1. A treatment guide Dr Paul Charlson GPSI Dermatology East Yorkshire
ACNE
A treatment guide
Dr Paul Charlson
GPSI Dermatology East Yorkshire

2. Treatment
Psychological
Mild
Moderate and Severe
Scarring

4. Actions of Anti Acne Therapies
Topical retinoids:
Normalize desquamation
Reduce inflammatory response
Oral Isotretinoin:
Reduces sebum
Normalizes desquamation
Inhibits P acnes
Reduces inflammatory response
Antibiotics:
Kill microorganisms
Reduce inflammatory response
ACTIONS OF ANTI-ACNE THERAPIES
Topical retinoid drugs have a dual role in acne: 1) they have a direct effect on both inflammatory lesions and comedones and 2) they target the microcomedo – a microscopic precursor of all acne lesions (pimples, whiteheads, and blackheads). By stopping the formation of microcomedones, topical retinoids prevent the formation of new acne lesions (both inflammatory lesions and comedones).
Antibiotics and benzoyl peroxide act by reducing P acnes concentrations; antibiotics also reduce the inflammatory response.
Hormonal therapy reduces sebum production by blocking ovarian and/or adrenal androgens.
Oral isotretinoin is the only available therapy that acts on all four areas of acne pathophysiology. However, isotretinoin is highly teratogenic and thus is reserved for use in severe and recalcitrant acne.
Hormones:
Reduce sebum production
Benzoyl peroxide:
Kills microorganisms

5. Acne-psychology Acne affects 80% of adolescents
Don’t underestimate the psychological impact
Acne suffers have a higher incidence of anxiety and depression
Make sure patients are clear about their treatments, side effects and time scales
Involve patients in their treatments

6. MILD ACNE

7. TREATING MILD ACNE GENERALLY USE TOPICALS
START WITH BPO - LOW TO HIGH STRENGTH
ADD TOPICAL RETINOID- OR START WITH IF MAINLY COMEDONES
TOPICAL ANTIBIOTICS+ZINC OR BPO OR RETINOID
IF INFLAMATION IS PRESENT TOO - TRY AZELIAC ACID 25% CREAM WHICH CAN RED POST INFLAMMATORY PIGMENTATION TOO

8. Topicals - General rules
Make sure patients treat whole area not just spots
Avoid abrasive cleansers may worsen acne by provoking inflammation
Gels for oily skin but sting dry skin
Cream for sensitive/dry skin but can make greasy

9. BENZOYL PEROXIDE EFFECTIVE AND CHEAP
ANTIMICROBIAL, SLIGHT ANTI-INFLAMMATORY
TENDS TO BE SLOW-MAY TAKE MONTHS
LOW STRENGTH CAN OFTEN BE AS EFFECTIVE AS HIGHER STRENGTH
SKIN IRRITANT
STAINS CLOTHES

10. TOPICAL RETINOIDS
RETIN A (TRETINOIN),ISOTREX GEL (ISOTRETINOIN),DIFFERIN (ADAPALENE)
ANTI COMEDONAL ,SOME ANTI-INFLAMMATORY EFFECT
USE ALT NIGHTS FIRST - IF SENS SKIN WASH IT OFF AFTER AN HR, IF IT IRRITATES USE LESS OFTEN-SOME PEOPLE CANT USE IT
IF NOT INCREASE TO NIGHTLY THEN BD
USE SUNSCREEN
AVOID EYES AND MOUTH-APPLY THINLY

11. TOPICAL ANTIBIOTICS REDUCE BACTERIA
NOT AS IRRITANT AS BPO BUT CAN CAUSE CONTACT DERMATITIS
EFFECT ON INFLAMMATION BETTER THAN COMEDONES
USE IN COMBINATION WITH BPO OR ZINC

12. MILD ACNE SUMMARY COMEDONAL -TOP RETINOID OR BPO THEN A COMBINATION
INFLAMMATORY - BPO IF NO RESPONSE AFTER 2/12 ADD IN TOPICAL ANTIBIOTIC
AZELIAC ACID MAY HAVE A PLACE IF BPO OR RETINOID TOO IRRITANT
NICOTINAMIDE AND N-LITE LASER PLACE UNCLEAR

13. MODERATE ACNE

14. MODERATE ACNE USE TOPICALS AND ADD AN ORAL ANTIBIOTIC
USE ANTIBIOTIC FOR 3/12 BEFORE CALLING “FAILURE”
AVOID RESISTANCE BY USING ADEQUATE DOSES

