Acne Vulgaris

Question 1

During puberty, in response to testosterone, the pilosebaceous gland begins to produce what?

Answer 1

Sebum (if the sebaceous glands become oversensitive to testosterone they produce excess oil and the skin becomes greasy: a hallmark of acne).

Question 2

Prior to puberty, dead cells are shed smoothly out of the ductal opening in the facial epithelium. At puberty, however this process is disrupted and results in what?

Answer 2

Results in the cells developing abnormal adhesion and partially blocking the opening and effectively reducing sebum outflow. Over time, the opening of the duct becomes blocked trapping oil in the hair follicle.

Question 3

Bacteria, particularly propionibacterium acnes, proliferates in the trapped oil of the hair follicle stimulating what?

Answer 3

Local cytokine production, which in turn produces local inflammation leading to the appearance of a spot.

Question 4

In acne, local cytokine production from bacteria in oil trapped in the hair follicle causes local inflammation and spot formation. What cells then infiltrate this area causing pus?

Answer 4

White blood cells infiltrate to kill the bacteria and in turn die leading to pus formation. The pustule eventually bursts on the skin, carrying the plug away and the whole process is restarted.

Question 5

Patients suffering from mild acne characteristically have predominatly what type of comedones and what number of active lesions confined to where?

Answer 5

Predominantly open and closed comedones with a small number of active lesions normally confined to the face

Question 6

What are the conditions to eliminate for acne?

Answer 6

Rosacea
Medicine caused acne-like skin eruptions
Perioral dermatitis
Polycystic ovary syndrome

Question 7

What are the trigger points indicative of referral with Acne?

Answer 7

Moderate or severe acne
Occupational acne
OTC treatment failure 
Patients over 25 years old presenting for the first time
Rosacea

Question 8

What is Rosacea?

Answer 8

An inflammatory disease of the skin follicles.
Uncertain what causes it but successful treatment with antibiotics points to a bacterial cause.
Normally seen in patients over 40 and is characterised by recurrent flushing and blushing of the central face especially the nose and medial cheeks.

Crops of inflammatory papules and pustules are also a common feature, but comedones are not present.

Question 9

What medicines can produce acne-like lesions?

Answer 9

Lithium,
Oral contraceptives (especially those with high progestogen),
Phenytoin, 
Azathioprine, 
Rifampacin,
Steroids.

Question 10

What is perioral dermatitis?

Answer 10

It is a skin condition which normally impacts women aged between 25 and 40 as an acne-like rash generally around the mouth and nasolabial folds.

Can be linked to overuse of moisturers etc.

Question 11

How is acne and polycystic ovary syndrome linked?

Answer 11

Clinical manifestations of PCOS can be acne vulgaris, any patient that also exhibits hirsuitism, is over-weight and has menstrual irregularity must be referred for further investigation.

Question 12

OTC acne treatments contain what ingredients?

Answer 12

1. Benzoyl peroxide (Acnecide)
2. Salicyclic acid
3. Sulphur
4. Nicotinamide
5. Antibacterial

Question 13

How does benzoyl peroxide treat acne?

Answer 13

Main effect is to reduce the concentraton of Propionibacterium acnes.

Additionally, it has a slight anti-inflammatory and mild anticomeddogenic effects.

N.B no evidence that 10% is more effective than lower strengths but does cause more side effects so avoid.

Question 14

Freederm is what?

Answer 14

Nicotinamide

Question 15

First line treatment of acne should be what?

Answer 15

Benzoyl peroxide 2.5% or 5%.

Question 16

How soon after first commencing first line treatment of acne with benzoyl peroxide 2.5% or 5% should an improvement be seen?

Answer 16

After 6 weeks, if patient’s symptoms fail to improve in this time then referral to the GP would be appropriate.
However, if beneficial, treatment should be continued for at least 4 to 6 months.

Question 17

What counselling should accompany Benzoyl Peroxide?

Answer 17

Improvement should be seen with 6 weeks, if not GP.
If improvement seen continue for at least 4 to 6 months.
Benzoyl peroxide has a potent bleaching effect. It has the ability to permanently bleach clothing and bed linen.
Patients should be advised to always wash their hands after applying the product.

Question 18

What is the age for benzoyl peroxide?

Answer 18

No children under 12 years of age.

Question 19

What are the directions of use for benzoyl peroxide?

Answer 19

Usually applied once or twice daily depending on patient response, although once daily application is often sufficient.

It should be applied to all areas of the skin where acne occurs and not just to the active lesions.

It can cause drying, burning and peeling on initial application.