Acne

Question 1

When to refer acne to secondary care

Answer 1

• nodulocystic acne
• acne with systemic Sx (fulminans)
• uncontrolled, developing scarring
• failure to respond to multiple interventions
• severe psychological distress
• diagnostic uncertainty

Question 2

Management of mild acne

Answer 2

• topical benzoyl peroxide
• topical retinoid +/- benzoyl peroxide
• topical Abx e.g. clindamycin IN COMBINATION with one of the above
• azelaic acid

Question 3

Management of moderate acne

Answer 3

• topical Abx IN COMBINATION with benzoyl peroxide/topical retinoid/both - max 3 months
• oral Abx (e.g. lymecycline) IN COMBINATION with benzoyl peroxide/topical retinoid/both - 3 months (<4-6) then continue topical
• COCP for females (if not CI)
• co-cyprindiol (Dianette)

Question 4

Management of severe acne

Answer 4

isotretinoin (roaccutane)

• 4-6 month course
• take with food OD or BD
• avoid alcohol
• sun protection
• FBC, FASTING lipids and LFTs: before treatment, 1 month in, and every 3 months on treatment
• negative pregnancy test required
• pregnancy-prevention plan (2 methods contraception) or monthly pregnancy tests
• screen for mental health risk

Question 5

SEs of roaccutane

Answer 5

• initial flare (worsening) of acne
• dry skin and mucous membranes
• photosensitivity
• myalgia and arthralgia
• visual disturbance
• deranged LFTs and hepatitis
• elevated cholesterol and triglycerides
• nausea, colitis, pancreatitis (hypertriglyceridaemia)
• benign intracranial hypertension
• mood disturbance
• highly teratogenic

Question 6

Management of acne in pregnancy

Answer 6

• topical benzoyl peroxide
• topical erythromycin
• if no response, oral erythromycin

Question 7

Management of acne in PCOS

Answer 7

Consider (in secondary care):

• spironolactone
• metformin

Question 8

Management of acne rosacea

Answer 8

• soap substitutes
• sun protection
• mild: topical metronidazole or azelaic acid
• mod-severe: oral tetracycline for 4 months

Question 9

Acne rosacea

Answer 9

• chronic relapsing remitting disorder of blood vessels and pilosebaceous units in central facial areas
• typically fair-skinned people
• central facial rash
• erythema
• telangectasia
• papules and pustules (without comedomes)
• inflammatory nodules ± facial lymphoedema
• ocular rosacea: blepharitis and conjunctivitis
• in men: rhinophyma (swelling and soft tissue overgrowth of nose)

Question 10

Roaccutane assessment and monitoring (3)

Answer 10

1. FBC, fasting lipids, LFTs (before starting, 1 mon in, then every 3 months)
2. pregnancy tests
3. mental health considerations