Acne Flashcards
Acne:
What is it, who gets it, why and how?
What?
• Chronic inflammation of pilosebaceous unit
Who?
• Adolescence and young adults (Male > Female)
• Men resolve by about 25yo
• Women can continue into 30 - 40yo
Why?
• Genetics
• Androgen driven
How? • Increased sebum production • Formation of keratin plugs • Overgrowth of Cutibacterium acnes • Localised inflammation
Acne:
Symptoms?
Symptoms? • Comedomes (black and white heads) • Pustules • Papules • Cysts • Scarring *Can occur on face, head, neck, back, chest
Acne:
How to diagnose?
Diagnosis:
• Clinical diagnosis
• Important questions on history:
- Where is the acne
- Is there scarring
- Timeline of onset
- Relationship to menstruation or pregnancy
- Associated symptoms like alopecia, hirsutism, oligomenorrhoea, groin/axillae/thigh/buttock lesions
- Previous treatment
- Current medications and supplements (bodybuilders – creatinine, anabolic steroids)
- Current mental health/body image concerns/impact on life
Acne:
Differential?
• Differential diagnosis:
- Folliculitis
- Keratosis Pillaris
- Milia
- Hiddradenitis Suppurativa
- PCOS
Acne:
Non pharmacological management/principles?
1) Manage expectation of cure
• Acne is a chronic disease that can be managed but not typically cured
• Treatments typically take weeks to months to see success
2) Focus on mental health
• Severity of impact on mental health does NOT correlate with severity of acne
3) Good skin care
• Wash gently with soap free product
• Can use gentle antibacterial/antiseptic wash if desired
• Moisturise if dry with an oil free product
4) Avoid triggers
• Skin - Cosmetics, sunscreens, oil-based products
• Medication – COCP with high levonorgestrel, progestogen only
• Chemicals – iodine, bromine, chlorine
• Environmental – heat, humidity, grease exposure
• Food – individuals who consume 100g of fatty or sugary products per day are 50% more likely to have acne
Acne:
Pharmacological treatment and Principles?
Treat based on severity
• General considerations
-Treatment trials of 6 weeks
-Always consider trialling a different medication from the same class as response can differ
-Oral ABx ideally for ≤3 months at a time
-Combination therapy yields best benefit
-NEVER combine salicylic acid with retinoid due to pronounced dryness
-NEVER combine topical and oral ABx
*treatment is additive as you increase severity
MILD
• Facial lesions
• No scarring
1) Topical retinoid (Adapalene 0.1%, Tretinoin)
OR
Azelaic Acid 15% gel
2) Topical retinoid
AND
Benzoyl Peroxide (BPO)
adapalene 0.1%, benzoyl peroxide 2.5%
adapalene 0.3%, benzoyl peroxide 2.5%
3) Topical Clindamycin 1%
- Can try increasing potency of tretinoin
- Can try increasing potency of BPO
- topical retinoids are unsafe in family planning, pregnancy and breast feeding
- BPO bleaches clothing
- Azelaic acid may bleach dark skin
- If daily treatments are too irritating, then consider alternate day
MODERATE • Face and trunk • Papules • Pustules • Nodules • No scarring
ADD in
1) PO antibiotics
(Doxycycline 50 - 100mg daily, Minocycline 50 - 100mg daily, Erythromycin 250mg BD)
(women only) 2) COCP -Any initially -Then consider: Cyproterone Desogestrel Drospirenone Gestodene
3) Spironolactone 25 – 50mg
- Common side effect of doxycycline is reflux long term
- Lack of response to an antibiotic does not preclude trying others
- Do not use spironolactone in pregnancy due to virilisation risk
- COCP response typically takes up to 6 months then consider adding spironolactone
SEVERE = REFERRAL • Anywhere • Nodules • Cysts • SCARRING
Oral Retinoid (Isotretinoin) • CBE, EUC, LFT, lipids and pregnancy test prior • Not in pregnancy • Not with tetracyclines • Can promote prolonged remission • 6 - 9month course • Adverse effects include - dry eyes, nose and lips • No evidence of mental health impact
Acne:
Infantile Acne?
Infantile Acne • Onset > 3 months of age • Resolves > 12 months of age • To diagnose comedones must be present • CAN progress and scar
Treatment:
1) BPO 5% daily
2) Topical retinoid 0.1 - 0.025%
3) Combination BPO and topical retinoid
4) Refer
