Overview
Acne vulgaris (aka ‘acne’) is a very common disorder of the pilosebaceous follicles (oil glands). It results from excess production of sebum which is related to androgen (testosterone) levels. It is related with psychological distress (including depression, anxiety, and social phobia). Early treatment is associated with better outcomes and reduces the risk of long-term scarring. Diagnosis is clinical. It is important to remember that acne can be disfiguring, has a large psychological impact, and has the potential for (avoidable) scarring. Cystic acne should be referred to a specialist (dermatologist) to reduce the risk of scarring.
Acne peaks in teenage years (second decade) and may continue into adulthood where it affects 15% of women and 5% of men.
Lesions seen in acne
| Lesion | Description |
|---|---|
| Open comedones (blackhead) | Indicates hyperkeratinisation. Does not form cysts. |
| Closed comedones (whiteheads) | Obstructed pilosebaceous units. Can cause scarring and leads to cysts. |
| Papules (deep) | Small, inflammatory and usually raised, red lesions |
| Pustules | More superficial than papules |
| Nodules | Bigger papules |
| Cysts | > 5mm in size. Develops when there is further infection and inflammation by P. acnes. Can be treated with intra-lesion steroids, antibiotics, and isotretinoin |
| Atrophic scars | Fills up within the months after flare-up. Scarring is fully assessed once the inflammatory phase has resolved. |
- Causes of acne
- Androgenic stimulation of sebaceous gland (increased sensitivity to androgens)
- Polycystic Ovarian Syndrome (PCOS)
- Steroid Use
- Skincare products that increase oil load on the skin e.g. heavy make-up
- Full fat milk has a slight effect on the development, but there is no clear relation between acne and diet
- Areas affected by acne
- The face (universal)
- Chest, neck and back (severe cases)
- Signs and symptoms
- Non-inflammatory lesions (mild acne) – open and closed comedones
- Inflammatory lesions (moderate and severe acne) – papules, pustules, nodules, and cysts
- Differentials
- Rosacea: occurs later in life. Skin is not greasy and there are no comedones. Mainly affects the face (cheeks). If the nose is affected, it is most likely rosacea.
- Peri-orificial dermatitis
- Features of severe acne
- Large number of comedones
- Scarring
- Resistant to basic treatment
- Affects the trunk
- Has a large psychological impact
- Indications for early referral to a dermatologist (specialist) and isotretinoin treatment
- Concern for severe acne
- Strong family history
- Signs of scarring
- Rapid progression
- Complications of acne
- Post-inflammatory hyperpigmentation, scarring, and deformity
- Psychological and social effects e.g. Depression, Anxiety
Treatment of Acne
Treatment needs to be continued for at least 6 weeks to produce effects. Topical therapies are used for mild acne, oral therapies fo rmoderate-severe acne, and oral retinoids for severe acne
Principles of treating acne
| Principle | Treatment |
|---|---|
| Comedolysis (unblock pores) | Topical benzoyl peroxide, isotretinoin gel, adapalene lotion |
| Decrease bacterial load in sebum | Topical or oral antibiotics |
| Decrease sebaceous gland activity | Isotretinoin (oral), Combined Oral Contraceptives (women only), Spironolactone (women only) |
- Conservative management of acne
- Reassurance that acne is often mild and self-limiting
- Wash twice daily with soap and water
- Avoid the use of oily skin products (use cosmetics sparingly)
- Advice that sunlight can increase the risk of scarring/make the scars appear more visible
- Topical agents for treating acne
- Benzoyl peroxide (first line)
- Topical antibiotics (Clindamycin, erythromycin) given with benzoyl peroxide to reduce resistance
- Topical retinoids (adapeline), can be used in combination with benzoyl peroxide
- Systemic treatment of acne
- Oral antibiotics
- Tetracycline (Doxycycline, Minocycline) – first line
- Clindamycin, Erythromycin
- Isotretinoin – prescribed by a dermatologist, very effective and teratogenic, contraindicated wiht use of tetracycline (risk of benign intracranial hypertension), and with progesterone only pill (reduces effectiveness and increases the risk of pregnancy)
- Antiandrogens (Oral Contraceptive Pills, Spironolactone is used off-label)
- Oral antibiotics
