Acne vulgaris . Alison Layton (Consultant Dermatologist at the Harrogate and District Foundation Trust), Dr. Daron Seukeran (Consultant Dermatologist at James Cook University Hospital), Dr Tom Poyner (retired GPw. SI in Teesside) and the British Skin Foundation, which funds high- quality research into skin disease and skin cancer. Introduction. Aetiology. The aetiology of acne has four major features. Androgen- induced seborrhoea (excess grease). The more sebum (grease) the greater degree of acne. Sebum is produced by the pilosebaceous glands, which are predominantly found on the face, back and chest. Evidence suggests that in most patients the seborrhoea is due to increased response of the sebaceous glands to normal levels of plasma androgens. Comedone formation (blackheads, whiteheads and microcomedones), which is known as comedogenesis. Is due to an abnormal proliferation and differentiation of ductal keratinocytes. It is controlled, in part, by androgens. In pre- pubertal subjects comedones are seen early and they precede the development of inflammatory lesions. Colonisation of the pilosebaceous duct with Propionibacterium acnes (P. This is a complex process involving an interaction between. Biological changes occurring in the duct as a result of comedone formation and P. Images must only be used for teaching purposes and are not for commercial use. Notice and credit must be given to the PCDS and any other named contributor. Figure: 1. Acne secondary to Polycystic Ovarian Syndrome Acne and hirsuites. Figure: 2. Mild acne. Comedones (blue arrow), pustules (black arrow) and excoriated lesions (green arrow)Figure: 3. Acne secondary to anabolic steroids Figure: 4. Pomade acne. Figure: 5. Acne secondary to lithium. Figure: 6. Acne with open comedones (blackheads)Figure: 7. Acne with closed comedones (whiteheads)Figure: 8. Mild papular/pustular acne. Figure: 9. Moderate inflammatory acne on the chin Figure: 1. Moderate inflammatory acne with papules and pustules. Figure: 1. 1Moderate acne Figure: 1. ![]() ![]() Acne in a patient with darker skin. Figure: 1. 3Severe acne. Figure: 1. 4Severe inflammatory acne; many pustules and actively inflamed nodules. Figure: 1. 5Severe cystic acne. Figure: 1. 6Severe acne with nodules. Copied with kind permission from Dermatoweb. Figure: 1. 7Hyperpigmentation resulting from acne Figure: 1. Ice- pick scars. Figure: 1. The start of atrophic scarring. This has developed from previously severe inflammatory acne. Figure: 2. 0Atrophic scars. Figure: 2. 1Severe inflammatory acne nodules now progressing into keloid scars. Figure: 2. 2Keloid scars. Acne vulgaris typically. Acne vulgaris. Virtually every adolescent has a few “spots”, however, about 15% of the adolescent population have sufficient problems to seek treatment. Investigations. The vast majority of patients with acne do not require investigations. Free testosterone levels should be checked in patients suspected of having Polycystic Ovarian syndrome (PCOS), which is suggested by. Oligomenorrhoea (less than nine periods a year). Free testosterone levels may be elevated between the levels of 3- 5 nmol/l (refer to the chapter on hyperandrogenism for more information). Another condition that needs to be considered from time- to- time is late onset (non- classical) congenital adrenal hyperplasia, which may have the following features. Clinical features in childhood include precocious puberty, acne and accelerated bone age. Clinical features in adolescent and adult females include persistent acne, moderate- severe hirsutism, menstrual irregularity / fertility problems and a short stature. ![]() There is often a family history. Patients normally have biochemical evidence of hyperandrogenism. ![]() Test for serum levels of 1. Patients suspected of having a more serious underlying endocrinopathy, including those found to have a testosterone level greater than 5 nmol/l, or with other features of virilisation, should be referred urgently to an endocrinologist. Such cases are very rare. Please refer to the chapter on hyperandrogenism for more information. Management. Key management principles. Provide patients with a patient information leaflet. The primary aim of acne treatment is to prevent or minimise scarring, once scarred the skin will never return to normal, accordingly. ![]() ![]() Acne; general information. Authoritative facts about the skin from DermNet New Zealand. Knowing which type of acne you have is key to successfully clearing it from your skin. Here are the different types of pimples and how to treat them. Topical antibiotics in combination with retinoids are the Foundation of most treatment programs for acne. Benzoyl peroxide is available in several forms (gels, washes. View list of generic and brand names of drugs used for treatment of Acne. You can find more information including dosage, side effects of the Acne medicine. Patients with severe acne eg nodular scarring acne should be referred immediately. Papular- pustular acne can also scar, as such patients starting to scar who do not respond to the treatments referred to in steps 2 and 3 (below) should also be referred. Ideally patients with scarring should be referred