Acne

What is acne?

Overview

• Acne is an inflammatory condition affecting the pilosebaceous units of the skin, and only occurs in the presence of androgens

• Skin changes usually include increased sebum production, hypercornification causing keratinous plugs, colonisation of more virulent strains of Cutibacterium acnes, and inflammation

  • These are characterised as comedones (open = blackhead, closed = whitehead), papules and pustules, and may be with or without scarring

• Clinical manifestation can range from mild to severe, and only mild-moderate cases can be managed OTC

Who does it affect?

• Most common in adolescents and young adults

• More severe in pubescent males

• More likely to persist in females

Risk Factors for Acne (Modifiable vs Non-Modifiable)

• Drugs that can cause acne

  • Anabolic steroids and testosterone

  • Some contraceptives (COCPs with higher doses of levonorgestrel, progestogen-only contraceptives)

    • Switch to a formulation that contains a progestogen that is antiandrogenic (e.g. dienogest, drospirenone, cyproterone) or less androgenic than levonorgestrel (e.g. desogestrel, gestodene, norethisterone)

  • Oral corticosteroids

  • Antiepileptics such as phenytoin and carbamazepine

  • Anti-tuberculosis medications such as isoniazid and rifampicin

  • Lithium

  • Ciclosporin

  • Fluconazole

  • Vitamin B6 and B12

• Skincare, cosmetics and sunscreens that is comedogenic and oil-based

• Diet

  • High GI foods and dairy products may exacerbate acne

• Occupation and leisure activities

  • Comedogenic substances, cosmetics, sunscreens, industrial oils and fumes, and grease exposure may cause or aggravate acne

  • Hot, humid environments (e.g. chefs, baristas, visiting a spa or sauna) may also cause of aggravate acne

Differential Diagnosis

Rosacea

• An inflammatory disease of the skin follicles

• Presents as:

  • Flushing and redness

  • Most common in women aged 30-50 years

• Differs by:

  • No comedones present

  • Age

Medicine-Induced Skin Eruptions

• Adverse reactions triggered by drugs, ranging from mild to severe and life-threatening

• Presents as:

  • Commonly caused by lithium, OCP, azathioprine, phenytoin and oral steroids

  • May or may not have comedones

  • Mostly uniform, itchy or painful red bumps

• Differs by:

  • Abrupt onset within days of exposure

  • Extends beyond the usual acne areas, i.e. the trunk, arms and legs

  • Itchy or painful bumps

  • Monomorphic (all look the same)

Perioral Dermatitis

• An inflammatory skin condition around the mouth, nose and eyes

• Presents as:

  • Red, itchy, scaley, acne-like bumps around the mouth and nasolabial folds

  • Commonly triggered by topical steroid use, heavy cosmetics, fluorinated toothpastes, overuse of anti-ageing or exfoliating products, and hormonal changes

• Differs by:

  • Skin itching and burning

  • Skin is dry rather than oily

Folliculitis

• An infection of the hair follicles caused by bacterial, viral, fungal or parasitic pathogens

• Presents as:

  • Uniform red, painful bumps at the hair follicle

  • Can occur anywhere on the body where hair grows

  • Triggered by sweat, shaving microorganisms and friction

• Differs by:

  • Monomorphic and only appear where hair grows

  • Itching and burning sensation

Questions to Ask

• Can you tell me about your symptoms?

  • Could you describe what the skin looks like? (Assess for comedones, papules, etc.)

  • Has it spread to anywhere else on the body?

  • Do you have any burning, itching or pain?

  • Is the skin broken, weeping or bleeding?

• Have you had this before?

• How long have you had this for?

• Is there a personal or family history of scarring from acne?

• Have you started any medications recently?

• Could you tell me about your lifestyle? What do you do for work/school? What is your diet like?

• Have you tried anything yet?

