Acne Vulgaris

Question 1

Introduction to Acne Vulgaris?

Glands?

Answer 1

• disorder of Pilosebaceous Follicles (oil glands)
• v common, universal in second decade of live, also affects adults
• initially result of excess sebum productions (related to androgen ie testosterone levels)
• associated with psychological problems including depression, anxiety, social phobia
• early treatment has better outcome and less longterm scarring

Question 2

Epidemiology of Acne Vulgaris?

Answer 2

• rare before 10 year old
• peaks in teenage girls 13-14yrs
• peaks in teenage boys 18-19yrs
• may continue into adulthood, after 25yo it affects 15% of women and 5% of men

Question 3

Aetiology of Acne Vulgaris?

Answer 3

Androgenic stimulation of the sebaceous gland:

• excessive sebum production
• leakage into surrounding dermis
• colonisation or infection with Propionibacterium Acnes (normal commensal)

Not an excess of androgen but increased sensitivity to it, although:

• slight tendency towards boys
• boys may get it worse

Without treatment many cases last up to 10 years

Associated factors include:

• PCOS
• steroid use
• skincare prducts which increase oil load on skin, esp heavy makeup use

Diet and Acne?

• no clear proven pattern
• possibly full fat milk has an affect
• probably not a huge factor in development and management of acne

Question 4

Presentation of acne?

Lesions and distribution

Answer 4

• often adolescent
• greasy skin

LESIONS:
Open comedones (blackheads)
- indicates hyperkeratinisations
- usually don’t form cysts

Closed comedones (whiteheads)

• obstructed pilosebaceous units
• can cause scarring
• can lead to cysts

Papules (deep)
- small, inflammatory and usually raised, red lesions
Pustules (more superficial)
Nodules (bigger papules)

Cysts

• develop when there is further infection and inflammation due to P. Acnes
• usually >5mm
• indicate a strong inflammatory response in deep dermis
• can be treated with intralesion steroids, Abx and isotretinoin

Atrophic scars

• often fill somewhat within the months after flareup
• cant really fully assess scarring until the inflammatory phase has fully resolved

DISTRIBUTION:

• face (almost always)
• chest, neck and back (more severe)

(If cystic acne is present then refer to a dermatologist to reduce risk of scarring)

Question 5

Differential diagnoses when considering Acne Vulgaris

Answer 5

Rosacea

• usually if in middle age or later
• skin is not greasy and there are no comedones (spots)
• typically affects the cheeks
• if nose is affected its more likely rosacea

Peri-orifical dermatitis

Question 6

Principles of management of Acne Vulgaris?

Answer 6

Principles:

1. Unblock the pores - comedolysis
   - using topical benzoyl peroxide, isotretinoin gel, or adapalene lotion
2. Decrease bacterial load in the sebum
   - using topical or oral Abx
3. Decrease sebaceous gland activity
   - isotretinoin (oral)
   - oestrogens (COCP), females only
   - spironolactone, usually females only too

Defining severity:
- no universal guide
more severe if:
- large number of comedones
- scarring
- resistant to basic treatment
- affecting trunk
- large psychological impact
Severe /refer:
- strong FHx
- signs of scarring
- rapid progression

Question 7

Conservative management of Acne Vulgaris?

Answer 7

• advise and reassure, often mild and self limiting
• wash twice daily with soap and water
• sunlight can increase risk of scarring
• skin products, avoid oily, cosmetics sparingly
• most people will have tried basic measures by the time they present eg benzoyl peroxide is OCT med

Question 8

Medical / drug management of Acne Vulgaris?

Answer 8

Topical

• encourage skin peeling
• reduce inflammation
• antibiotic effect
• apply to all areas, not just lesions

1. Benzoyl peroxide
   - often first line
   - can cause drying and irritation but persevere
   - start with 2.5% and increase strength as required
2. Topical Abx
   - usually clindamycin or erythromycin
   - using topical Abx alone is not recommended due to resistance
   - give with Benzoyl Peroxide to reduce resistance
3. Topical retinoids
   - eg ADAPELINE
   - reduce inflammation
   - low systemic absorption but same CI as oral
   - irritating to skin
   - takes 12 weeks to be effective
   - can be used with other agents (COC and oral Abx)
   - combo with benzoyl peroxide as EPIDUO

Systemic

• may take several months to act
• allow 4 months to assess effects
• can combine with topical treatment
• useful for truncal acne

1. Oral Abx
   - tetracyclines usually first line (eg oxytetracycline, doxycycline, minocycline)
   - clindamycin and erythromycin also used
   - probably no more effective than a benzoyl peroxide plus Abx cream
2. Isotretinoin (roaccutane)
   - prescribed by a dermatologist
   - a retinoid, reduces serum secretion
   - very effective (16 week course works in 80% of cases) but toxic and side effects
   - teratogenic for up to 1 month after stopping, be very careful if they may become pregnant
   - dry skin, lips and eyes is common
   - myalgia related to exercise
   - rarely can exacerbate acne
   - probably no link to psychiatric illness
   - CI with a tetracycline (risk benign intracranial hypertension) and CI with progesterone only pill (reduces effectiveness)
   - useful in trunk acne
3. Antiandrogens
   Oestrogen contraceptive pill is often effective:

• reduces oil load by reducing sebum
• reduces free testosterone
• takes 3-6 months to have effect
• cessation of pill may cause a flare in acne
• avoid norethisterone containing contraceptives
• eg Brenda 35-ED

Spironolactone:

• can’t be used in pregnancy
• 50-100mg daily
• 30:30:30 cure:good:mild improvement
• can be combined with topical retinoids
• off-label use

Consider psychological impacts, missing school or work. Risk of depression and suicide, debate over Isotretinoin (roaccutane) but probably not a cause.