Acne Vulgaris and Rosacea

Question 1

Describe the pathophysiology of acne

Answer 1

1. Basal keratinocyte proliferation in pilosebaceous follicles (driven by hormones)
2. Increased sebum production
3. Propionibacterium acnes colonisation
4. Inflammation
5. Comedomes (white and black) blocking secretions causing papules, nodules, cysts and scars

Question 2

Describe the clinical presentation of acne

Answer 2

Comedomes both black (open) and white (closed), erythematous papules or pustules, scarring and cysts
Suicidal ideation is a red flag
Important to clarify mood and body image self esteem

Question 3

How do we classify acne as mild, moderate and severe?

Answer 3

Mild Acne
Facial Comedomes with a total lesion count of <30

Moderate Acne
Inflammatory lesions, papules and pustules dominating the face and sometimes torso with a total lesion count between 30-125

Severe Acne
Nodules, cysts, scars and inflammatory papules and pustules with a total lesions count >125

Question 4

How is mild acne managed?

Answer 4

Topical benzoyl peroxidase (2.5%, 5% and 10% start low) or topical retinoid e.g. tretinoin or adapalene gel
Azelaic Acid
Low dose COCP (in combination with a topical treatment)
Treatment takes up to 8 weeks to be effective

Question 5

How is moderate acne managed?

Answer 5

Topical Antibiotic (erythromycin or clindamycin) combined with topical benzoyl peroxidase or topical retinoid 
Oral antibiotics – tetracycline, doxycycline, oxytetracycline or lymecycline (erythromycin if pregnant or under age of 12 due to teeth colouring). Use maximum of 3 months with benzoyl peroxidase. Topical and oral antibiotics should not be used together 

Topical retinoid plus benzoyl peroxidase is poorly tolerated but worth trying
Consider COCP as adjunct

Question 6

How is severe acne managed?

Answer 6

Refer to specialist
Isotretinoin – reduced sebum and pituitary hormones. Required specialist prescribing and must be on 2 x contraception and regular pregnancy checks.

Question 7

What is acne rosacea?

Answer 7

Chronic relapsing remitting disorder of blood vessels and pilosebaceous glands

Question 8

How does acne rosacea present?

Answer 8

Flushing triggered by stress/blushing, spices and alcohol
Central facial rash- erythematous and telangiectasia
Papules and pustules but no Comedomes
Inflammatory nodules and facial lymphoedema
Blepharitis/conjunctivitis
Rhinophyma – large, red, bumpy or bulbous nose

Question 9

What general advice should be given to patient suffering from acne rosacea?

Answer 9

Soap substitutes

Avoid sun exposure and use high factor sun cream

Question 10

What management options can be offered to patients with acne rosacea?

Answer 10

Mild disease – topical metronidazole gel or cream or topical azelaic acid. Topical brimonidine gel for patient with predominant flushing but limited telangiectasia

Moderate-severe disease – oxytetracycline (or erythromycin if allergic), for 4 months to gain control of papules.

Question 11

How is ocular rosacea managed?

Answer 11

Ocular rosacea – eyelid hygiene, ocular lubricants and ciclosporin

Question 12

What investigations may be required for acne vulgaris?

Answer 12

Skin swabs may be necessary if prescribing antibiotics

Hormonal tests in females

Question 13

How is drug induced acne distinguished from other types of acne?

Answer 13

Acne vulgaris and rosacea can be distinguished from drug induced acne because this is usually monomorphic for example pustules are usually seen in steroid use.

Question 14

What is acne fulminans?

Answer 14

Acne fulminans is a very severe acne associated with systemic upset such as fever. Hospital admission is usually required, and the conditions responds to oral steroids.

Question 15

Is pregnancy contraindicated for both topical and oral retinoids or just oral?

Answer 15

Pregnancy is contraindicated for both topical and oral retinoid treatment and so females should be warned and on some form of contraception.

Question 16

What are the adverse effects of isotretinoin?

Answer 16

Teratogenicity – if oral then must be on two contraceptives
Dry skin, eyes lips/mouth (this is the most common side effects)
Low mood
Raised triglycerides
Hair thinning
Nose bleeds (due to dry mucus membranes)
Intracranial hypertension (so do not combine with tetracycline)
Photosensitivity

Question 17

What is folliculitis

Answer 17

This is an infected hair follicle that results in an erythematous papules sometimes with pustules. Both acnes are types of folliculitis.

Question 18

What organisms cause folliculitis?

Answer 18

Bacterial – staphylococcus aureus 
Yeasts – Malassezia 
Fungi – tinea 
Viral – herpes simplex 
Parasite – scabies often provokes it 

Can also arise as a result of re-growing hairs