Acne (Bacterial Skin infection)

Question 1

Background

Answer 1

Acne is inflammatory skin condition that leads to lesions
Acne represents a non-infectious form of folliculitis as a result of follicular obstruction by a keratin plug.

Most common in adolescence but can affect any age.
Severity can be mild, moderate or severe. Severity characterised by the lesion type(s) and quantity.

Question 2

Signs and Symptoms/ Diagnosis

Answer 2

Acne-like lesions (can be non inflammatory or inflammatory):
NON - black heads, whiteheads
Inflammatory - papulonodules (small raised lesion), pustules, nodules/cysts.
Other symptoms:
- Scarring
- Pigmentation

Acne vulgaris Mainly affects face, back, and chest.

Diagnosis:
History taking and examine person (look for symptoms and severity)

Question 3

Severity (Background info)

Answer 3

Mild to moderate acne:1 or + of: non-inflammatory lesions (any number), up to 34 inflammatory lesions, up to 2 nodules.
Moderate to severe acne: 35 or + inflammatory lesions and/or 3 or + nodules.

Mild acne — mainly non-inflamed lesions with few inflammatory lesions.
Moderate acne — more widespread with >inflammatory papules and pustules.
Severe acne — widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present.

Question 4

Treatment (Non-Pharmacological)

Answer 4

Non alkaline synthetic detergent cleansing product BD on acne prone skin.
Photodynamic therapy for moderate to severe when others FAIL

Avoid oil/comedogenic skin care products, sunscreens, make up, avoid picking lesions

Question 5

Treatment (BNF/CKS)

Answer 5

1ST LINE
All 12 week courses
Acne of any severity OD:
Topical adapalene + topical benzoyl peroxide (0.1% or 0.3% adapalene + 2.5% benzoyl peroxide).
- Topical tretinoin + topical clindamycin (0.025% tretinoin + 1% clindamycin).

Mild - Moderate acne:
1st line 12 weeks OD - options:
Above (any severity) OR
- Topical benzoyl peroxide + topical clindamycin (3% or 5% benzoyl peroxide + 1% clindamycin).

Moderate to severe acne:
Above (Any severity) OR
- Topical adapalene + benzoyl peroxide + oral lymecycline 408mg OD or doxycycline 100mg OD, OR
- Topical azelaic acid (15% or 20%) BD + oral lymecycline 408mg OD or doxycycline 100mg OD

ALT antibacterial: trimethoprim [unlicensed] or macrolide (eg erythromycin).

COOC + Topical agents can be used as ALT to antibiotics in women

ALT to 1st line
- wish to avoid antibiotics or topical retinoids. Topical benzoyl peroxide monotherapy.

Reassessment and further treatment
Review after 12 weeks if cleared consider maintenance.
If acne cleared and treatment included oral antibacterial consider stopping and continuing topical. BUT if treatment only improved can continue antibiotics for >6months but REVIEW/3 months.

Mild - moderate:
IF Treatment FAIL try different 1st line option if 2 fail consider REFERRAL.
Moderate to severe:
IF FAIL with NO antibiotic try different 1st line option with 1. IF did have antibiotic REFER.

Female PCOS 1st line FAIL consider + ethinylestradiol with cyproterone (co-cyprindiol) review at 6 months or ALT COOP.

Question 6

SEVERE resistant to adequate courses of oral antibiotic-containing 1st line treatments - ISOTRETINOIN

Answer 6

ISOTRETINOIN:
Oral. given by specialist.
Initiated at 0.5 mg/kg/day for 4 weeks and increased as tolerated dose of 120-150 mg/kg
Need PPP - Pregnancy Prevention Programme.
MAX 30 days’ supply and dispensed within 7 days. Pregnancy testing should ideally be carried out on the same day as prescription issuing and dispensing.
NEED 2 negative pregnancy test results

If have a FLARE after starting isotretinoin start course of oral prednisolone

Question 7

Relapse

Answer 7

If responded well try same course as last time OR ALT 1st line option.

If relapse’s after isotretinoin use:
- Currently mild to moderate, offer 1st line treatment option.
- Currently moderate to severe offer a 12-week course of 1st line treatment option OR re-referral

Moderate to severe acne that relapses after a 2nd course of oral isotretinoin - REFER

Question 8

Maintenance

Answer 8

Not always needed. If relapse Hx: Consider - fixed combo of topical adapalene + benzoyl peroxide.

ALT Topical monotherapy with either adapalene, azelaic acid, or benzoyl peroxide.

Review after 12 weeks

Question 9

Drug info

Answer 9

Topical retinoids:
Contraindication - P (use contraception), allergy, severe acne, perioral dermatitis, rosacea or Hx/ family Hx skin cancer, UV light exposure (sun), with keratolytics, abrasive cleaners cosmetics, broken or sun burned skin, skin, eyes.
AE - skin/eye irritation, sensitivity to UV light

Benzoyl peroxide:
Contraindicated - Allergy, broken skin, eyes, mouth and mucous membranes, excessive sun light,
AE - Skin irritation, Increase risk of sunburn, can bleach fabrics and hair

Topical antibiotics:
Clindamycin (lacosamide inhibitor)
Erythromycin (macrolide)
Both -{inhibits bacterial protein synthesis binds to 50s ribosome subunit}
Contraindicated - Allergy,
AE - Skin irritation, GI disturbances

Oral antibiotics:
Contraindicated - Allergy, (Lymecycline <8yrs), (tetracyclines - myasthenia gravis, systemic lupus erythematosus, Hepatic and renal impairment), (Erythromycin acute porphyria)
AE - T - Anaphylaxis, hepatotoxicity and liver failure, SJS. E - QT prolongation, Hepatotoxicity, reversible hearing loss

Azelaic acid:
Contraindicated - allergy, eyes/mouth/ mucous membranes
AE - Skin irritation, worsen asthma