Acne Vulgaris

Question 1

What is acne vulgaris?

Answer 1

Acne vulgaris (acne) is an extremely common condition, often affecting people during puberty and adolescence. Most people are affected at some point during their lives, and symptoms can range from mild to severe.

Question 2

Briefly describe the pathophysiology of acne vulgaris

Answer 2

Acne is caused by chronic inflammation, with or without localised infection, in pockets within the skin known as the pilosebaceous unit. The pilosebaceous units are the tiny dimples in the skin that contain the hair follicles and sebaceous glands. The sebaceous glands produce the natural skin oils and a waxy substance known as sebum.

Acne results from increased production of sebum, trapping of keratin (dead skin cells) and blockage of the pilosebaceous unit. This leads to swelling and inflammation in thepilosebaceous unit. Androgenic hormones increase the production of sebum, which is why acne is exacerbated by puberty and improves with anti-androgenic hormonal contraception. Swollen and inflamed units are called comedones.

The Propionibacterium acnes bacteria is felt to play an important role in acne. This is a bacteria that colonises the skin. It is thought that excessive growth of this bacteria can exacerbate acne. Many of the treatments of acne aim to reduce these bacteria.

Question 3

How does acne present?

Answer 3

It presents with red, inflamed and sore “spots” on the skin, typically distributed across the face, upper chest and upper back.

There are few terms used to describe the appearance of the lesions:

• Macules
• Papules
• Pustules
• Comedomes
• Blackheads
• Ice pick scars
• Hypertrophic scars
• Rolling scars

Question 4

What are macules?

Answer 4

Macules are flat marks on the skin.

Question 5

What are papules?

Answer 5

Papules are small lumps on the skin.

Question 6

What are pustules?

Answer 6

Pustules are small lumps containing yellow pus

Question 7

What are comedomes?

Answer 7

Comedomes are skin coloured papules representing blocked pilosebaceous units.

Question 8

What are blackheads?

Answer 8

Blackheads are open comedones with black pigmentation in the centre.

Question 9

What are ice pick scars?

Answer 9

Ice pick scars are small indentations in the skin that remain after acne lesions heal.

Question 10

What are hypertrophic scars?

Answer 10

Hypertrophic scars are small lumps in the skin that remain after acne lesions heal.

Question 11

What are rolling scars?

Answer 11

Rolling scars are irregular wave-like irregularities of the skin that remain after acne lesions heal.

Question 12

What is the aim of acne treatment?

Answer 12

The aim of treatment is to reduce the symptoms of acne, reduce the risk of scarring and minimise the psychosocial impact of the condition. Always explore the psychosocial burden and any potential anxiety and depression that may be associated with the condition.

Question 13

Briefly describe the stepwise treatment of acne

Answer 13

Treatment is initiated in a stepwise fashion based on the severity and response to treatment:

• No treatment may be acceptable if mild
• Topical benzoyl peroxide
• Topical retinoids (chemicals related to vitamin A)
• Topical antibiotics such as clindamycin (prescribed with benzoyl peroxide to reduce bacterial resistance)
• Oral antibiotics
• Oral contraceptive pill
• Oral retinoids for severe acne

Question 14

How does topical benzoyl peroxide work?

Answer 14

Topical benzoyl peroxide reduces inflammation, helps unblock the skin and is toxic to the P. acnes bacteria.

Question 15

How do topical retinoids (chemicals related to vitamin A) work?

Answer 15

Topical retinoids (chemicals related to vitamin A) slow the production of sebum (women of childbearing age need effective contraception).

Question 16

What topical antibiotic can be prescriped for acne?

Answer 16

Clindamycin.

Question 17

What oral antibiotic can be prescribed for acne?

Answer 17

Lymecycline.

Question 18

What combined contraceptive pill is prescribed in acne?

Answer 18

Co-cyprindiol (Dianette) is the most effective combined contraceptive pill for acne due to it’s anti-androgen effects. It has a higher risk of thromboembolism, so treatment is usually discontinued once acne is controlled and it is not prescribed long term.

Question 19

What is the role of oral isotretinoin (Roaccuatnce) in treating acne?

Answer 19

Oral isotretinoin (Roaccutane) is very effective at clearing the skin. It is a retinoid, and works by reducing production of sebum, reducing inflammation and reducing bacterial growth. It can only be prescribed under expert supervision by a dermatologist.

It is strongly teratogenic (harmful to the fetus during pregnancy). Patients need to have effective and reliable contraception and must stop isotretinoin for at least a month before becoming pregnant.

Question 20

What is the risk of oral isotretinoin (Roaccutane)?

Answer 20

It is strongly teratogenic (harmful to the fetus during pregnancy). Patients need to have effective and reliable contraception and must stop isotretinoin for at least a month before becoming pregnant.

Question 21

What are the side effects of isotretinoin?

Answer 21

Side effects of isotretinoin include:

• Dry skin and lips
• Photosensitivity of the skin to sunlight
• Depression, anxiety, aggression and suicidal ideation
• Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis

Question 22

What needs to be screened prior to a patient starting oral isotretinoin (Roaccutane)?

Answer 22

Patients should be screened for mental health issues prior to starting treatment.