Referral Points

• Treatment failure

• Unpleasant side effects from current treatment

• Moderate-severe acne

• Patient >25 years with acne for the first time

• Occupational acne

• Rosacea

• PMOS

• Scarring history

• Psychological stress

• Medicine-induced acne

• Children ≤6 years

• Unclear diagnosis

Treatment: General Measures

• The aim for treatment is to reduce the number of lesions and improve the skin condition to prevent scarring

• Treatment is to help eliminate pathogens and reduce the impact of psychological stress on the patient

• Before starting treatment for acne, identify any contributing factors and consider whether they can be modified or removed

First Line: Benzoyl Peroxide

Product

Benzac Gel - 2.5%, 5%, 10%

Directions

• Apply a thin layer to the affected areas (not just pimples) and rub gently

• Initially apply and leave on for TWO hours then rinse off for THREE consecutive nights, then leave on overnight if tolerating. If after tolerating for SEVEN days, increase to TWICE daily

Special Instructions

• This takes time to work. You will know after 6 weeks if this is working for you - see your doctor if there is no response

• Wash the area with a mild soap or soap substitute and warm water than pat dry - Cetaphil Gentle Cleanser is a good option

• Wash hands before and after application

Side Effects

• Skin dryness or peeling; feeling of warmth; mild stinging or erythema

Pregnancy

• Safe to use

• Category not listed

Breastfeeding

• Safe to use

Children

• No age restrictions as per manufacturer

Precautions

• Inflamed or broken skin (may increase irritation)

Contraindications

• N/A

Other Info

• Increase dose at monthly intervals if needed

• Typically start with 5% unless there is a history of dermatitis or dry/sensitive skin

• 10% is no more effective than 5%

First Line: Azelaic Acid

Product

• Finacea 15% Cream

• Azclear 20% Gel

Directions

• Apply a thin layer to the affected areas (not just pimples) and rub gently

• Initially apply and leave on for TWO hours then rinse off for THREE consecutive nights, then leave on overnight if tolerating. If after tolerating for SEVEN days, increase to TWICE daily

Special Instructions

• This takes time to work. You will know after 4 weeks if this is working for you - see your doctor if there is no response

• Wash the area with a mild soap or soap substitute and warm water than pat dry - Cetaphil Gentle Cleanser is a good option

• Wash hands before and after application

Side Effects

• Scaling; itch; burning; mild transient erythema; hypopigmentation

Pregnancy

• Safe to use

• Category B1

Breastfeeding

• Safe to use

Children

• No age restrictions as per manufacturer

Precautions

• Inflamed or broken skin (may increase irritation)

• Dark complexions (may cause bleaching)

Contraindications

• N/A

Other Info

• 
  

Other Treatments

• Adapalene - S3

• Benzoyl peroxide 5% wash - useful for trunk

Comparisons

• In sensitive skin or benzoyl peroxide intolerance, use azelaic acid

• In oily skin, use a gel formulation as this absorbs quicker and dries matte

• In dry or sensitive skin, use a lotion formulation as this is richer and more hydrating to the skin barrier

Inappropriate Treatment

• Essential oils, keratolytics and triclosan (Phisohex) have limited evidence

Lifestyle Advice

• To help these products work the best way they can, it’s recommended to follow a good skincare routine

  • Wash face morning and night with a mild skin cleanser (such as Cetaphil Gentle Skin Cleanser) with warm (not hot) water

  • Use a light moisturiser tat is water-based and non-comedogenic

  • Avoid exfoliating scrubs as these can aggravate the skin

  • Use sunscreen and makeup that is oil-free and non-comedogenic

• These products may cause some bleaching effects. Make sure you wash your hands thoroughly and be cautious with bedding and clothing. Tie hair back where possible

• These products can make your skin more sensitive to the sunlight. Make sure to follow sun safe behaviours like wearing sunscreen and a hat

• Do not pick or squeeze acne lesions as this can increase the severity of inflammation, cause scabs and increase the risk of scarring

• Stress may exacerbate acne. Develop your own stress management techniques

• Consistency is key!

“We have covered a lot of information today. I will provide you with a Self Care Fact Card and a CMI that goes through the information we have discussed plus some. Do not hesitate to contact us if you have any further questions or concerns.”