers that might be irritant or occlusive.

Use of other products, especially corticosteroid preparations.

Prescription and over-the-counter acne medications that have been used, and their effect.

Recreational use of steroids e.g., gym use.

Presence of acne-induced psychosocial distress, depression or poor self-esteem.

Question 2

Flares of acne can be provoked by:

Answer 2

1. Polycystic ovarian disease
2. Drugs: steroids, hormones, anticonvulsants, epidermal growth factor receptor inhibitors and others
3. Application of occlusive cosmetics
4. High environmental humidity
5. Diet high in dairy products and high glycaemic foods.

Question 3

It is characterised by:

Answer 3

Open and closed uninflamed comedones (blackheads and whiteheads)

Inflamed papules and pustules

In severe acne, nodules and pseudocysts

Post-inflammatory erythematous or pigmented macules and scars

Adverse social and psychological effects.

Question 4

Assessment

Answer 4

1. Take a history.
2. Perform examination:

· Face and trunk – assess for the presence of:

• non-inflammatory lesions e.g., closed and open comedones and cysts.
• inflammatory lesions e.g., papules, pustules, nodules.
• secondary lesions e.g., excoriations, erythematous or pigmented macules, scars.

· Check BP if concern regarding hormonal cause.

· Look for hirsutism and striae.

3. Consider and acknowledge the patient’s level of distress irrespective of the clinical assessment.
4. Assess severity – clinical severity is based on previous treatments, level of psychological distress, and the number, type, and distribution of lesions:

• Mild acne: total lesion count <30
• Moderate acne: total lesion count 30–125
• Severe acne: total lesion count >125

– the definition is not solely based on physical signs and can be indicated by significant psychosocial distress or the failure of conventional treatment

Question 5

Mild acne

Answer 5

Comedones (non-inflammatory lesions) predominate

A few inflammatory lesions (papules and pustules) may also be present

Only a small number of lesions (papules and pustules) may also be present

Facial

Minimal treatments tried

Question 6

Moderate acne

Answer 6

Greater numbers of papules, pustules, and comedones present

Trunk affected

Failure to respond to topical treatments

Significant psychosocial distress

Question 7

Severe acne

Answer 7

Widespread inflammatory lesions (papules and pustules) and nodules commonly involving the face, chest, and back.

Focally severe acne.

Scarring is usually present.

Moderate acne that has not responded to 3 months of appropriate treatment.

Significant psychological distress.

Question 8

Mild acne Ry

Answer 8

A). Advise on general measures.

B). Treat using topical therapies as the first-line treatment of mild acne:

1. General consideration
2. Benzyl peroxide; beneficial for papulo pustular acne but not for predominantly comedonal acne – use a retinoid.
3. Topical retinoid preparation; particularly effective for comedonal lesions but can also be used for papulo-pustular acne.
4. Azelaic acid
5. Topical antibiotics

• must be combined with either benzoyl peroxide or topical retinoids (or both) as they can cause bacterial resistance if used alone.
• They are effective for mild inflammatory acne but have no effect on

6. Comedones: Consider a topical combination product.

Question 9

Mild acne Ry, General measures

Answer 9

Advise patient:

• Excessive washing can cause dryness and dermatitis.
• Over the counter face washes that contain salicylic acid can be useful.
• Use water-based, oil-free facial products.
• Remove all make‑up before sleeping.
• Advise against picking or squeezing pimples.

Question 10

Mild acne Ry, General considerations

Answer 10

Trial for at least 3 months to see if there is any improvement.

Different topical treatments can be combined if needed.

Do not use a single agent topical antibiotic as the only therapy.

For predominantly comedonal acne, use a topical retinoid first then azelaic acid.

For papulo-pustular acne, use benzoylperoxide, or a topical retinoid or azelaic acid or a fixed combination.

Advise patients to apply them to all of the skin of the face and not just where they see the acne lesions.

