Acne

Question 1

What is acne?

Answer 1

• Acne is inflammaton of the sebaceous(oil) glands of the skin

Question 2

What is the pathophysiology of acne?

Answer 2

• It is due to excessive sebum productiondue to the action of androgen
• Glands become blocked (blackheads and whiteheads) due to increased keratinisation of the sebaceous duct
• The bacteria in the sebum produces lipases with the resultant fatty acids provoking inflammation

Question 3

What are the types of acne?

Answer 3

• Infantile occurs in the first few months of life mainly on the face, mainly boys and self limiting
• Adolecent is the most common thype; 13-16 years commonest, males more commonly affected
• Cosmetica is mostly in women due to prolonged use of skin care products
• Oil occurs mainly on the legs of workers exposed to petroleum
• Drug induced due to corticosteroids, iodides, lithium, some OCPs and anti-epileptics

Question 4

What are the key features on history?

Answer 4

• Duration of acne
• Location of acne
• Impact on social life an relationships
• What has been tried for Mx
• Perception about acne
• General halth including periods

Question 5

What are the examination features of acne?

Answer 5

• Examine the affected areas
• Confirm acne
• Describe comedones, pustules, erythema, nodules, cysts or scars

Question 6

What is the typical appearance of acne?

Answer 6

Question 7

What are the general principles of Mx?

Answer 7

• Adolescents needs sympathetic care and support from the family
• Dispel myths
• Diet and oily hair are not contributors
• Chlorine in pools do not make it worse
• Blackheads are not dirt and do not dissolve in hot water
• Use a normal soap and wash gently; do not scrub
• Avoid oily cosmetcis/moisturisers
• Avoid picking/squeezing blackheads
• Moderate sunlight might improve

Question 8

What are the differetial diagnosis?

Answer 8

• Staph.aureus folliculitis
• Pseudofolliculitis barbae
• Rosacea
• Perioral dermatitis
• Malassezia.folliclulitis on the skin

Question 9

What IX are needed?

Answer 9

• None usually
• LFTs/lipids are needed if planning systemc isotretinoin

Question 10

What are the principles of treatment?

Answer 10

• Unblock the pores with keratolytics such as salicylic acid/ benzoyl peroxide
• Decrease bacteria in the sebum with systemic Abx such as tetracyclines/eryhtromycin or topical Abx such as clindamycin
• Decrease sebaceous gland activity with oestrogens/spironolactone/cyproterone acetate or isotretinoin

Question 11

What are the recommended treatment regimens?

Answer 11

• For mild to moderate acne; use isotrtinoin gel or cream 0.05% each night(tretinoins are photosensitive). After 2 weeks, add benzoyl peroxide in the morning and continue isotretinoin for 3 months and review. Clindamycin topical can be added on if not improving.
• Clindamycin is very useful in pregnancy
• Moderate acne can be treated with above regimens with oral ABx such as tetracyclines. In females, combined OCP with a third generation progesterone (Diane 35-cyproterone acetate) is beneficial
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Question 12

What are the indications and contraindications for systemic retinoids?

Answer 12

• Severe recalcitrant nodular cystic acne or acne conglobata or acne refractory to first line topical/ABx are the indications
• Oral isotretinoin(roaccutane) leads to remission in almost all cases in months and lasts for months to years
• It is teratogenic and pregnancy is a contraindication. Preventive and effective contraception is a must in females. It should not be combined with tetracyclines as it can cause pseudotumour cerebri