Acne vulgaris Flashcards
Define acne vulgaris
Chronic inflammatory skin condition characterised by the blockage and inflammation of the pilosebaceous unit (hair follicle, shaft and sebaceous gland)
pathophysiology of acne
Follicular hyperkeratinisation -> formation of follicular plugs (comedones)
Hormonal influence on sebum production and composition (androgenic stimulation of the sebaceous glands → increased sebum excretion rate → sebum flow obstruction)
Inflammation, in part mediated by proprionibacterium acnes/cutibacterium acnes
Aetiology of acne
Occupational, acne cosmetica, pomade: exposure to insoluble, follicle-occluding substances e.g. cutting oils, petroleum-based products, coal tar, aromatic hydrocarbons
Chloracne: hydrocarbon exposure
Mechanica: repeated mechanical and frictional obstriction e.g. helmets, chin straps, suspenders, collars, prosthesis, violin
Tropical: extreme heat
Radiation: post radiation dermatitis
Medication: dioxins e.g. chloracne, corticosteroids, antiseizure e.g. phenytoin, carbamaxepine, phenobarbital, valproate, lamotrigine, levetiracetam, oxcarbazepine), lithium, isoniazid, ciclosporin, Vitamin B1/B12, anabolic steroids
What are the types of acne
Non-inflamed lesions (comedones)
- Open comedone = blackhead
- Closed comedone = whitehead
- Microcomedone = clinically invisible
Inflammatory
- Papules
- Pustules
- Nodules
- Cysts
Conglobate: rare and severe form found often in men, presenting with extensive inflammatory papules, suppurative nodules (can coalesce to form swinuses) and cysts on the trunk and upper limbs
Acne fulminans: sudden severe inflammatory reaction that preceipitates deep ulcerations and erosions, sometimes with systemic effects e.g. fever, arthralgia, myalgia
Risk factors for acne
Family history
High glycaemic index diset, milk, whey proteins
Hormonal: first few days of menstrual period
PCOS
Hyperandrogenism
How is acne graded
Mild: predominantly non-inflamed lesions with few inflammatory lesions
<20 comedones, <15 inflammatory lesions
Moderate: more widespread with an increased number of inflammatory papules and pustules
20-100 comedones, 15-50 inflammatory lesions
Severe: widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present
>5 pseudocysts, comedone count >100, total inflammatory lesions >50
What is the management for mild acne
Advice
First line: topical treatment
- Benzoyl peroxide + clindamycin (Duac)
- Comedones → topical retinoids (adapalene)
- Pustular → topical retinoid ± topical Abx
Second line: alternative topical retinoid, azelaic acid, salicylic acid
What is the management for moderate acne
Advice, try mild acne treatment
First line: PO Abx e.g. lymecycline, doxycyline (MAX 3 months) AND BPO or adapalene
Alternative: COCP in girls
Second line (scarring or not responding after 2 courses) → refer to dermatology → isotretinoin (Roaccutane)
IMPORTANT: A topical retinoid or benzyol peroxide should always be co-prescribed with PO antibiotics to reduce the risk of antibiotic resistance developing
What are the side effects of isotretinoin
teratogenic → must be on 2 forms of contraception (barrier and hormonal) + regular pregnancy tests (once a month)
Dryness, pruritus, conjunctivitis, muscle aches, photosensitivity, teratogenic, deranged LFTs
Low mood and suicidal ideation
Follow up for acne vulgaris
Review each treatment step at 8-12 weeks
Adequate response -> continue for at least 12 weeks
PO abx -> consider stopping abx and continuing topical treatment
Prognosis for acne
Chronic and may persist for many years
Tends to affect adolescents and resolve after end of growth
Females are more likely to have acne persist onto adulthood
Risk of hypertrophic or atrophic scarring, especially in darker skin
