Acne Flashcards
What questions do you want to ask in a history about acne?
- Are there times when your face becomes flushed or very red? - can be rosacea
- What treatment have you tried? - OTC and prescribed
- What other parts of your body is affected?
- Has anyone in your family had this problem? - patients often have parents/siblings similarly affected
- No causal link between smoking/diet and acneiform eruptions
- Age of onset and duration
- Exacerbating factors e.g. menstruation in women, anabolic steroids
- Other health problems (hirsustism, obesity and menstrual irregularities migh suggest PCOS)
- Effects on social interactions/work/life
What are the types of lesions in acne?
- Pustules
- Papules
- Open comedones (blackheads)
What is acne vulgaris?
Inflammatory condition where lesions develop from the sebaceous glands around hair follicles on the skin of the face, chest, back and anogenital regions. It affects 80-100% of individuals at some point in their lives. It typically starts in teenage years and is often dismissed as self-limiting disease but 5% adults are affected by it. It is seldom life-threatening but it is more the psychological impact on the patient and effects on self-confidence/esteem.
What scoring systems are used for acne?
Look at changes on their skin and psychosocial impact of the disease. Can use scoring systems to assess this and asking them about self-confidence, impact at work or social relationships. Example: The Assessment of the Psychological and Social Effects of Acne (APSEA) Scale. Then the Leeds scoring system grades the clinical severity of acne vulgaris - categorises lesions into inflammatory and non-inflammatory, ranging from 0 (mild) to 12 (severe - nodules, cysts, scars).
What OTC medications can be given for acne?
Antiseptic washes with ticlosan or benzyl peroxide, hydrogen peroxide in stabilised cream.
What topical agents can be prescribed for acne?
- Antibiotics such as clindamycin solution (Topicil, ClindaTech) or erythromycin solution (Stiemycin) and gel (Eryacne) which are best used with benzyl peroxide or azelaic acid to reduce the chance of abx resistance. It is not appropriate to prescribe topical abx alongside oral abx.
- Retinoids i.e. tretinoin (ReTrieve, Retin-A), isotretinoin (Isotrex), adapalene (differin) (good for comedones and inflammatory lesions in mild-moderate acne)
What is the dose of Adapalene cream for acne?
Adapalene cream 0.1% (Differin cream) every 24hrs at night and oxytetracycline 500mg every 12hrs for 3 months - targets both microcomedome and inflammatory papules/pustules.
What are indications for treatment with oral retinoids (isotretinoin) for acne vulgaris?
- Moderate acne, unresponsive to conventional therapy or relapsing after conventional therapy
- Severe acne
- Acne scarring
- Psychological effects resulting from acne and scarring
- Unusual form of acne
What are the treatment options for acne?
- Drugs that inhibit sebaceous gland function - anti-androgens, oestrogens, isotretinoin
- Inflammatory papules - drugs with anti-inflammatory effects - antibiotics, corticosteroids
- Comedone - drugs that normalise pattern of follicular keratinisation - topical retinoids
- Drugs with antibacterial effects - abx (topical and oral), Benzyl peroxide, retinoids (indirect)
What are people with darker skin tones and acne more at risk of?
Developing post-inflammatory hyper- and hypo-pigmentation. Scarring is more likely to be keloidal (acne keloidalis nuchae). These longer lasting effects result in a greater impact on an individual patient so patients should be managed pro-actively.
What medications can be offered as a 12 week course for moderate to severe acne?
- Fixed combination of topical adapalene with topical benzoyl peroxide - OD in evening
- Fixed combo of topical tretinoin with topical clindamycin - OD in evening
- Fixed combo of topical adapalene with topical benzoyl peroxide OD in evening with either oral lymecycline 408mg or oral doxycycline 100mg OD
- Topical azelaic acid (15 or 20%) applied twice daily, with either oral lymecycline 408mg or oral doxycycline 100mg OD.
What medications can be offered if there are contraindications to 1st line moderate to severe acne treatment?
- Consider topical benzoyl peroxide as monotherapy if these options are contraindicated or the person wishes to avoid using a topical retinoid or abx
- Contraindications/not tolerating oral lymecycline or doxycycline - trimethoprim or oral macrolide e.g. erythromycin
- OCP (if not contraindicated) in combination with topical agents can be considered as alternative to abx - 3rd and 4th gen COCP preferred (progesterone only or implants may exacerbate)
What medications can be offered as a 12 week course for mild to moderate acne?
OD in evening:
- Fixed combo of topical adapalene with topical benzoyl peroxide (0.1%/0.3% adapalene, 2.5% BP)
- Fixed combo of topical tretinoin and topical clindamycin (0.025% and 1%)
- Fixed combo of topical benzoyl peroxide with topical clindamycin (3/5% with 1%)
What medications can be offered if there are contraindications to 1st line mild to moderate acne treatment?
- Consider benzoyl peroxide as monotherapy if options contraindicated or the person wishes to avoid using a topical retinoid or abx
- Creams or lotions may be preferable for people with dry or sensitive skin and less greasy gels for oily skin
- Concentration or frequency of topical treatments can be reduced/lowered if skin irritation
- Advise person that frequency can gradually be increased from once/twice per week to daily if tolerated.
