Acne vulgaris

Question 1

What is it

Answer 1

obstruction of the pilosebaceous follicle with keratin plugs which results in comedones, inflammation and pustules.

Question 2

What is the cause

Answer 2

follicular epidermal hyperproliferation resulting in the formation of a keratin plug. This in turn causes obstruction of the pilosebaceous follicle. Activity of sebaceous glands may be controlled by androgen, although levels are often normal in patients with acne

Question 3

What is seen in patients

Answer 3

Different types of lesions are seen

Question 4

What can cause colonisation

Answer 4

colonisation by the anaerobic bacterium Propionibacterium acnes

Question 5

What do inflammatory lesions form and when

Answer 5

Inflammatory lesions form when the follicle bursts releasing irritants
papules
pustules

Question 6

An excessive inflammatory response may result in:

Answer 6

nodules
cysts

Question 7

What can it lead to

Answer 7

This sequence of events can ultimately cause scarring
ice-pick scars
hypertrophic scars

Question 8

What happens in steroid induced acne

Answer 8

drug-induced acne is often monomorphic (e.g. pustules are characteristically seen in steroid use)

Question 9

What happens in acne fulminans

Answer 9

very severe acne associated with systemic upset (e.g. fever). Hospital admission is often required and the condition usually responds to oral steroids

Question 10

When does it occur

Answer 10

Adolescence

Question 11

What can is mild acne

Answer 11

open and closed comedones with or without sparse inflammatory lesions

Question 12

What is Moderate

Answer 12

widespread non-inflammatory lesions and numerous papules and pustules

Question 13

What is severe

Answer 13

extensive inflammatory lesions, which may include nodules, pitting, and scarring

Question 14

What advice should be given

Answer 14

To avoid over-cleaning the skin (which may cause dryness and irritation). Acne is not caused by poor hygiene.
To use a non-alkaline (skin pH neutral or slightly acidic) synthetic detergent cleansing product twice daily on acne-prone skin.
To avoid oil-based comedogenic skin care products, make-up and sunscreens, and if make-up is used it should be removed at the end of the day.
That persistent picking or scratching of lesions can increase the risk of scarring.
That treatments may irritate the skin, especially at the start of treatment.
To reduce the risk of skin irritation associated with topical treatments, start with alternate-day or short-contact application (for example washing off after an hour).

Question 15

What is the 1st line

Answer 15

single topical therapy (topical retinoids, benzoyl peroxide)

Question 16

2nd line

Answer 16

topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)

Question 17

What antibiotics

Answer 17

tetracyclines: lymecycline, oxytetracycline, doxycycline

Question 18

What should be used in pregnancy

Answer 18

tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age
erythromycin may be used in pregnancy

Question 19

What is contraindicated with pregnancy

Answer 19

topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy.

Question 20

Which tetracycline should not be used

Answer 20

minocycline - pigmentation irreversable

Question 21

How long should abx be used

Answer 21

Max 3 months

Question 22

What should be given alongside abx

Answer 22

topical retinoids or benzoyl peroxide to reduce abx resistance

Question 23

What should you never do

Answer 23

Topical + oral abx

Question 24

What can happen as a result of long term abx use

Answer 24

Gram-negative folliculitis

Question 25

What is treatment for gram -ve folliculitis

Answer 25

high dose oral trimethoprim

Question 26

What is an abx alternative for women

Answer 26

COCP + topical agents

Question 27

When can dianette be used

Answer 27

2nd line sometimes used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs. only be given for 3 months and women should be appropriately counselled about the risks

Question 28

What to give for mild to moderate

Answer 28

Offer a 12-week course of one of the first-line options to be applied once daily in the evening

Question 29

When to use benzoyl monotherapy

Answer 29

Consider topical benzoyl peroxide as monotherapy as an alternative if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic.

Question 30

When are creams and lotions best

Answer 30

Dry skin

Question 31

When should refer

Answer 31

Urgently refer people with acne fulminans on the same day to the on-call hospital dermatology team, to be assessed within 24 hours.

Question 32

When to refer to consultant

Answer 32

Mild to moderate acne has not responded to two completed courses of treatment.
Moderate to severe acne has not responded to previous treatment that includes an oral antibiotic.
They have acne with scarring.
They have acne with persistent pigmentary changes.
Their acne of any severity, or acne-related scarring, is causing or contributing to persistent psychological distress or a mental health disorder.

Question 33

When should isotretinoin be used

Answer 33

Refer to term for severe scarring and when abx not working