Acne Vulgaris

 

Virtually every adolescent has a few “spots”, however, about 15% of the adolescent population have sufficient problems to seek treatment. In most patients, but not all, the acne clears up by the late teens or early 20s. More severe acne tends to last longer. A group of patients have persistent acne lasting up to the age of 30 to 40 years, and sometimes beyond. Patients with persistent acne often have a family history of persistent acne. Acne may scar - most of the time this is preventable by using the correct treatment given in a timely fashion

Referral and Treatment Criteria applies: – see RaTC - Acne scarring (procedures for)

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Diagnosis

A person with acne usually presents with a history of troublesome 'spots', most commonly affecting the face, shoulders, back, and chest. The person is most commonly an adolescent or young adult, but acne can continue into adulthood or occur for the first time in later life

Examine all affected areas of skin (including the back and shoulders):

  • The skin and hair may have an oily texture and appearance
  • Depending on the severity of the acne, there may be non-inflammatory comedones, inflamed papules or pustules, or a mixture of both:
    • Closed comedones (whiteheads) appear as raised bumps on the skins surface, and are skin-coloured or slightly reddened
    • Open comedones (blackheads) have a characteristic black 'plug' caused by oxidised oil and dead skin cells
    • Papules are small, round or oval, inflamed (red), raised elevations of the skin
    • Pustules resemble papules, but have a central pocket of pus
    • Nodules are poorly demarcated swellings that are usually red and tender. They may be fluctuant on palpation. In very severe acne, nodules may track together and form large, deep sinuses (acne conglobata)
    • Haemorrhagic acne is caused by bleeding inflammatory lesions, and may be very painful and distressing
  • Look for evidence of scarring and hyperpigmentation
    • Scarring may occur when acne heals, particularly when nodules have been present. It is most commonly atrophic in nature, leading to the formation of 'ice-pick' scars or 'pock marks'
    • Hyperpigmentation may occur after acne resolves, especially in people with darker complexions

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If the features are atypical of acne vulgaris, consider the possibility of a severe form or clinical variant of acne

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Assessment

Ask about the problems the person has experienced with their acne. Enquire about:

  • The reasons for the person presenting, how long they have had acne, and whether it is worsening
  • Any treatments the person has already tried (for example over-the-counter medication)
  • Possible causes or aggravating factors (for example occupational exposure to halogenated hydrocarbons)

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In women, consider whether the acne could be secondary to a hormonal cause. Features of hyperandrogenism include:

  • Irregular periods
  • Androgenic alopecia or hirsutism
  • Acne resistant to conventional treatment (or relapse immediately after a course of oral isotretinoin)
  • Premenstrual flares of acne or a sudden onset of severe acne

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Assess the severity of the acne. Physically, acne can be categorized as mild, moderate, or severe, but other factors, such as the extent of acne and evidence of scarring, should also be considered

  • Mild acne predominantly consists of non-inflammatory comedones
  • Moderate acne consists of a mixture of non-inflammatory comedones and inflammatory papules and pustules
  • Severe acne is characterized by the presence of widespread nodules and cysts, as well as a preponderance of inflammatory papules and pustules
  • Scarring often indicates previous episodes of severe acne (its presence may warrant more aggressive treatment to prevent further scarring)
  • Acne conglobata and acne fulminans are severe variants that require immediate referral (see Clinical variants of acne)

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Ask about the psychosocial impact of the acne (such as problems at work or school). If the psychological impact seems to be particularly severe or disproportionate, consider using a validated quality of life scale such as the Cardiff Acne Disability Index (which can be downloaded from www.dermatology.org.uk). This can also be used to monitor the person's psychological state during subsequent management

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When to refer

NOTE:  Procedures (resurfacing and any other interventions) for acne scarring are not routinely funded

The main indication for referral is for isotretinoin treatment. The criteria for Isotretinoin treatment are:

  • Severe nodulo-cystic acne
  • Moderate acne that has not responded to > 6 months of systemic antibiotics in addition to topical treatment
  • Mild to moderate acne in patients who have an extreme psychological reaction to their acne and have not responded to a prolonged (> 6 months) course of systemic antibiotics and topical treatment

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Treatment

Milder cases can be managed with topical treatments.  Warn patients that most topical treatments will cause drying of the skin - advise use of a non-comedogenic moisturiser at a different time of day if needed.  Treatments work by preventing new lesion formation so must be applied to all acne prone areas not only to individual spots

Acne Primary Care Treatment Pathway (PCDS)

Mild to Moderate Acne

Defined as:  uninflammed lesions, open and closed comedones +/- pustules papules

Treatment:

  • Topical benzoyl peroxide +/- topical antibiotic
  • Topical retinoids – avoid in pregnancy
  • Topical antibiotic combinations with BPO/Zinc/retinoid may be more effective and improve compliance

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If there are a greater number or more extensive, inflamed lesions:

  • Add oral antibiotics to topical treatment above (do not continue topical antibiotic with oral antibiotics)
  • Switch antibiotic at 3 months if no benefit seen (use Benzoyl peroxide for 2 weeks to clear resistant bacteria before switching antibiotic and continue if tolerated)
  • Where possible, a topical antibiotic course should be limited to a maximum of 12 weeks

