Acne Flashcards
What is acne? What is it characterised by? Where does it appear?
acne vulgaris is a chronic inflammatory skin condition
- mainly affects the face, back and chest
causes spots and oily skin
- characterised by blockage and inflammation of pilosebaceous unit (hair follicle, hair shaft, sebaceous gland)
What causes acne?
sebaceous glands underneath the dermis produce sebum that keeps skin smooth
- pores on skin allow sebum and hair to come to surface
these hair follicles become keratinised as they mature.
- keratin becomes unusually cohesive and sebum accumulates within it forming keratin plugs (thicker skin at pores combined with dead skin cells)
causes comedones (whitehead and blackheads) - pores or hair follicles that have gotten blocked with bacteria, oil, and dead skin cells to form a bump on your skin
What are triggers for acne?
polycystic ovary syndrome (PCOS) can increase level of male hormones in females
chemicals
= e.g. halogenated hydrocarbons
hormonal changes make up hair oil/products picking spots sweating heavily
medicines
- phenytoin
- steroids
- lithium
- POC
- testosterone
What are myths about acne?
not caused by poor hygiene
unclear if linked to stress
unclear if UV light (sunlight) can help acne
unclear if linked to diet
is not contagious
severe acne has a tendency to run in families
darker skin is not tougher than lighter skin and should be treated sensitively
How can acne present on patients? What areas are affected?
red papules
- raised, red bump with no pus
- may appear as darker spots in darker skin
blackheads
- small black or yellowish bumps caused by the hair follicle
pustules
- small red bumps with white or yellowish centres (build up of pus)
whiteheads
- raised white bump (will not empty when squeezed)
- is not inflamed
greasy skin – T zone
areas affected:
- face (mostly)
- back
- chest
What are differential diagnosis for acne?
rosacea - butterfly rash, flushing perioral dermatitis - red rash circling mouth/papules folliculitis and boils - small red bumps or white-headed spots around hair follicles - hard, painful, pus-filled lump
ingrown hairs (more common in curly, coarse hair)
- red bumps and/or whiteheads
- hair growing out of follicle improperly
keratosis pilaris
- small bumps on skin when keratin build-up blocks hair follicles; harmless, chronic condition
ADR
- corticosteroids
- anti-epileptics e.g. phenytoin, carbamazepine
- lithium
- hormone treatment
How does the skin change with acne?
scarring
- hypertrophic (keloid) = thickened, wide, often raised scar
- atrophic = indented scar that heals below the normal layer of skin tissue (sunken/pitted)
post-inflammatory hyperpigmentation (PIH) or depigmentation
- hypo- and hyperpigmentation and/or keloid scars more common in darker skin
PIH can occur due to abnormal release or overproduction of melanin during healing process
- can take longer to heal than acne (6 months to years)
What are practical/lifestyle measures to manage acne?
do not wash more than normal (twice a day)
- excess washing and scrubbing may cause more inflammation, dryness and irritation and possibly make acne worse
use a mild soap (non-alkaline) and lukewarm water (very hot/cold water may worsen acne)
do not scrub hard when washing acne-affected skin
- use a soft wash-cloth and fingers instead
black tip of a blackhead is melanin and cannot be removed by cleaning or scrubbing
some topical acne preparations may dry the skin
- if this occurs, use a fragrance-free, water-based moisturiser cream
- do not use ointments or oil-rich creams as these may clog pores
avoid oil-based comedogenic skin care products, make-up and sunscreens
remove make-up at end of day
persistent picking or scratching of lesions can increase risk of scarring
What are pharmacological treatment options of acne? What do they do?
Retinoids
- e.g. Adapalene, tretinoin, isotretinoin
= unplug blocked pores, reduces some inflammation
Topical antibiotics
- e.g. Clindamycin
= reduce bacteria and inflammation
Azelaic acid
= unplugging blocked pores, reduces some inflammation
What is the first line option for mild-moderate acne?
offer a 12-week course of first-line option once daily in evening:
- topical adapalene (0.1% or 0.3%) with topical benzoyl peroxide (2.5%)
- topical tretinoin (0.025%) with topical clindamycin (1%)
- topical benzoyl peroxide (3% or 5%) with topical clindamycin (1%)
consider topical benzoyl peroxide as monotherapy if other options are contraindicated or patient wants to avoid retinoid or antibiotic e.g. pregnancy
What is first line option for moderne-severe acne?
offer a 12-week course of a first-line option:
- topical adapalene (0.1% or 0.3%) with topical benzoyl peroxide (2.5%) od in evening
- topical tretinoin (0.025%) with topical clindamycin (1%) od in evening
- topical adapalene with topical benzoyl peroxide (od in evening) + oral lymecycline 408mg or oral doxycycline 100mg od
- topical azelaic acid (15% or 20%) bd + oral lymecycline 408mg or oral doxycycline 100mg od (oral tetracycline)
consider benzoyl peroxide as monotherapy
If oral tetracyclines not tolerated or contraindicated, consider replacing with trimethoprim or oral macrolide e.g. erythromycin
Consider oral contraceptives in combination with topical agents as alternative to systemic antibiotics in women
What should be done if oral tetracycline are not tolerated/are contraindicated?
if oral tetracyclines not tolerated or contraindicated
- consider replacing with trimethoprim or oral macrolide e.g. erythromycin
consider oral contraceptives in combination with topical agents as alternative to systemic antibiotics in women
What should be done when reviewing products used in acne treatment?
review at 12 weeks
- if using oral antibiotic then consider stopping but continue topical tx
- continue alongside topical tx for further 12/52 (12 weeks)
exceptional circumstances are needed to continue topical or oral antibiotic for more than 6 months
What is the pregnancy prevention programme?
used for child-bearing people taking any oral retinoids
retinoids are contraindicated in pregnancy as high risk of congenital malformations
effective contraception must be used for at least 1 month before starting tx, during and at least 1 month after stopping tx
- use at least 1 method of contraception but ideally 2 methods
- oral POC not considered effective
barrier methods should be used in conjunction with another method
- exclude pregnancy a few days before tx, every month during tx (unless no risk of pregnancy) and 4 weeks after stopping
discontinue treatment and seek prompt medical attention if become pregnant or within 1 month of stopping
When can isotretinion be prescribed? What are the important safety information?
is an oral retinoid
can only be prescribed under specialist care
- for severe acne
= e.g. nodular, risk of permanent scarring etc. which is resistant to standard therapy
safety information:
- rare: sexual side effects e.g. erectile dysfunction, reduced libido
- neuropsychiatric reactions therefore monitor for signs of depression, suicidal ideation, mood changes etc.
