Acne vulgaris

Question 1

What is the pathophysiology of acne vulgaris?

Answer 1

Chronic inflammation with or without localised infection (in the pilosebaceous units - hair follicles and sebaceous glands)
- Increased production of sebum traps heratin, and leads to the blockage of the pilosebaceous unit
- Androgenic hormones increase the production of sebum

Question 2

What are the risk factors for acne vulgaris?

Answer 2

Teenagers/young adults
Family history
Medications
- Androgens
- Corticosteroids

Question 3

What are the clinical features of acne vulgaris?

Answer 3

Mild - non-inflamed lesions (open and closed comedones - whiteheads and blackheads)

Moderate - more widespread with increased number of inflammatory papules and pustules

Severe - widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present

Question 4

What investigations may be useful in patients with acne vulgaris?

Answer 4

Endocrine screen - if suspected hyperandrogenism
- Testosterone
- LH and FSH

Question 5

What is the first line management of acne vulgaris?

Answer 5

Topical retinoid +/- benozyl peroxide
Topical antibiotic - clindamycin (prescribed with benzoyl peroxide)
Topical azelaic acid 20%

Question 6

What is the second-line treatment of acne vulgaris?

Answer 6

Oral tetracycline (prescribed with benozyl perioxide or topical retinoid)
COCP - co-cyprindiol

Question 7

What is the third-line management of acne vulgaris?

Answer 7

Oral isotretinoin - indicated if there is scarring, or if unresponsive to 2 or more different antibiotics

Question 8

What are the complications of acne vulgaris?

Answer 8

Acne fulminanas
Post-inflammatory changes
Retinoid side effects
Gram-negative folliculitis (due to long term antibiotic use)

Question 9

What are the side effects of retinoids?

Answer 9

Dry skin and lips
Photosensitivity of skin
Depression, anxiety, and suicidal ideation
Steven-Johnson syndrome and topical epidermal necrolysis