Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS

epidermiology Almost every teenager can expect to experience acne to some degree during the adolescent years. They tend to "grow out of it" by the early 20s but it can persist rather longer. Being mediated by androgens, it tends to affect boys more than girls. Acne tends to occur in adolescence, when hormones are in a state of flux. In girls it may flare up when they are pre-menstrual. The severity of the problem is probably less related to androgen levels as to end-organ sensitivity. ‘it remains a conundrum why a condition that so undermines self assurance and self esteem should strike at such a vulnerable time in life.’

pathology This is a disorder of the pilosebaceous follicles found in the face and upper trunk. It is characterized by the obstruction of the follicle with keratin plugs. At puberty, androgens increase the production of sebum from enlarged sebaceous glands that become blocked and infected with Propionibacterium acnes causing an inflammatory reaction. The primary lesion is the comodone which is a follicle impacted and distended by incompletely desquamated keratinocytes and sebum. Comedones are seen as small white nodules below the skin surface.

sebum Mixed with lipids (from the surface skin cells), sweat and environmental material,makes the covering oil of skin surface Sebum is produced by sebaceous glands,found over most of the body. sebaceous glands consists of lobes connected by ducts, which are lined with cells similar to those on the skin surface. Most sebaceous glands open out into the hair follicle. Some free sebaceous glands open directly onto the skin surface. These include Meibomian glands on the eyelids and fordyce spots on the upper lip or genitals. Sebaceous glands on the mid-back, forehead and chin are larger and more numerous than elsewhere (up to 400-900 glands per square centimetre). Sebum production is under the control of Androgens i.e increased by Androgens

pathogenesis Patients with acne often have increased production of sebum,hence oily skin. This may be because of: High overall levels of sex hormones (mainly the androgen, testosterone). Hyperandrogenism in females Increased free testosterone because of low levels of circulating sex-hormone-binding-globulin (SHBG). More active conversion of weaker androgens to stronger androgens such as dihydroxytestosterone (DHT) by the enzyme 5-reductase within the skin. Higher sensitivity of the skin to DHT.

Aetiology Normal physiological reaction in puberty Disease of the ovaries Polycystic ovarian syndrome Benign or malignant ovarian tumors Disease of the adrenal gland Partial deficiency of the adrenal enzyme 21 Hydroxylase Benign or malignant adrenal tumors Disease of the pituitary gland Cushing’s syndrome due to excessive adrenocorticotrophic hormone Acromegaly due to excessive growth hormone production Adenoma of the adrenal gland especially prolactinoma Obesity and the metabolic syndrome Medication-phenytoin,steroids,barbiturates,OCPills.

presentation The primary lesions are comedomes. They present at the time of puberty and continue for a variable number of years thereafter, usually stopping in late teens or early 20s but uncommonly continuing well into adulthood. They may extend beyond the face to the shoulders, back and chest (seborrhaeic areas). They tend to run a variable course with marked fluctuations, often being worse in girls who are pre-menstrual. The severity of the condition varies enormously between individuals. It is unsightly but the degree of psychological distress does tend to be disproportionate.

Types of acne lesions Non-inflammatory/primary lesions: Open comedones (blackheads) Closed comedones (whiteheads)

Closed comedone (whitehead)

Open comedones (blackheads)

Close up of blackhead

Inflammatory lesions Papules (small red bumps) Pustules (white or yellow ‘squeezable’ spots) Inflamed nodules (large red lumps)

cause of inflammatory acne? Chemicals produced by P. acnes diffuse into the surrounding skin (dermis) and attract white blood cells (polymorphonucleocytes and monocytes). The cells lining the sebaceous ducts also produce inflammatory mediators so pimples may occur in the absence of bacteria. Foreign body reaction White blood cells (macrophages and giant cells) removing the debris may cause a more severe granulomatous inflammatory reaction. Irritation by lipids Free fatty acids and sebum penetrate the dermis after the duct has ruptured Hypersensitivity (allergy) to P. acnes

Secondary lesions Excoriations (picked or scratched spots) Erythematous macules (red marks from recently healed spots, mostly in fair skin) Pigmented macules (dark marks from old spots, mostly in dark skin) Scars

Acne scar

Acne conglobata Unpleasant form of nodulocystic acne Interconnecting abscesses and sinuses, which result in unsightly hypertrophic (thick) and atrophic (thin) scars. There are groups of large macrocomedones and cysts that are filled with smelly pus. It is occasionally associated with hidradenitis suppurativa,

Acne conglobata

Acne fulminans Allergic reaction to P. acne Abrupt onset Inflammatory and ulcerated nodular acne on chest and back Severe acne scarring Fluctuating fever Painful joints Malaise (ie. the patient feels unwell) Loss of appetite and weight loss Raised white blood cell count.

