1.  Question: Take a history from May Ling 15 years, examine her face,outline the most likely diagnosis and a management plan

2.  Rapport  Concerns + expectations  Specific questions  Examination  Management

3. (1) Duration: months/years (2) Location : hormone or post adolescent acne (3) Previous treatments: how long and what works best? (4) Triggers: What does she think causes the acne? (5) Family history : scarring or isotretinoin (6) Impact: how do you feel about your skin ? Does it stop you from doing anything? (7) Periods –regular? (8) Seek permission to examine

4. (1) Site: face chest, back (2) Severity of the acne: mild moderate and severe (3) Inflammatory? Pink or red (4) Scarring evidence (5) Psychological impact

5. (1) Rosacea (2) Perioral dermatitis (3) Acneiform drug eruptions (4) Folliculitis of the trunk

6. MildModerateSevere Open comedones ( blackheads) ++++ Closed comedones( white heads) ++++ Inflammatory Papules occasional++ Pustulesoccasional++ Inflammatory Nodules + deeper lesions (cysts) + scarring _occasional ++

10. (1) Mild, moderate or severe clinical form. (2) Postadolescent women + may continue into the 40s age group. (3) Often history of an acne flare premenstrually, typically one week b4 the menses or during ovulation. (4) Usually inflammatory and + deep; describe as ‘blind’ pimples lasting weeks. (5) Characteristic distribution : lower third face, along the jawline + neck. (6) Possible associations: hirsutism, menstrual irregularity and signs of polycystic ovary syndrome.

11. (1) 6 months to 3 years of age (2) Comedones and inflammatory lesions (3) Cheeks, forehead and chin (4) Usually settle after a few months (5) Scarring can occur with inflammatory and deeper lesions

12. (1) Resulting from moderate or severe inflammatory acne lesions that heal with the formation of fibrous tissue (2) As inflammatory lesions heal there are colour changes of purple, red and pink which gradually fade with time + hypo- + hyperpigmentation. (3) Scars may be depressed + pit-like (termed ‘ice pick’) or flat, thin atrophic scars. (4) Other scars are thick and lumpy + are hypertrophic or keloid in nature

13.  Explain medical understanding of cause of acne  Acne can be treated  Diet is not proven to change acne  Advise against picking or squeezing  Regular washing soap: twice a day  Avoid oily or greasy skin preparations  Follow up

15.  Strength of recommendation: (1) A: consistent + good quality patient oriented evidence: topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics + oral contraceptives (2) B: inconsistent or limited quality patient oriented evidence : herbal treatments + effect of diet

16. Benzoyl peroxide Topical retinoids AntibioticsOral isotretinoin Decreased sebum +++++++ Decreased abnormal kearatinisatio n +++ +++ Decreased P. acnes +++++ Decreased inflammation ++++++++++

17. Acne Grading Topical therapy Oral antibiotics Androgen blocker Oral contraceptive s(females) Mild(1) Topical retinoids: nightly (2) Topical antibiotics( more inflammatory papules + pustules) _ Indicated if failure topical therapy or inflammatory lesions increase or deeper __ Moderate (1)Combinati on with topical antibiotic (2)Pulse therapy:5- 7 days (1)Doxycycli ne 50-100 mg daily (2)Bactrim (1)Spironolac tone 50 – 100 mg (2)Cyprotero ne acetate 50 mg days 5-15 menstrual cycle Oral contraceptive

18. (1) Preparations: adapalene ( differin gel or cream), adapalene + benzoyl peroxide ( epiduo gel), isotretinoin ( isotex cream), tretinoin ( retin – A, Retrieve cream, Stieva A), tazarotene ( Zorac cream) (2) Applied nightly to all areas of the face (3) Thin layer to a cool dry face (4) If sensitive face use every second night (5) Results 6-8 weeks (6) Maintenance therapy months

19. CompositionBrand names Ethinyloestradiol + cyproterone acetate Brenda -35 ED, Dianne -35 ED, Estelle -35 ED, Juliet -35 ED Ethinyloestradiol + desogestrelMarvelon Ethinyloestradiol + dienogestValette Ethinyloestradiol + drospirenoneYasmin, Yaz

20. (1) Doxycycline : 50-100 mg daily ( some use 200 mg 1 st 2 weeks + 100 mg thereafter) (2) Bactrim (3) Do not use topical + oral antibiotics at same time (4) Oral antibiotics for 6-12 weeks course (5) If longer course use benzoyl peroxide for a week between courses (6) Side effects: photosensitivity with doxycycline

21. (1) Severe acne, unresponsive conventional therapy + psychological therapy (2) Common side effects: dry gritty eyes, dry skin, dry, chapped skin, headaches, muscle aches + secondary bacterial infections (3) Contraindicated in pregnancy: start 2 nd or 3 rd day menstrual cycle + relatively contraindicated depression (4) Starting dose 0.5 mg /kg/day (5) Stop when acne free 2-3 months (6) Stop all topical treatments + antib iotics