Acne

Another useful website is https://www.acne.org.au

Clinical Features:

Chronic inflammatory disease of pilosebaceous units
Characterised by formation of comedomes, papules, pustules, nodules and cysts.
- comedomal
- papules
- pustular
Face 99%, back 60-%, chest 15%
Most adolescents develop mild comedomal acne

Factors Involved in developing acne

Aetiology

Increased sebum production (active sebaceous glands, stimulation by androgens at puberty, PCOS in females)
Ductal hypercornification ( the ductal keratinocytes at the opening of the sebaceous glands proliferating, blocking the gland – resulting in blackheads)
Ductal colonisation with propionibacterium acnes ( is not infectious, cause inflammation, there number relates to severity of acne, produces inflammatory mediators which diffuse into the dermis
Inflammation (can cause scarring- the deeper the process the higher the risk of scarring).

Classification;

Comedomal and microcomedomal
Mild inflammatory
Moderate Inflammatory ( can feel it getting deeper- deep seated papules and pustules)
Nodulocystic acne ( deep, painful, takes 4 – 6/52 to settle, scarring if not treated)

Assessment

History ( how long has it been active, any triggers identified, is there a family history of acne and acne scarring, treatment given to family members, how do you feel about it)
Examination: assess face, chest, back- grade the predominant acne at each site, palpate skin to assess induration, assess signs of hyperandrogenisation, signs of scarring or potential for scarring

Investigations:

Differential Diagnosis:

Rosacea
Perioral dermatitis- trigerred often by a steroid or other creams
Acneiform drug eruption
Folliculitis on the trunk
- Bacterial or pityrosporum- bx and ask them to look for putyrosporum if pityrosporum- a yeast very itchy- clothing that doesn’t breathe, application of greasy sunscreens, an oily skin tendency, stress or fatigue, diabetes, OCP: topical therapy is not always effective- but worth a try- pts may also have tinea versicolor or seborrheic dermatitis- nizoral shampoo or Selsun Shampoo or oral nizoral or sporonox.

Treatment:

Comedomal
- Usually treated with topical therapies
- Keratolytic (thin the thickened skin on top of the acne e.g salicylic acid- good in seborrheic dermatitis cradle cap, acne)and comedolytic agents ( benzoyl peroxide, tretinion, adapalene
- Retinoids the topical treatment of choice in both comedomal and mild inflammatory, avoid in pregnancy ADEC D –Adapalene: ( differin) combo product with benzoyl peroxide is (epiduo), isotetinoin (isotrex)
- Benzoyl Peroxide (use 2.5% or 5% no benefit in using 10% just dries skin out more Brevoxyl, Benzac, Clearasil) continue for six weeks before assessing efficacy
- Azaleic Acid ( inhibits growth of propionibacterium acnes and reduces follicular keratinisation)acne, rosacea, melasma
Mild Inflammatory Acne
- Use a combo needs an exfoliating ( comedolytic agent), and an antibiotic.
- g clindamycin with benzoyl peroxide ( Duac once daily)
- Adapalene and benzoyl peroxide ( Epiduo Gel – now PBS listed)

Moderate Inflammatory acne
- Clindamycin, benzoyl peroxide plus a topical retinoid
- Anti androgen in a female, topical BP, retinoid antimicrobial

Severe Cystic Acne
- Needs oral isotetinoin to achieve remission
- Maintenance with a topical retinoid.
- Minor flares after isotretinoin use combo antimicrobial, retinoid, BP