What is acne vulgaris?
Acne vulgaris is a disorder of the pilosebaceous follicles found in the face and upper trunk
When does acne typically present?
Just after puberty
Why does acne typically present just after puberty?
Because at puberty, androgens increase the production of sebum from enlarged sebaceous glands that become blocked
What bacteria is involved in lesion production in acne?
What is the role of propionobacterium acne?
It's exact role is unclear, but it's a skin commensal that colonises the follicles in acne
What are comedones?
Follicles impacted and distended by incompletely desquamated keratinocytes and sebum
What are the types of comedones?
Open (blackheads) or closed (whiteheads)
What can inflammation of comedones lead to?
Papules, pustules, and nodules
How can acne cause problems mentally?
It can cause severe psychological problems, undermining self-assurance and self-esteem at a vulnerable time in life
How does acne usually present?
Greasy skin with a mixture of comedones, papules, and pustules
How long does acne last for?
It can continue for a variable number of years, usually stopping in the late teens or early 20's
In what respects is acne variable?
It runs a variable course with marked fluctuations, and the severity of the condition can vary enormously between individuals
What are the differential diagnoses of acne vulgaris?
- Acne rosacea
- Folliculitis and boils
- Perioral dermatitis
What is the difference between acne rosacea and acne vulgaris?
Acne rosacea usually presents in middle age or later in life
What is the difference between acne vulgaris and folliculitis/boils?
Folliculitis and boils may present with pustular lesions
What are milia?
Small keratin cysts that tend to be whiter than acne whiteheads, and are most commonly seen around the eyes
How is acne vulgaris investigated?
Usually, no investigations are required, however they are sometimes needed to explore a possible underlying cause
How is mild acne managed?
- Reassure patient about natural course of condition, advising that it is very common, will usually clear up later in life without leaving significant scarring, and that treatments can be effective but take time to work and may irritate the skin.
- You should dispel common myths about acne
- Information about self care
What common myths about acne should be dispelled?
- It is not caused by poor hygeine
- Excessive washing will not help - may actually aggrevate acne
- Diet has little or no effect on acne
- Acne is not infectious, and cannot be passed to other people
What self care advise should be given to people with acne?
- Should not wash more than twice a day
- Use mild soap or cleanser and lukewarm water
- Avoid excessive use of makeup and cosmetics
- Use of OTC medications such as benoxyl peroxide
Is prescription medication required in mild acne?
In mild acne, pharmacological treatment is not normally required, as the physical severity of the condition is limited, and scarring is unlikely. However, the psychological impact may be disproportionate, which is an indication for more aggressive treatment
What is the first line pharmacological treatment for mild acne?
A topical retinoid, for example tretinoin or benzoyl peroxide
What should be done if first-line pharmacological treatments for acne are poorly tolerated?
Azelaic acid should be prescribed
Is combined treatment necessary for mild acne?
When should follow up be arranged for in pharmacological treatment for mild acne?
What should be done at the 6-8 week follow up after pharmacological treatment for mild acne?
Review effectiveness, tolerability, and compliance with treatment
How should moderate acne be managed?
- Same information regarding natural course of condition, popular myths about acne, and self-care advice as with mild acne
- Prescription medication
Why is prescription medication required in moderate acne?
In moderate acne, inflammatory lesions (papules and pustules) predominate, and the acne may be widespread with a risk of scarring. There is also a considerable psychosocial morbidity, all of which are indications for aggressive treatment
What pharmacological treatment should be considered in moderate acne that is limited and unlikely to scar?
A single topical drug, such as benozyl peroxide or topical retinoid, or azelaic acid if these are poorly tolerated
What pharmacological treatment should be considered in patients with moderate acne which is at risk of scarring?
Combined topical treatment with a topical antibiotic and benozyl peroxide or a topical retinoid
What is the advantage of a combination of topical antibiotic combined with benozyl peroxide or a topical retinoid in the management of moderate acne?
It is proven effective, and may limit the development of bacterial resistance
When should an oral antibiotic be considered in the management of moderate acne?
- When there is acne on the back or shoulders that is particularly extensive or difficult to reach
- If the is significant risk of scarring or substantial pigment change
What is the first-line oral antibiotic in the management of moderate acne?
Tetracycline or doxycycline
What is an alternative if oral tetracycline or doxycycline are poorly tolerated or contraindicated in moderate acne?
What should not be done when prescribing an oral antibiotic in moderate acne?
- Prescribe oral antibiotic alone
- Combine oral and topical antibiotic
- Continue for any longer than shortest possible period
When should a person with moderate acne be referred to dermatology?
- Development of, or risk of development of, scarring, despite primary care interventions
- Failed to respond adequately to treatment over a period of at least 6 months. Treatment failure should be judged on person's perspective of their condition
- Features that make diagnosis uncertain
How should severe acne be managed in primary care?
- Give patient same information regarding natural course of condition, popular myths about acne, and self-care as with mild and moderate acne
- Prescription medication
- Referral for specialist assessment and treatment
Why is prescription medication required for severe acne?
In severe acne, there are nodules and cysts, as well as inflammatory papules and pustules. There is a high risk of scarring, and there is likely to be considerable psychosocial morbidity
What pharmacological interventions can be given in primary care whilst the person awaits a specialist assessment?
Oral antibiotic in combination with topical drug
What are the treatment options for severe acne in secondary care?
- Oral isotretinoin
- Laser treatment
- Surgical treatment
What are the complications of acne?