1. Presentation by: Francine Carson SUNY IT Utica-Rome NUR 652
Acne Vulgaris
Presentation by:
Francine Carson
SUNY IT Utica-Rome
NUR 652

2. Definition of the Problem
Pathophysiology
Etiology
Inflammatory disorder of pilosebaceous unit
Hormonal influence
Androgens
(Lavers, 2014, p.330)
pilolsebacesous
Four key processes are involved in the pathogenesis
of acne:
1. Androgen-driven excessive sebum production
2. Abnormal keratinization (hyperkeratinization)
3. Colonization with Propionibacterium acnes (P. acnes )
4. Release of inflammatory mediators
(Lavers, 2014, p.330)
Normal pilosebaceous unit [Illustration] Retrieved September 14, 2014 from

3. Incidence Effects persons of all ages
“Most common dermatological condition worldwide”(Lavers, 2014, p.330)
Effects persons of all ages
80-100% will be effected in their lifetime
Begins around puberty; peaks in adolescence; tends to resolve third decade of life
May be present in the newborn (Watkins, 2013)
May be present in the new born (under influence of maternal hormones

4. Screening/Risk Factors
Drugs
Family History
Stress
Hormonal changes
Pregnancy, menstrual cycle
Conditions with excess androgen production
Polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing’s Syndrome
Smoking
Occlusion of skin surface
Cosmetic products
(Lavers, 2014 p.332; Lavers & Courtenay, 2011, p.58)
Corticosteroids
Polycystic ovary syndrome, congenital adrenal hyperplasia and Cushing’s (condition with excess androgen production)
Stillunclear if diet has an effect. Still need evidence based studies to determine.
Cosmetic products with oils

5. Clinical Findings Other findings
Diagnosis based on clinical findings, H&P :
Other findings
Inflammatory & Noninflammatory lesions (Titus & Hodge, 2012)
Noninflammatory
Open or Closed Comedones
Inflammatory Lesions
Papules, pustules, nodules, and cysts
May feel hot, painful, and tender to pressure
Visible to naked eye (Lavers & Courtenay , 2011, p.58)
Distributed to face, neck, chest, upper back, and shoulder (Lavers, 2013)
Seborrhoea
Scarring
Post-inflammatory pigmentation
Grading severity helps determine treatment
A diagnosis of acne
vulgaris cannot be confirmed unless typical
comedones are seen, with the naked eye, in one
or more of the following areas: face, neck, chest,
upper back and shoulders ( - these are areas with many sebacous glands

6. Images Retrieved September 14th , 2014 from

7. Assessing Severity of Acne
Mild
Seborrhoea
Predominantly comedonal lesions
Micro-comedones (first stage of comedone formation)
Open (blackheads) and closed (whiteheads) comedones
Few papular inflammatory raised lesions
Typically limited to the face
Moderate
Open and closed comedones
Moderate acne presents with greater numbers of inflammatory papules and pustules, involving face and trunk
Severe
Papular and pustular inflammatory lesions
Nodular-cystic lesions
Scarring
(Lavers, 2014, p.334)
(Image from British Journal of School Nursing, 2011, p. 382)

8. Differential Diagnosis
Rosacea
Seborrheic dermatitis
Drug-induced acne
Bacterial folliculitis
Perioral/Periorbital dermatitis
Keratosis pilaris
(Lavers, 2014; Lavers & Courtenay, 2011; Titus & Hodge, 2012)

9. Social/Environmental Considerations
Psychological impact (Lavers, 2014, p.333)
Stress
Anxiety
Depression
Suicidal ideations
Low self-esteem
Poor body image
Social withdrawal & higher rates of unemployment - especially in teenagers (Joseph & Sterling, 2010, p. 122)
These do not correlate with severity of acne.

10. Laboratory Testing/Diagnostics
Acne vulgaris is diagnosed by clinical appearance
Culture for sensitivities (Watkins, 2010, p.115)
Test for underlying condition
Hyperandrogenism
LH, FSH, Free testosterone (Domino, 2013, p.16)
Grading acne
Hirsutism

