Acne Vulgaris

Question 1

Definition

Answer 1

Common skin disorder caused by chronic inflammation of hair follicles and sebaceous glands = commonly occurs in adolescence

Question 2

Epidemiology and Risk Factors

Answer 2

12-25 years, peak age:
- 14 = girls
- 16 years = boys
Family history
Medications:
- androgens,
- corticosteroids,
* NO DIET is associated with acne *

Question 3

Aetiology

Answer 3

1. Hyperandrogenism = excess sebum production by sebaceous glands, (which have androgen receptors) -> excess production of keratin by keratinocytes -> blockage of follicles with subsequent comedone formation
2. Propionibacterium acnes colonisation of follicles -> production of inflammatory cytokines and lipases, -> papulae, pustule, cyst, and nodule formation.

Question 4

Acne characterisation

Answer 4

Obstruction of the pilosebaceous follicles with keratin plugs resulting in comedones, inflammations and pustules.

Question 5

Comedone definition

Answer 5

NON-INFLAMMATORY lesions
- open = blackheads
- closed = whiteheads
When the follicle bursts inflammatory lesions such as papules and pustules may form.
Excessive inflammation results in nodules, and cysts

Question 6

Inflammatory lesions increase the risk of…

Answer 6

development of post-inflammatory scarring (ice-pick and hypertrophic scars)

Question 7

Signs

Answer 7

Mild = mostly non-inflamed lesions (open and closed comedones) + few inflammatory lesions
Moderate = more widespread with an increased number of inflammatory papules and pustules
Severe = Widespread inflammatory papules, pustules and nodules or cysts
scarring may be present

Question 8

DDx

Answer 8

Acne Rosacea

Question 9

Diagnosis

Answer 9

Clinical diagnosis
Consider endocrine screen for testosterone, LH, FSH if hyperandrogenism suspected

Question 10

Treatment

Answer 10

FIRST LINE = One of the following
- Topical retinoid +/- benzoyl peroxide
- Topical antibiotic: TOPICAL CLINDAMYCIN. Abx should always be prescribed with topical benzoyl peroxide or retinoid to prevent Abx resistance
- Topical azelic acid 20%
Second line =
- Oral tetracycline + benzoyl peroxide or topical retinoid
- combined oral contraceptive pill
= co-cyprindiol (dianette)
= offer when other treatments have failed as associated with DVT
= use + topical therapy
= discontinue after 3 months when acne controlled
Third line =
- Oral isotretinoin (Accutane)

Question 11

Who should avoid tetracyclines?

Answer 11

If pregnant or breastfeeding or if younger than 12 years old
- erythromycin is an option in pregnancy

Question 12

Complications

Answer 12

• Acne fulminans: a severe form of acne with systemic upset, almost always occurring in adolescent males. Usually requires hospital admission and responds to steroids.
• Scarring
• Retinoid side effects: dry skins, depression
• Isotretinoin and tetracyclines can cause intercranial hypertension and should not be co-prescribed
• Gram negative folliculitis: long term Abx use