ACNE Flashcards
Facts about Acne
A chronic inflammatory disorder of the sebaceous glands
Primarily affects the young adolescent patient group but can affect up to 12% of women and 3% of men over the age of 25
Treatment aims are to prevent scarring both physical and psychological
Scarring is preventable (and treatable depending on how mild it is) if treatments are started in a timely manner
State the aetiology of Acne
1 .Androgen-induced seborrhoea(excess grease)
- Comedone formation(blackheads, whiteheads and microcomedones
- Colonisation of the pilosebaceous duct withPropionibacterium acnes(P. acnes)
- Production of inflammation.
Explain cause of acne due to Androgen-induced seborrhea
Androgen-induced seborrhoea(excess grease)
The more sebum (grease) the greater degree of acne
Sebum is produced by the pilosebaceous glands, which are predominantly found on the face, back and chest
Evidence suggests that in most patients the seborrhoea is due to increased response of the sebaceous glands to normal levels of plasma androgens
Facts about Comedone formation as a cause of acne
Comedone formation(blackheads, whiteheads and microcomedones), which is known as comedogenesis
Is due to an abnormal proliferation and differentiation of ductal keratinocytes
It is controlled, in part, by androgens
In pre-pubertal subjects comedones are seen early and they precede the development of inflammatory lesions
Facts about colonisation of the pilosebaceous duct withPropionibacterium acnes as a cause of acne
Colonisation of the pilosebaceous duct withPropionibacterium acnes(P. acnes)
Is a later stage in the development of acne lesions (especially inflammatory lesions)
The seborrhoea and comedone formation alter the ductal micro environment, which results in colonisation of the duct
P. acnes is the most important organism
Facts about production of inflammation as a cause of acne
Production of inflammation. This is a complex process involving an interaction between:
Biological changes occurring in the duct as a result of comedone formation and P. acnes colonisation of the duct
And the patients cellular (especially lymphocytes) response within the dermis, which responds to pro-inflammatory cytokines spreading from the duct to the dermis
State the aggravating factors of acne
- Hormonal factors About 70% of females will notice an aggravation of the acne just before or in the first few days of the period
Polycystic Ovarian Syndrome (PCOS) / other endocrinological disorders - Stress This is a controversial issue - there is some evidence that stress makes acne worse but data to support this view is limited
Stress may manifest itself as acne excoriee, where patients, usually females, habitually scratch the spots the moment they appear (refer to the related conditions at the top of this page)
3. Drugs Topical and oral corticosteroids Anabolic steroids Lithium Ciclosporin Oral Homeopathic remedies (iodide content) 4. cosmetics 5. Diet
state the relieving factors in acne
uv light
weight loss
Management of acne
Manage expectation, treatments will take time to work,
Oral Abx should be prescribed with a non-abx topical preparation
NEVER offer topical antibiotics alone if you can help it – resistance
step 1 treatment of acne
Mainly comedonal acne - a topical retinoid
Choices include adapalene (Differin ®), adapalene combined with benzoyl peroxide (Epiduo 0.1% ®), or isotretinoin (eg Isotrex ®)
In order toreduce excessive dryness/irritationadvise patients to leave on for 30-60 minutes before washing off, then gradually increase the duration of treatment as tolerated (eventually many patients can apply at bedtime and leave on overnight)
Step 2 of acne treatment
Mild to moderate papular / pustular acne
Use afixed dose combination treatment, ideally containing benzoyl peroxide (BPO),which reduces bacterial resistance, with either a topical retinoid or topical antibiotic:
First-line: Epiduo ® 0.1% or 0.3% gel (adapalene + BPO)
Second-line: Duac ® gel (clindamycin + BPO)
Other options: Treclin ® gel (clindamycin and tretinoin), or, Aknemycin ® Plus solution (erythromycin and tretinoin)
Advise as step 1 regarding adverse effects
Step 3 tx for acne
Not responding to the above and/or more widely distributed (without significant scaring)
Combine systemic antibiotics with an appropriate topical agent,preferably Epiduo ® 0.1% or 0.3% gel or if not tolerated use BPO or adapalene as single agents. Choice of antibiotic:
First-line: lymecycline 408 mg OD or doxycycline 100 mg OD, if partial response consider increasing the dose of either to BD (both contraindicated in pregnancy and children under 12 years of age)
Second-line: check with local guidelines as there are several options -
The tetracycline not used above as first-line
Clarithromycin 250-500 mg BD - higher levels of bacterial resistance than tetracyclines, but lower when compared to erythromycin
Trimethoprim 300 mg BD - patients need to be counselled as to the very small risk of severe cutaneous adverse reactions, and agranulocytosis (patients and their carers should be told to seek immediate medical attention if symptoms such as fever, sore throat, rash, mouth ulcers, purpura, bruising or bleeding develop. The BNF also recommends regular FBC)
Children under 12 years of age: clarithromycin (dose dependent on weight)
Duration of systemic antibiotic treatment
Ideally 3 months, evidence suggests that for most patients there is little additional benefit in using antibiotics for more than 3 months in any given treatment period - however, patients relapsing quickly after stopping treatment may be better suited to 6 month courses
Once stopped, many patients will need to remain on their topical agent (step 2)
The antibiotic course can be repeated in the future if needed
Step 4 tx for acne
Step 4: Active scarring acne
Patients with active acne and significant scarring should bestarted on treatment(as in step 3)andreferredat the same time as semi-urgent (ideally to be seen within 6-12 weeks). Theonly exceptionmay be some cases of early scarring in mild-moderate papulopustular acne (as opposed to nodular), when it may be deemed appropriate to commence treatment (as in step 3) and review at 6 weeks - if there are no signs of significant improvement then refer
State other options in the treatment of acne
Spironolactone – 50-150 mg OD, fine if renal function normal, safe, for women of course
Dapsone – 50-100 mg OD, monitor bloods for haemolysis
Things sold in private clinics e.g. laser, photodynamic therapy, chemical peels,
Intralesional steroids if large scars, plus surgical options, lasers
Camouflage make up – please refer via changing faces
Not suitable for men as the side effects – feminization, breast development
Management and practical advice in acne
Self care Monitor response – serial photography Topical retinoids useful for all grades Gradual introduction - 2xweekly can help manage irritant reaction Recommend a non-comedogenic moisturiser
provide an NHS choices link via accuRx
Adapalene is better tolerated than other topical retinoids, gradual introduction of these and BPO can help manage sensitisation
