3Classification Mild to moderate Moderate to severe Other causes Plugged poresSebum collectionModerate to severePropionibacterium acnesInflammation, pustulesCysts, nodules, scarringOther causesPCOSHalogenated hydrocarbons
13MythsPoor hygieneDietStressWater intakeSunshineCannot be cured
14Topical Treatments Benzoyl peroxide Available over the counter Good for comedones & infected lesions2.5-10% available, start low and increase as toleratedWash skin beforehand, wash off after several hoursStart od, bd if tolerated.
15Topical Treatments Topical Retinoids Adapalene, tretinoins and isotretinoinUnblock pores, reduce inflammationS/E: skin redness and peeling, sun sensitivity – apply at night and wash off in morning.Use lower strength if not tolerated.Avoid in pregnancy – discuss contraception!
16Topical Treatments Topical antibiotics Erythromycin and clindomycin Good for inflammation but don’t unblock poresLocal guidelines recommend topical for those who cannot tolerate oral.Can use with short courses benzoyl peroxide/ azelaic acidTopical abx need to be used for 6 months.
17Topical Treatments Azelaic acid Unblocks pores, some reduction of inflamed acneLess effective than topical antibiotics or benzoyl peroxide
19Oral Treatments Antibiotics Reduce inflammation, Not good at unblocking pores – may need concommitant topical bp/aaLocal guidelines: doxycycline, lymecycline, erythromycinUse for 3 months and reviewTetracyclines: not for under 12s, not in pregnancy – discuss contraception. Women on cocp need additional precautioins for first 3 weeks.
21Oral Treatments Co-cyprinidol Cyproterone acetate with ethinylestradiol aka DianetteContains anti-androgenSame effectiveness as oral broad spectrumUseful if a woman also requires oral contraception, although not licensed as a contraceptive.Increased risk of venous thromboembolismUse only in women with severe acne and hirsutism
22When to Refer? Immediate referral Urgent referral Routine referral Acne fulminansUrgent referralSevere/Nodulocystic acne and may benefit from oral isotretinoinSevere psychological/social problemsRoutine referralAt risk of or are developing scarring despite therapyModerate acne failing to respond (2 x 3 month courses abx)Possible underlying endocrinological cause eg PCOS