Question 11

Benzoyl peroxide

Answer 11

Available as a cream or gel

3 strengths:

• 2.5% (general sale)
• 5% (general sale)
• 10% (pharmacist-only medicine)

Usually start with 5% on alternate days or 2.5% strength for fair-skinned individuals.

Most common side-effect is skin irritation – dryness and redness. If necessary, switch to a lower strength.

Bleaches clothes, towels, and bedding.

Not subsidised – over the counter.

Also available in combination with clindamycin and adapalene, see topical combination product.

Question 12

Topical retinoid preparations

Answer 12

Two subsidised preparations are available:

• Topical adapalene (Differin Cream/Gel) – Differin
• Topical tretinoin (ReTrieve Cream) – ReTrieve

Reduce comedone formation and prevent new lesions.

Useful for inflammatory and non-inflammatory acne.

Skin irritation is common, so slowly increase frequency of use and use small amounts.

Apply at night as they are degraded by sun exposure.

Other topicals can be combined in the treatment regime and applied in the morning.

Advise about using sun protection.

Question 13

Azelaic acid

Answer 13

Available as a 20% cream or lotion

May cause local irritation, skin discolouration, and (rarely) photosensitivity

• Unfunded
• Pharmacy only

Question 14

Topical combination product

Answer 14

Benzoyl peroxide + clindamycin

• Prescription medicine
• Not subsidised

Question 15

Moderate acne Ry

Answer 15

Treatment requires either oral antibiotics or the combined oral contraceptive pill depending on patient suitability in conjunction with topical therapy.

1. Treatment duration:

• Treat the pt for a min of 3/12 and then review the response.
• Don’t prescribe antibiotics for prolonged periods if they are ineffective as antibiotic stewardship is important.
• Don’t prescribe antibiotics for longer than 6 months. Topical treatments may be continued for more than 6 months.

2. If using oral antibiotics, always combine with topical retinoids, benzoyl peroxide, or azelaic acid for efficacy, and to avoid bacterial resistance:

• First-line are tetracyclines. Doxycyline is preferable as minocycline may be associated with pigmentation, hepatic dysfunction, and systemic lupus erythematosus (SLE).
• Reserve erythromycin for children aged ≤ 12 years, pregnant women, and those unable to take, or unresponsive to, tetracyclines.

3. If using combined oral contraceptives for women:

• Useful for premenstrual flares of acne especially if involving the lower face and neck.
• Useful for women with acne and needing contraception.
• All COCs are effective for acne.
• If possible PCOS, consider an anti-androgenic COC, containing either cyproterone or drospirenone.
• Usually takes up to 6 cycles to see an effect.
• All oestrogen-dominant and have an anti-androgenic effect.
• Progesterone-only contraceptives may worsen acne.

If these treatments fail, scarring, or psychosocial distress, consider oral isotretinoin

Question 16

Moderate acne Ry, Antibiotics

Answer 16

1). Tetracyclines

• Warn about photosensitivity and oesophagitis.
• If used with oral contraceptives, 3 weeks of initial barrier contraceptive cover is needed.
• Do not use in pregnancy, breastfeeding, and children

First-line – doxycycline:

• Fully subsidised
• 100 mg once a day
• If 100 mg once a day is not tolerated, try a 50 mg formulation e.g., Doxy-50 twice a day (partially subsidised).
• Advise patient not to halve, crush, or chew due to increased risks of oesophagitis.

Second-line – minocycline:

• 50 mg tablets twice a day
• 100 mg capsule once a day
• Partially subsidised

2). Erythromycin

• Dose is 400 mg twice a day with food
• Fully subsidised

Question 17

Sever acne Ry

Answer 17

1. Consider oral isotretinoin in pts:

• with severe acne.
• with early scarring.
• for whom adequate trials of other available treatments have failed or are contraindicated.
• with significant psychosocial adverse effects.

