Acne Justin Walker October 2009

Classification Mild to moderate Moderate to severe Other causes Plugged pores Sebum collection Moderate to severe Propionibacterium acnes Inflammation, pustules Cysts, nodules, scarring Other causes PCOS Halogenated hydrocarbons

Differentials

Differentials Rosacea Older age group Absence of comedones, nodules and scarring

Differentials

Differentials Folliculitis Infected hair follicle, responds to abx. NB demodex folliculitis caused by mites, pityrosporum folliculitis caused by yeasts.

Differentials

Differentials Perioral dermatitis Distribution! Associated with fluorinated steroids.

What makes it worse? Progesterone only pill Hormone changes with periods Make up Picking and squeezing Humid environment/sweating Tight clothing Drugs – phenytoin, steroid creams Anabolic steroids

Myths Poor hygiene Diet Stress Water intake Sunshine Cannot be cured

Topical Treatments Benzoyl peroxide Available over the counter Good for comedones & infected lesions 2.5-10% available, start low and increase as tolerated Wash skin beforehand, wash off after several hours Start od, bd if tolerated.

Topical Treatments Topical Retinoids Adapalene, tretinoins and isotretinoin Unblock pores, reduce inflammation S/E: skin redness and peeling, sun sensitivity – apply at night and wash off in morning. Use lower strength if not tolerated. Avoid in pregnancy – discuss contraception!

Topical Treatments Topical antibiotics Erythromycin and clindomycin Good for inflammation but don’t unblock pores Local guidelines recommend topical for those who cannot tolerate oral. Can use with short courses benzoyl peroxide/ azelaic acid Topical abx need to be used for 6 months.

Topical Treatments Azelaic acid Unblocks pores, some reduction of inflamed acne Less effective than topical antibiotics or benzoyl peroxide

Oral Treatments Antibiotics Reduce inflammation, Not good at unblocking pores – may need concommitant topical bp/aa Local guidelines: doxycycline, lymecycline, erythromycin Use for 3 months and review Tetracyclines: not for under 12s, not in pregnancy – discuss contraception. Women on cocp need additional precautioins for first 3 weeks.

Oral Treatments Isotretinoin Suppresses sebum production Specialist initiation Teratogenic S/E dry skin/mucous membranes, nosebleeds, joint pains Minimum course 16 weeks.

Oral Treatments Co-cyprinidol Cyproterone acetate with ethinylestradiol aka Dianette Contains anti-androgen Same effectiveness as oral broad spectrum Useful if a woman also requires oral contraception, although not licensed as a contraceptive. Increased risk of venous thromboembolism Use only in women with severe acne and hirsutism

When to Refer? Immediate referral Urgent referral Routine referral Acne fulminans Urgent referral Severe/Nodulocystic acne and may benefit from oral isotretinoin Severe psychological/social problems Routine referral At risk of or are developing scarring despite therapy Moderate acne failing to respond (2 x 3 month courses abx) Possible underlying endocrinological cause eg PCOS

Acne fulminans

Thank you!