Acne

Question 1

What is acne?

Answer 1

blockage and inflammation of the pilosebaceous unit (the hair follicle, hair shaft and sebaceous gland). It presents with lesions which can be non-inflammatory, inflammatory or a mixture

Question 2

Non inflamatory lesions

Answer 2

Comedones
Open - blackheads
Closed - whiteheads

Question 3

Inflammatory acne lesions

Answer 3

Papules and pustules - 5mm or less in diamteer
Deep pustules
Nodules

Question 4

Pathology of acne

Answer 4

Altered follicular keratinocyte proliferation leading to formation of follicular plugs (comedones).
Androgen induced seborrhoea (increased sebum production) within the sebaceous follicles which usually occurs around puberty.
Proliferation of bacteria (such as Propionibacterium acnes) within sebum in hair follicles.
Inflammation of the pilosebaceous unit.

Question 5

Complications of acne

Answer 5

Scarring - hyper or atrophic scars
Post inflam hyperpigmentation or depigmentation
Pscyjoscocial effects

Question 6

History to take for acne

Answer 6

Duration, type and distribution of lesions
Prev treatment incl OTC + response
Exacerbating factors - menstruation, contraceptives. cosmetics, creams
Systemic features - acne fulmimans
Psychosocial impact
Family history - endocrine disorders, polycystic ovarian syndrome, acne etc

Question 7

Underlying causes of acne

Answer 7

Drugs
hyperandrogenism - irregular periods, androgenic alopecia, hirsutism

Question 8

Differnetials for acne

Answer 8

Rosacea
Perioral dermatitis
Folliculitis + boils
Drug induced acne
Keratosisi pilaris

Question 9

Drug induced acne - which drugs?

Answer 9

Androgens
corticosteroids
isoniazid
ciclosporin
lithum
antiepileptics - phenytoin + carbamexapine
Vit B1, B6, B12
Dioxins - chloracne

Question 10

What acne drugs are contraindicated in pregnancy?

Answer 10

Topical retinoids and oral tetracyclines

Question 11

First line treatment mild to moderate acne

Answer 11

12 week course of:
topical adapalene 0.1% with benzoyl peroxide 2.5%
topical tretinoin 0.025w clindamycin
Topical benzoyl peroxide (3 or 5%) with cliindamycin (1%)
Apply once daily in evening

Question 11

First line treatment mild to moderate acne

Answer 11

12 week course of:
topical adapalene 0.1% with benzoyl peroxide 2.5%
topical tretinoin 0.025w clindamycin
Topical benzoyl peroxide (3 or 5%) with cliindamycin (1%)

Question 12

Moderate to severe acne first line

Answer 12

12 week course of:
tretinoin w clindamycin once daily

Topical adapalene + BP once daily or topical azelaic acid (15-20%) twice daily
+/-
Oral lymecycline 408mg or oral doxycycline 100mg once daily

Question 13

Lymecycline or doxycycline replacement if allergic or cnat toilerate

Answer 13

Trimethoprin or macrolide eg erythromycin

Question 14

Other option for acne control in women

Answer 14

COCP + topical

Question 15

What are the problems with using contraception for acne?

Answer 15

Oral progesterone only or progesterone implant may exacerbate acne - ise 3rd and 4th grn COCPs

Question 16

Referral with acne when

Answer 16

Acne fulminans - same day to on call dermatology team

Dermatology if -
-Diagnostic uncertainty
Acne conglobata
Nodulocystic ance
Mild to moderate acne doesnt respond to two complete courses of treatment
Mod to severe not responded to prev treatment incl oral antibiotic
ance with scarring or persistent pigementary changes
Causing psychological distress - potential mental health services

Question 17

Acne follow up (response to oral antibiotic)

Answer 17

1st line treatment at 12 weeks
Treatment including oral antibiotic - completely clears - stop antibiotic, continue topical
Improved but not cleared - consider continuing for 12 more weeks

Question 18

What is the treatment for severe acne resistant to topical and antibiotic therapy

Answer 18

Isotretinoin - retinoid oral, vit A derivative (accutane)

Question 19

Why can isotretinoin be dangerous?

Answer 19

V strongly teratogenic

Question 20

What antibiptics offered in acne are teratogenic?

Answer 20

Lymecycline and doxycycline

Question 21

Why does acne often occur at the onset of puberty?

Answer 21

Increase in androgen levels