Acne fulminans

Infantile acne Infantile acne Generally affects the cheeks, and sometimes the forehead and chin, of children aged six months to three years. More common in boys and is usually mild to moderate in severity. In most children it settles down within a few months. The acne may include comedones inflamed papules and pustules, nodules and cysts. It may result in scarring.

Infantile acne

What is the cause of infantile acne? The cause of infantile acne is unknown. It is thought to be genetic in origin. Hormone abnormalities in older children with acne may be associated with the following conditions: Congenital adrenal hyperplasia Cushing's Disease 21-Hydroxylase deficiency Precocious puberty Androgen-secreting tumors

Should any tests be done? In most babies with acne, no investigations are necessary. In older children, or if there are other signs of virilisation, the following screening tests may be useful. Blood tests: DHEAS, testosterone, 17-hydroxyprogesterone, LH, FSH, prolactin

Solar comedones

What tests should be done? About 50% of females with acne have an imbalance of hormones although this is usually only mild. Any symptoms suggestive of primary cause should be investigated in full. Otherwise, not necessary

General principles of treatment Acne can be effectively treated, but response is usually slow Face washing bed-rock of management Where possible, avoid excessively humid conditions Ultraviolet light helps. Try not to apply irritant oils or cosmetics to the affected skin. Abrasive skin treatments can aggravate acne Try not to scratch or pick the spots No relationship between particular foods and acne has been proven

Treatment mild acne Wash affected areas twice daily with a mild cleanser and water or an antiseptic wash. Acne products should be applied to all areas affected by acne, rather than just put on individual spots. A thin smear should only be applied to dry clean skin at nighttime. Acne products may work better if applied in the morning as well. They often cause dryness particularly in the first 2-4 weeks of use. This is partly how they work. The skin usually adjusts to this. Apply an oil-free moisturizer only if the affected skin is obviously peeling.

Topical medication retinoid preparations eg tretinoin 0.1-0.25%, isotretinoin 0.05%, adapalene 0.1%. treatment of choice for comedonal acne anti-inflammatory effect prevents comedone formation application at bedtime (retinoids inactivated by light) azelaic acid is an allternative anticomedonal preparation benzoyl peroxide 2.5-10% eg benzamycin gel salicyclic acid Tea tree oil products

Topical antibiotics clindamycin 1% Erythromycin 2% and 4% with zinc acetate 1.2% - most useful when inflammatory lesions predominate topical antibiotics should be used in combination with retinoids to prevent antibiotic resistance

Treatment of moderate acne Step 1 plus oral antibiotics an adequate dose of antibiotic should be given for at least three months before deciding that a patient has failed to respond after three months therapy then a reduction of acne lesions by 30-50 per cent should have occurred(pt assessment) Good response? continued for a further three months and then the patient maintained on an appropriate topical regimen Poor response to oral antibiotic therapy then an alternative antibiotic may be substituted

Oral antibiotics First line - Tetracycline, 2nd line-Erythromycin, doxycycline, minocycline(causes SLE), Trimethoprim is increasingly used by dermatologists

Oral antiandrogen: cyproterone acetate 2mg with ethinyloestradiol 35 mug (Diannette) dly Similar efficacy as oral antibiotics but also contraceptive and controls hirsutism risk of venous thromboembolism is high conventional low-dose second- or third-generation COCs are more appropriate

NSAIDS Some patients are helped by nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen

Treatment severe acne Many patients will be treated with oral isotretinoin. If this is not suitable, the following may be used: High dose oral antibiotics for six months or longer In females, especially those with polycystic ovary syndrome, oral antiandrogens such as Diannette or spironolactone may be suitable long term. Systemic corticosteroids are sometimes used for their antiandrogenic effect. Flutamide and finasteride also been reported to be of benefit in hyperandrogenic women, though not liscenced

Physical treatments for acne Sunlight is anti-inflammatory and can help briefly.o skin cancer. Cryotherapy Intralesional steroid injections Comedones can be expressed by cautery or diathermy. Microdermabrasion can help mild acne. Lasers and light systems (blue light) X-ray treatment-no longer recommended for acne as it may cause skin cancer.

Who to refer Immediate referral indicated (within a day): have a severe variant of acne such as acne fulminans or gram-negative folliculitis Urgent referral have severe or nodulocystic acne and could benefit from oral isotretinoin have severe social or psychological problems, including a morbid fear of deformity

Routine referral At risk of or are developing scarring despite management have moderate acne that has failed to respond to treatment which has included two courses of oral antibiotics, each lasting three months. are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs assessment