1. Acne
Justin Walker
October 2009

3. Classification Mild to moderate Moderate to severe Other causes
Plugged pores
Sebum collection
Moderate to severe
Propionibacterium acnes
Inflammation, pustules
Cysts, nodules, scarring
Other causes
PCOS
Halogenated hydrocarbons

4. Differentials

5. Differentials Rosacea Older age group
Absence of comedones, nodules and scarring

7. Differentials

8. Differentials Folliculitis Infected hair follicle, responds to abx.
NB demodex folliculitis caused by mites, pityrosporum folliculitis caused by yeasts.

9. Differentials

10. Differentials Perioral dermatitis Distribution!
Associated with fluorinated steroids.

11. What makes it worse? Progesterone only pill
Hormone changes with periods
Make up
Picking and squeezing
Humid environment/sweating
Tight clothing
Drugs – phenytoin, steroid creams
Anabolic steroids

13. Myths
Poor hygiene
Diet
Stress
Water intake
Sunshine
Cannot be cured

14. Topical Treatments Benzoyl peroxide Available over the counter
Good for comedones & infected lesions
2.5-10% available, start low and increase as tolerated
Wash skin beforehand, wash off after several hours
Start od, bd if tolerated.

15. Topical Treatments Topical Retinoids
Adapalene, tretinoins and isotretinoin
Unblock pores, reduce inflammation
S/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!

16. Topical Treatments Topical antibiotics Erythromycin and clindomycin
Good for inflammation but don’t unblock pores
Local guidelines recommend topical for those who cannot tolerate oral.
Can use with short courses benzoyl peroxide/ azelaic acid
Topical abx need to be used for 6 months.

17. Topical Treatments Azelaic acid
Unblocks pores, some reduction of inflamed acne
Less effective than topical antibiotics or benzoyl peroxide

19. Oral Treatments Antibiotics Reduce inflammation,
Not good at unblocking pores – may need concommitant topical bp/aa
Local guidelines: doxycycline, lymecycline, erythromycin
Use for 3 months and review
Tetracyclines: not for under 12s, not in pregnancy – discuss contraception. Women on cocp need additional precautioins for first 3 weeks.

20. Oral Treatments Isotretinoin Suppresses sebum production
Specialist initiation
Teratogenic
S/E dry skin/mucous membranes, nosebleeds, joint pains
Minimum course 16 weeks.

21. Oral Treatments Co-cyprinidol
Cyproterone acetate with ethinylestradiol aka Dianette
Contains anti-androgen
Same effectiveness as oral broad spectrum
Useful if a woman also requires oral contraception, although not licensed as a contraceptive.
Increased risk of venous thromboembolism
Use only in women with severe acne and hirsutism

22. When to Refer? Immediate referral Urgent referral Routine referral
Acne fulminans
Urgent referral
Severe/Nodulocystic acne and may benefit from oral isotretinoin
Severe psychological/social problems
Routine referral
At risk of or are developing scarring despite therapy
Moderate acne failing to respond (2 x 3 month courses abx)
Possible underlying endocrinological cause eg PCOS

23. Acne fulminans

24. Thank you!