15. ORAL ANTIBIOTICS ANTIBACTERIAL-ANTI INFLAMATORY-REDUCE KERATIN
USE WITH TOPICAL AGENT-RETINOID +- BPO
OXYTET 500 BD-RESPONSE 2-3 MONTHS-IF OK CONTINUE FOR AT LEAST 6/12 AND UP TO A YEAR
IF FAILS BY 3/12-CHECK COMPLIANCE-IF OK-CHANGE TO
LYMECYCLINE AND ADD BPO? AS WELL AS RETINOID
OR TRIMETHOPRIM (UNLICENSED)
THERE IS TOO MUCH RESISTANCE TO ERYTHROMYCIN
CONSIDER ANTI-ANDROGEN IN WOMEN

16. MAINTENANCE USE AFTER STOPPING ORAL ANTIBIOTIC
USE TOPICAL RETINOIDS FOR MAINTENANCE
USE FOR AS LONG AS NECESSARY - EVIDENCE SCANT
CAN ADD BPO IF NECESSARY

17. ANTI ANDROGENS REDUCE SEBUM AND COMEDONES NOT A FIRST LINE TREATMENT
DIANETTE IS USUALLY USED-35MCG OF EO-RISKS!
TAKES 2-3/12 MAX EFFECT
YASMIN MAY BE GOOD
OTHERS SPIRONOLACTONE,CYPROTERONE ACETATE ALONE AND FINESTERIDE (IN MALES TOO)

18. WHEN TO REFER ANY PTS WITH NODULES OR CYSTS THAT ARE SCARRING
FAILURE TO CONTROL ACNE WITH ORAL ANTIBIOTICS AT 6/12
PERSISTENT ACNE OVER 25
VERY DISTRESSED PATIENTS

19. SEVERE ACNE WITH CYSTS

20. ISOTRETINOIN SPECIALIST ONLY 0.5-1G DAILY FOR 4/12 -6/12
CONTRACEPTION AND PREG TESTS ESSENTIAL
VERY EFFECTIVE-40% CURE AFTER ONE COURSE
40% LOW LEVEL RECURRENCE,20% NEED A FURTHER COURSE
TERATOGENIC
ALL GET DRY LIPS/NOSE
DRY EYES, NOSE BLEEDS, MUSCLE ACHES
ACNE CAN GET WORSE FOR 2 WEEKS BEFORE IMPROVING
MAINTENANCE -RETINOIDS TOPICALLY

21. SCARS FROM SEVERE ACNE

22. SCARRING MACULAR ERYTHEMA CAN TAKE A YEAR TO FADE SCARS
FLAT SCARS USUALLY IN DARKER SKINS
HYPERTROPHIC/KELIOD SCARS
LOSS OF TISSUE
1. ICE PICK-SMALL JAGGED SCARS
2.BOX SCARS -U SHAPED FIBROTIC SCARS
3.ROLLING SCARS-DEEP SOFT ROLLED EDGES
4.ATROPHIC -SMALL, WHITE SOFT BARELY RAISED

23. TREATMENT OF SCARS
DEPRESSED SCARS-SUBSCISION AND FILL WITH A DERMAL FILLER- LARESSE? OR HA
DERMABRASION-MICRODERMABRASION FOR FAINT SCARS
CHEMICAL PEELS-IMPROVES PIGMENTATION AND IMPROVES MACULAR,ICE PICK AND BOX SCARS-MILD TO MEDIUM DEPTH PEELS
LASER RESURFACING
PUNCH EXCISION + - SKIN GRAFT
COMBINATION TREATMENTS

24. HOT TIPS
BE CONFIDENT- MOST CAN BE TREATED IN PRIMARY CARE SUCCESSFULLY
GRADE THE ACNE -USING A GRADING SCALE
HAVE A CLEAR MANAGEMENT PLAN
USE MORE TOPICAL RETINOIDS
COMBINATION INDIVIDUALISED TREATMENT IS “IN”
MANY TREATMENTS FAIL BECAUSE OF NON COMPLIANCE-EXPLAIN THERE IS NO INSTANT RESULT AND SOME AGENTS MAY HAVE SIDE EFFECTS
TREAT THE PSYCHOLOGICAL EFFECTS - IMPORTANT
DON’T GIVE UP TOO SOON