11. Management/Treatment Guidelines
Pharmacologic (Lavers, 2014, p )
Topical
Retinoids – for all grades of acne (except when oral retinoid used)
First line treatment
Adapalene – best tolerated
Antibiotics – mild-to-moderate inflammatory lesions
Combination with benzoyl peroxide or topical retinoid
Limit treatment to 12 weeks
First line: Clindamycin or Erythromycin
Benzoyl peroxide – Comedolytic, anti-inflammatory
Azelaic acid
Salicylic acid
Oral – moderate-to-severe or mild-to moderate acne
Antibiotics - moderate-to-severe inflammatory acne
Tetracycline (avoid use in pregnant women), Doxycycline
Limit course :12 weeks
Combine treatment with topical retinoid or benzoyl peroxide
Hormonal therapy – moderate-to-severe acne
Combined oral contraceptives, Spironolactone
Results: 3-6 months
Retinoids - severe acne
First line treatment
Accutane (Isotretinoin)
16-24 week course
Teratogenic
Treatment goals (Titus & Hodge, 2012, p.740)
Prevention of scars
Reduction of psychological manifestations
Resolution inflammatory/noninflammatory lesionsRetinoids – for all grades of acne (except when oral retinoid used) – first line treatment
Adapalene – best tolerated
Antibiotics – mild-to-moderate inflammatory lesions, use in combination with benzoyl peroxide or topicalretinoid, limit treatment to 12 weeks (antibiotic resistance)
First line: Clindamycin or Erythromycin
Benzoyl peroxide – comedolytic ,anti-inflammatory, non-antibiotic antimicrobial
Azelaic acid - normalizes keratinocytes, anti-inflammatory, treats post-inflammatory pigmentation
Salicylic acid - desquamating, comedolytic,

12. Management/Treatment continued
Non-pharmacological
Surgery; I&D for abscesses (Domino, 2013, p.17)
Laser and light therapy (Titus & Hodge, 2012, p.739)
Biofeedback
Acupuncture
Microdermabrasion

13. Complications Scarring Psychological manifestations
Antibiotic resistance
(Joseph & Sterling, 2010; Lavers, 2014, p.336)

14. Follow-up 4-6 weeks Reevaluate response to treatment Adverse effects
(Dunphy, Winland-Brown, Porter, & Thomas, 2011, p. 209)

15. Counseling/Education
Avoid picking at scabs or acne (Lavers & Courtenay, 2011, p.64)
If acne doesn’t improve, return for reevaluation
Wash face twice daily with a gentle cleanser
Wash oily hair regularly
Use medication as directed and give it time to work
6 weeks (Titus & Hodge, 2012, p. 740)
Scarring – ick at spots
May get worse first 2 weeks of treatment

16. Consultation/Referral
Dermatology
Family and peer group support
Psychological counseling

17. 10 Questions
1. A client returns after 2 weeks of treatment for acne and states it isn’t working. What should the practitioner tell the client?
a) Return in 4 weeks, b) Let’s change your treatment, c) Refer to dermatology
2. T/F : Popping acne is ok because it gets the pus out.
3. Which lab study should the provider obtain prior to starting a female client on Isotretinoin?
a) CBC, b) ESR, c) pregnancy test
4. Why are acne vulgaris lesions mostly located the face, back, neck, and chest
a) Lower concentration of ebaceous glands, b) Higher concentration of sebaceous glands, c) Skin pigmentation
5. A client says they have been scrubbing their face to get rid of the oils and their acne isn’t getting any better. What should you say to the client?
Scrubbing can irritate the skin and make the acne worse
It takes about 1 week of scrubbing to see improvement
Let’s take a look at your acne medication

18. 10 Questions (continued)
6. Who should the provider refer a client who is feeling embarrassed and depressed about their acne?
a) Psychologist, b) Plastic surgeon, c) School nurse
7. Why should the provider limit the duration of antibiotic treatment for clients?
a) Cdiff, b) Photosensitivity, c) Antibiotic resistance
8. Which medications can one use for treatment of acne? (Multiple correct)
a) Retinoids, b) Antibiotics , c) Oral contraceptives
9. Acne vulgaris is diagnosed based on:
a) Culture results, b) clinical appearance, c) TSH studies
10. T/F: Clients taking corticosteroids or women with polycystic ovarian syndrome are at risk for acne vulgaris?

19. References
British Journal of School Nursing, Oct 2011, Vol. 6 Issue 8, p , 5p, 2 Color Photographs, 1 Black and White Photograph, 1 Diagram, 1 Chart Color Photograph; found on p382 Domino, F. (2014). Griffith’s 5-minute clinical consult (22nd ed.). Philadelphia: Lippincott Williams & Wilkins Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia: F.A. Davis. Joseph, D., & Sterling, A. (2010). The psychological effects of acne in teenagers. British Journal Of School Nursing, 5(3), Lavers, I. (2013). Therapeutic strategies for acne vulgaris. Nursing Times, 109(48),

20. References
Lavers, I. (2014). Diagnosis and management of acne vulgaris. Nurse Prescribing, 12(7), Lavers, I., & Courtenay, M. (2011). A practical approach to the treatment of acne vulgaris. Nursing Standard, 25(19), , 58, 60 passim. Titus, S., & Hodge, J. (2012). Diagnosis and treatment of acne. American Family Physician, 86(8), Watkins, J. (2013). Looking at the potential impact and management of acne. British Journal Of School Nursing, 8(3),