2. Determine any contraindications for isotretinoin
3. Discuss:

• pregnancy and manage pregnancy risk.
• Mood and mood changes
• Common side‑effects

4. Obtain informed consent.
5. Arrange pre-treatment blood tests.
6. General practitioners can prescribe using an Isotretinoin Special Authority

Question 18

Contraindications for isotretinoin

Answer 18

1. Pregnancy or risk of pregnancy.
2. Potential for additive risk of raised intracranial pressure with tetracyclines.
3. Severe hepatic impairment or hypervitaminosis A.
4. Commercial pilots due to effects on night vision.
5. Not to be used within 6 months of laser eye surgery.
6. Hyperlipidaemia is a relative precaution.
7. Isotretinoin can be used with close monitoring, especially of triglycerides.

Question 19

Manage pregnancy risk, Isotretinoin

Answer 19

Isotretinoin is a potent teratogen and causes spontaneous abortions and severe birth defects.

For all women of childbearing potential, regardless of their age or likely behaviour:

• Obtain a current sexual history.

If needed, provide effective contraception starting 1 month before, for the duration, and for 1 month after treatment. Advise the patient to ideally use 2 forms of contraception.

• The progesterone-only pill is less reliable than the COC, but may be used together with a barrier method if the patient cannot tolerate the COC.
• Aim to start isotretinoin on day 2 or 3 of the menstrual cycle with a check serum b‑hCG. Consider repeat serum b-hCG after 1 month of treatment.
• If the pt has unprotected sex during isotretinoin therapy, advise them to urgently seek medical treatment to consider emergency contraception.
• Consider offering a prescription for emergency contraception in case of contraceptive failure.

Question 20

Mood and mood changes in acne

Answer 20

Mood change is common for patients with acne vulgaris.

Pts with severe acne-causing depression may benefit from isotretinoin.

If the patient has a history of suicidality, carefully consider and discuss the risks of isotretinoin.

It is uncertain if serious mood disorders are linked with isotretinoin. Inform pts that serious depression and suicide have been reported in pts with acne.

If the pt has symptoms of serious depression or suicidality, request acute child and youth mental health assessment or acute adult mental health assessment.

Question 21

Isotretinoin dose

Answer 21

The usual starting dose is 10 to 20 mg once a day with food, usually with the biggest meal of the day.

Some pts with inflammatory acne or a large number of macro-comedones can experience a severe flare when starting isotretinoin, particularly with larger initial doses (> 0.5 mg/kg/day), causing scarring. If so, consider:

• starting with very low doses of isotretinoin, possibly 5 mg once a day.
• erythromycin 400 mg twice a day or trimethoprim 300 mg once a day for at least 2 weeks prior to starting isotretinoin and for at least 2 to 4 weeks after starting.
• oral prednisone with erythromycin or alone, starting at 30 to 40 mg once a day reducing gradually over 4 to 6 weeks. Avoid tetracyclines.
• seeking dermatology advice if severe acute inflammatory reaction.

Pt tolerance of isotretinoin varies so adjust the dose or advise to adjust the dose.

Many pts do not tolerate doses > 40 mg once a day.

Question 22

Duration of course of isotretinoin

Answer 22

Ensure that all comedones (closed and open) have resolved to avoid relapse.

The goal is full acne clearance.

Continue treatment for 2 to 4/12 after acne has cleared.

Do not be unduly influenced by weight- or time-based guidelines.

Commonly a dose of 10 to 40 mg once a day may be needed for 9 to 12 months.

Macrocomedonal acne may take 12 to 18 months to clear on low-dose isotretinoin.

Question 23

Request

Answer 23

1. If the patient has symptoms of serious depression or suicidality, request:

• acute child and youth mental health assessment if aged
• acute adult mental health assessment if aged ≥ 18 years.

2. Seek dermatology advice if:

• a severe acute inflammatory reaction occurs while on isotretinoin.
• concerns, complications, or treatment failure despite adequate course in an adherent pt.