as semi- urgent and seen within six weeks. For patients with mild- moderate acne. Topical preparations containing benzoyl peroxide and/or topical retinoids are an essential part of the treatment. It is important to explain to the patient that such treatments will dry the skin and cause local irritation, in order to reduce adverse effects patients may wish to start using the treatments two to three evenings (or nights) a week and gradually increase the frequency and duration of applications. There are increasing levels of Propionibacterium acnes resistance to antibiotics, especially erythromycin, the use of which should be restricted. The type of acne is important. For example there are some variants such as sandpaper acne and macrocomedonal acne that respond poorly to conventional treatment. It is important to have a way of monitoring response to treatment. This could be done as follows. Serial photography is perhaps the best method. Using standardised grading methods (see images below). Treatment ladder. Step 1: treatment of comedonal acne (figures 6 and 7 above)First line - a topical retinoid. A topical retinoid is needed as this reduces comedonal activity. Choices include adapalene (Differin . If patients cannot tolerate BPO use a topical retinoid. Antibiotic choice . Doxycycline can occasionally cause a photosensitive eruption. Minocycline is rarely used due to the increased risk of hepatotoxicity and lupus- like conditions. Macrolides Should generally be avoided due to high levels of P. They are first line in pregnancy and in children under the age of 1. The dose of erythromycin is 5. BD, or, clarithromycin 2. BD - smaller doses are required in patients aged under 1. Trimethoprim. Again there are concerns of bacterial resistance, so this treatment may best be reserved for young children who do not tolerate macrolides Duration of treatment. The evidence suggests that there is little additional benefit in using antibiotics for more than three months, and in addition, prolonged use increases the resistance of P. It is therefore recommended that antibiotics should be stopped after three months, however, the patient should remain on their topical agent. The antibiotic course could be repeated in the future if needed. If the patient does not respond to two types of antibiotics, especially if they are starting to scar, the patient should be referred for consideration of Isotretinoin Step 4: treatment of moderate- severe acne in a woman. If no contraindications consider adding in Dianette . This wording is chosen for compliance with other European states but in the United Kingdom refers to consultant dermatologists. Consultant dermatologists and experienced GPw. SIs working within an integrated service may wish to develop a locally agreed care pathway and accreditation process to facilitate the prescribing of isotretinoin in the community. However, they need to be mindful that this is an 'off- licence' indication and be cognisant of the MHRA view. They may also wish to seek the advice of their professional indemnity organisation. Management of scarring. Up to 5. 0% of scars (especially smaller scars) may improve naturally over 6- 1. Treatment of established scars is difficult and while some patients will benefit from treatment others will not. Patients should only be referred to dermatologists / plastic surgeons familiar with treating scars. Funding will vary depending on local commissioning arrangements. Atrophic scars. The development of ablative lasers combined with appropriate surgical techniques has led to a significant improvement in the way that certain atrophic scars can be treated. Punch excision of small atrophic scars which can be very helpful prior to resurfacing. For deep scars - scar revision may help. Other options include intradermal injections of collagen or compounds, which stimulate collagen synthesis Hypertrophic / keloid scars. Silicone gels applied to scars can be prescribed by general practitioners. Local steroids for a trial period of two to three months. Look closely for side- effects such as skin thinning and telangiectasia. Treatments can be administered as topically ie a potent or super- potent steroid cream or ointment carefully applied, Haelan . This procedure is only possible through specialised hospital departments. Additional images. Figure: 1. Acne grading - face, grade 1+2. Figure: 2. Acne grading - face, grade 3+4. Figure: 3. Acne grading - face, grade 5+6. Figure: 4. Acne grading - face, grade 7+8. Figure: 5. Acne grading - face, grade 9+1. Figure: 6. Acne grading - face, grade 1. Figure: 7. Acne grading - trunk, grade 2+1. Figure: 8. Acne grading - trunk, grade 4+3. Figure: 9. Acne grading - trunk, grade 6+5. Figure: 1. 0Acne grading - grade 8+7. Figure: 1. 1Irritant dermatitis secondary to topical acne treatments Figure: 1. Photosensitivity from doxycycline. Figure: 1. 3Isotretinoin and dry skin. Isotretinoin (Roaccutane . As the treatment course progresses some patients will also develop dry and inflammed skin especially on the hands and arms. This can be improved with the use of emollients and a mild topical steroid.
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