Acne

Question 1

What proportion of the adolescent population have sufficient problems with acne to seek treatment?

Answer 1

15%

Question 2

By what age does most acne tend to clear?

Answer 2

late teens or early 20s; more severe tends to last longer, sometimes up to 30-40 years (sometimes beyond)

Question 3

Why is it key to give acne medication in a timely fashion?

Answer 3

prevent scarring

Question 4

What are the 4 major features of the aetiology of acne?

Answer 4

1. Androgen-induced seborrhoea (excess grease)
2. Comedone formation (blackheads, whiteheads and microcomedones)
3. Colonisation of pilosebaceous duct with propionibacterium acnes (P. acnes)
4. Production of inflammation

Question 5

What are 5 factors which may calm/modifiy acne?

Answer 5

1. Hormonal factors
2. UV light can benefit
3. Stress - not much evidence
4. Diet - evidence not strong but may be helped by low-glycaemic index diet
5. Cosmetics - oily based can worsen

Question 6

What are 5 drugs which may cause acne?

Answer 6

1. Topical and oral corticosteroids
2. Anabolic steroids
3. Lithium
4. Ciclosporin
5. Iodides taken orally, which amy be part of some homeopathic therapies

Question 7

What are 5 clinical findings in acne vulgaris?

Answer 7

1. Greasy skin (seborrhoea)
2. Comedones - non-inflamed skin lesions
3. Inflamed lesions - papules, pustules and nodules
4. Scarring - los sof tissue (atrophic or ice pick scar) or increased fibrous stissue - hypertrophic or keloid scar
5. Pigmentation - especially a problem in dark skin

Question 8

What investigations are required for most cases of acne?

Answer 8

most do not require investigations

Question 9

What are 2 possible investigations that may be performed in acne?

Answer 9

1. Free testosterone levels - if suspect PCOS
2. Rule out late onset (non-classical) congenital adrenal hyperplasia - test for serum levels of 17-hydroxyprogesterone levels in the follicular phase around 9am

Question 10

What other features might a patient with acne caused by non-classic congenital adrenal hyperplasia?

Answer 10

precocious puberty, acne and accelerated bone age in childhood

in adolescent: persistent acne, moderate-severe hirsutism, menstrual irregularity/feritlity problems and short stature

often family history

Question 11

What are 2 situations when you should refer a patient to secondary care for their acne before starting treatment?

Answer 11

1. Patients with severe acne e.g. nodular scarring acne should be referred immediately
2. Papular-pustular acne can also scar, if starting to scar and not responding to treatments - refer
3. If severe psychological symptoms - regardless of physical signs

Question 12

What kind of secondary care referral should be made for patients with scarring ideally?

Answer 12

semi-urgent, seen within 6 weeks

Question 13

What is the key treatment for mild-moderate acne?

Answer 13

topical preparations containing benzoyl peroxide and/or topical retinoids

Question 14

What must you explain to patients when prescribing benzoyl peroxide and/or topical retinoids for acne?

Answer 14

explain they will dry the skin and cause irritation; should start using two to three evenings a week and gradually increase frequency and duration of applications

Question 15

The use of which drug should now be restricted in acne treatment and why?

Answer 15

erythromicin - propionibacterium acne resistance increasing

Question 16

What should be done alongside treatment of acne to monitor response?

Answer 16

serial photography is best method; standardised grading methods can also be used

Question 17

What are the 5 steps of acne management?

Answer 17

1. Topic retinoid first line e.g. adapalene (Differin, adapalene+benzyl peroxide Epiduo) or isotretinoin (Isotrex)
   
   • second line = azelaic acid
2. Fixed dose combination treatment containing BPO with either topical retinoid or topical antibiotic
   
   • Epiduo (adapalene + BPO)
   • Duac (clindamycin + BPO)
3. Combine systemic antibiotics with appropriate topical agent - BPO to reduce bacterial resistance
   
   • tetracycles
   • macrolides - generally avoided
   • (trimethoprim - young children)
4. If woman: Dianette
5. Referral to secondary care or GPwSI
   
   • oral isotretinoin
   • high dose oral antibiotics such as lymecycline
   • Dianette with additional cyproterone acetate
   • short courses of oral corticosteroids

Question 18

When should the use of topical retinoids be avoided?

Answer 18

pregnancy - but safe in non-pregnant women of childbearing age even if not on contraception (stop as soon as get pregnant)

Question 19

What are first and second line of stage 2 of management - fixed dose combination of BPO with retinoid or anitbiotic?

Answer 19

1. First line: Epiduo gel - adapalene + BPO
2. Second line: Duac - clindamycin + BPO

other options are Treclin gel and erythromycin combinations

Question 20

What are the 3 oral antibiotic choices for step 3 of acne management not responding to previous steps or more widely distributed?

Answer 20

1. Tetracyclines
2. Macrolides
3. Trimethoprim

Question 21

What is the best first line oral antibiotic to treat acne?

Answer 21

Lymecycline 408mg OD (Tetralysal)

Question 22

What are macrolides such as erythromycin rarely used for acne management?

Answer 22

P. acnes resistance

Question 23

What are 2 situations when macrolides are first line management for oral antibiotics for acne?

Answer 23

1. Pregnancy
2. Children <12 years

Question 24

If given, what dose is used for oral macrolide antibiotics to treat acne?

Answer 24

erythromycin 500mg BD, or clarithromycin 250mg BD

Question 25

What is the usual duration of oral antibiotic treatment for acne and why?

Answer 25

3 months - no evidence of additional benefit for longer, and prolonged used increases resistance of P. acnes

but patient should remain on topical agent

can be repeated in future if needed

Question 26

When would you consider referral for consideration of isotretinoin following oral antibiotics?

Answer 26

if patient doesn’t respond to either of 2 types of antibiotics, ad especially if starting to scar

Question 27

In which type of patients may using dianette be of particular use to treat acne?

Answer 27

those suffering with significant endocrinopathies such as PCOS

Question 28

What is a particular problem of acne in pigmented skin?

Answer 28

post-inflammatory hyperpigmentation

Question 29

What are 4 treatment options that a patient may be offered for acne once referred to secondary care/ GPwSI?

Answer 29

1. Oral isotretinoin (see below)
2. High dose oral antibiotics such as lymecycline 408 mg BD or trimethoprim 300 mg BD
3. Dianette ® with additional cyproterone acetate (50-100 mg/10 days)
4. Short courses of oral corticosteroids may be required

Question 30

When can isotretinoin (oral) be prescribe din the community?

Answer 30

can be prescribd by physicians with expertise in use of systemic retinoids for treatment of acne and full understanding of risks and monitoring requirements - consultant dermatologists and experienced GPwSIs working in integrated service may wish to develop locally agreed care pathway (but this is off-licence still)

Question 31

What are 4 options for the management of atrophic (ice pick) acne scars?

Answer 31

1. Ablative lasers combined with appropriate surgical techniques has improved way certain atrophic scars can be treated
2. Punch excision of small atrophic scars can be helpful prior to resurfacing
3. Deep scars - scar revision may help
4. Other options - intradermal injections of collagen or compounds, which stimulate collagen synthesis

Question 32

What are 3 options for the treatment of hypertrophic/ keloid acne scars?

Answer 32

1. Silicone gels applied to scars
2. Local steroids for trial period (watch for SEs)
3. Pulsed dye laser can reduce redness + flatten

Question 33

What is acne vulgaris?

Answer 33

common skin disorder, usually occurs in adolecsence and typically affects face, neck and upper trunk

characterised by obstruction of pilosebaceous follicle with keratin plugs whihc result in comedones, inflammation and pustules