Acne
Justin Walker
October 2009
Classification
Mild to moderate
Plugged pores
Sebum collection
Moderate to severe
Propionibacterium acnes
Inflammation, pustules
Cysts, nodules, scarring
Other causes
PCOS
Halogenated hydrocarbons
Differentials
Differentials
Rosacea
Older age group
Absence of
comedones, nodules
and scarring
Differentials
Differentials
Folliculitis
Infected hair follicle,
responds to abx.
NB demodex folliculitis
caused by mites,
pityrosporum folliculitis
caused by yeasts.
Differentials
Differentials
Perioral dermatitis
Distribution!
Associated with
fluorinated steroids.
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
Myths
Poor hygiene
Diet
Stress
Waterintake
Sunshine
Cannot be cured
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.
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!
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.
Topical Treatments
Azelaic acid
Unblocks pores, some reduction of inflamed acne
Less effective than topical antibiotics or benzoyl
peroxide
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.
Oral Treatments
Isotretinoin
Suppresses sebum production
Specialist initiation
Teratogenic
S/E dry skin/mucous membranes,
nosebleeds, joint pains
Minimum course 16 weeks.
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
When to Refer?
Immediate 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
Acne fulminans
Thank you!