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Moderate-Severe Acne

Defined as:  papules/pustules with deeper inflammation and some scarring

Treatment:

  • Systemic treatment as for mild to moderate acne, plus topical therapy
  • Consider additional hormonal treatment in women particularly if contraception needed

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Severe Acne

Defined as:  confluent or nodular lesions usually with significant scarring

Treatment:

  • Commence systemic therapy and refer immediately for systemic isotretinoin treatment

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Reducing and Stopping Treatment

Step down treatment once control is good for 6 months - stop oral treatment first, continuing topical treatment alone for another 6 months at least

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Prescribing Agents Used to Treat Acne

Benzoyl peroxide

  • Antimicrobial, anti-inflammatory and comedolytic
  • Reduces antibiotic resistance of skin bacteria when used with antibiotics
  • Warn re bleaching of bedding clothing and hair. Fair skins less tolerant than dark
  • Start with 2.5% strength and increase to 5% if needed
  • Use once at night or build up tolerance by using 2-3x/week initially or washing off after 2-4 hours and increase exposure time gradually
  • All retinoids except adapalene are unstable with benzoyl peroxide so apply separately

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Topical retinoids

  • Keratolytic/comedolytic
  • Use as mono therapy for mild non-inflammatory comedonal acne
  • Use with antimicrobials or benzoyl peroxide with inflammatory lesions
  • Useful for maintenance therapy due to suppression of micro-comedome formation
  • Adapelene best tolerated
  • Warn patients re teratogenicity and sun sensitivity and build up tolerance as per BPO
  • Do not use in breast feeding and pregnant women
  • Women of childbearing age need contraception counselling documented

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Topical Antibiotics

  • Antimicrobial and anti-inflammatory
  • Use for mild to moderate acne with inflammatory lesions
  • Clindamycin and erythromycin mainly used but resistance growing concern so limit duration (ideally 12 weeks) and use in combination regimes i.e. with retinoid or benzoyl peroxide

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Other topical treatments

Azeleic acid

  • Alternative to retinoids with comedonal, antimicrobial and anti-inflammatory properties
  • Risk of hypopigmentation in darker skinned patients

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Salicylic Acid

  • OTC availability
  • Desquamating and comedolytic properties
  • Less potent but better tolerated than other agents
  • Useful if standard agents can’t be tolerated

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Treclin

  • Treclin (clindamycin 1% + 0.025% tretinoin) has been introduced to the primary care formulary for use in the treatment of acne vulgaris when comedones, papules and pustules are present in patients 12 years or older. Recommendation is to discontinue if no response in 8-12 weeks

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Oral Antibiotics

Tetracyclines - do not use in pregnancy, breast-feeding mothers or children under 12, warn patients of risk of teratogenicity. All can cause sun sensitivity

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Lymecycline - 408 mg daily- usual first line as good absorption even with food/milk, well tolerated, reasonable cost.  Other tetracyclines-30 mins before food and not with milk

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Oxytetracycline - 500 mg bd, doxycycline 100 mg od.  Larger doses may be required, usually doubled for more severe cases, marked seborrhea or larger patients

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Avoid minocycline - 100 mg od (has increased risk of significant side effects and needs blood monitoring with long term use-LFT, ANA, ANCA every 3 months-see BNF. Do not increase doses)

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Erythromycin - 500 mg bd

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Trimethoprim - 200-300 mg bd (unlicensed use). 6 monthly FBC

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Switching antibiotics - if no response switch after 3 months. Use BPO daily for 2 weeks to clear resistant bacteria before starting another antibiotic, and continue during antibiotic use if tolerated

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Anti-androgens

Combined Hormonal Contraception (CHC)

NOTE Prescription of a CHC should be considered for women who require contraception. Standard COCs are suitable for most women since the an-ovulatory effect will reduce testosterone levels

  1. Avoid Progestogen only contraception; any progesterone containing Rx may exacerbate acne including IUS, implant, depomedrone, any POP
  2. There is no evidence that Yasmin® – ethinylestradiol 30micrograms and drospirenone 3mg is superior in acne and it is considerably more expensive
  3. Co-cyprindiol (Dianette®) should be considered only when topical treatment or systemic antibiotics has failed. Co-cyprindiol has a 1.5–2 times statistically significant increase in venous thromboembolism (VTE) risk compared with levonorgestrel-containing pills. It is thought that this risk is similar to that of contraceptives that contain desogestrel, gestodene, or drospirenone. They also increase the risk of benign intracranial hypertension, especially in combination with oral tetracyclines. Step down to standard CHC once control of acne has been good for 4-6 months, or to topical Rx if contraception is not required

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Investigations prior to referral

The following preliminary investigations should be undertaken if the decision is taken to refer:

  • FBC
  • U&E
  • LFT
  • Fasting cholesterol and triglycerides

Organise contraception in all sexually active females (and those likely to become so shortly) before referral if oral isotretinoin may be considered. Isotretinoin can be combined with any oral contraceptive

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Information to include on referral letter

Include the following information when making a referral:

  • Include treatment – current and past, include duration and dosages
  • Details of contraception in females, or detail sexual history
  • Relevant past medical/surgical history
  • Current regular medication
  • BMI/smoking status

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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