ACNE VULGARIS

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ACNE VULGARIS

• Caroline Jewels
• ST3
• 14-1-9

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Causes

• Increased sebum
• Abnormal follicular differentiation
• Colonization of pilosebaceous duct with
  Propionibacterium acnes
• Release of inflammatory mediators Genetic factors
  ie FHx
• Endocrine factors - PCOS, excessive
  corticosteroids
• Psychological stress and depression
• Environmental factors - cosmetics, petroleum
  oils, physical occlusion
• Medication - hormonal, antiepileptics, anti-TB,
  antidepressants, ciclosporin, B vitamins

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ACNE - Aims

• Decrease scarring
• Decrease unsightly appearance
• Decrease psychological stress
• Explain long length of treatment may be several
  months and initial response may be poor but must
  persevere (poor compliance has been demonstrated
  in studies at 3/12)

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ACNE

• Classification
• Blackheads (open comedones)
• Whiteheads (closed comedones)
• Inflammatory papules
• Cystic areas
• Nodules and scars from old lesions /- keloid
  formation

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Acne vulgaris comedones dominant
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Acne vulgaris- pus dominant
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Management

• Dont dismiss as trivial
• Dispel myths
• Gentle soap and water BD
• Apply medications to all skin area
• Look for underlying depression
• Assess every 6-8 weeks
• Examine all acne prone areas

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Management cont.

• Benzoyl peroxide bd /- topical Abx (Duac) or
  Azelaic acid (Skinoren)
• Topical retinoids (Differin, Retin A, Isotrex)
• Nicam gel (inflammatory acne)
• Topical Abx - Zineryt, Dalacin (be aware of
  resistance to Propionibacterium acnes)
• Oral tetracycline/oxytetracycline 500mg bd or
  Trimethoprim 300mg BD - 4-6/12
• Anti-androgen (Dianette also Cilest/Marvelon)
• Oral retinoid (Roaccutane) - specialist only

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Benzoyl peroxide

• Cheapcheerful
• Start at low strength 2.5 at night
• Mild erythema - transient
• Bleaches clothes
• Build up to 10 gradually
• Stop if irritation occurs
• In combination with Abx (Duac once daily)
• Expect improvement within 2/12

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Topical retinoids (Isotretinoin/adapalene)

• Start low strength (0.025)every other night -
  may cause redness/irritation
• Increase strength until response
• Avoid sunlight/uv light pregnancy

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Topical Antibiotics

• ? Better than benzoyl peroxide
• Reduces propionobacterium acnes
• Less irritation
• Glows in UV light (warn patient not to go
  clubbing)

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Azelaic acid

• Antimicrobial and anticomedonal properties
• Alters composition of fat/decrease bacteria
• Short term use only (1/12)
• May cause irritation/ photosensitivity (although
  less likely than benzoyl peroxide)

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Oral Antibiotics

• Oxytetracycline 500mg bd (tetracycline/trimethopri
  m)
• Warn patient can take 6/52 for response-must be
  compliant.
• Treat for 6 months
• Avoid milk,and have 30mins before meals
• If effective reduce dose to 500mg od and then
  250mg od at 3/12 intervals
• Do not give in combination with topical Abx due
  to risk of resistance

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Hormonal

• In women on COCP consider less androgenic
  progestogen (marvelon/cilest) but increased risk
  of DVT
• Consider cyproterone acetate with
  oestrogen(Dianette)

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When to refer? (NICE)

• Acne fulminans
• Nodulocystic acne
• Dysmorphophobia
• Scarring
• Failure to respond to 6/12 topical and systemic
  treatment
• Suspected underlying endocrine cause

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Rosacea

• Flushing/erythema, telangectasia, papules,
  pustules, absence of comedones
• Metronidazole gel (Rosex)
• Oral Abx (OTC 500mg BD, Tetralysal 1mg OD,
  Erythromycin 500mg BD)
• Combination treatment
• Long courses
• May need referral for isotretinoin
• May need surgery/laser for rhynophyma
• Laser may help erythema but not permanent and not
  NHS

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Perioral/periorbital dermatitis

• Nearly always female
• Monomorphic itchy pustules around mouth
• Topical steroids exacerbate - Oral
  tetracyline/erythromycin 3/12