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Background and epidemiology
ACNE DR JO-ANN SEE,
dermatologist in Sydney and
Bondi Junction, NSW; chair of
the All About Acne group, and a
member of the Global Alliance to
Improve Outcomes in Acne.
ACNE is a common skin disease severe acne if there is a family his- Psychological problems can include surround the disease. As acne may fluc-
affecting up to 85% of people. tory of acne scarring. lack of self-confidence, anxiety and tuate it is important to recognise that
Although infants and the elderly can Many people consider acne to be depression. Quality of life can be modifications in therapy may be
be affected, the peak years are during trivial and short-lived. In fact acne affected and acne can have an impact needed over time and that treatment
adolescence. An increasing number can persist for years — even decades on their lives similar to that of other should be individualised for each
of mature women experience the — and some people simply do not chronic diseases such as asthma or patient. An understanding of the patho-
acne variant called hormonal acne. ‘grow out of it.’ For some patients epilepsy. genesis of acne is vital to tailoring treat-
Genetics may play a role in that lesions are painful, scarring may be Safe and effective treatment to avoid ment according to the severity of the
there is often a family history of hor- permanent and the emotional hurt later permanent scarring is essential, as disease.
monal acne and an increased risk of they experience is immense. well as dispelling the many myths that cont’d next page
HOW TO TREAT Acne
THE target organ in acne is Figure 1: Pathogenesis of acne. It is likely that lumen and then excreted. colonises the pilosebaceous
the pilosebaceous unit. Acne However in acne, the ker- duct. Skin surface counts of
occurs in areas of the body the host’s atinocytes hyperproliferate P acnes do not correlate
with the greatest concentra- Hair
response to the and become clumped with acne severity, although
tion of sebaceous glands, Skin surface together in the follicular there is a correlation
namely the face, chest and inflammation duct. This abnormal follicu- between reduced P acnes
back. caused by lar desquamation leads to a counts and clinical improve-
The four key causative fac- microcomedone. ment.
tors are (figure 1): P acnes is what The microscopic micro- Reduced counts of P acnes
1. Increased sebum produc- is important. comedone is made up of are associated with reduced
tion. densely packed skin cells, levels of pro-inflammatory
2. Abnormal follicular 3. Increased monofilaments and lipid mediators. It may be the
growth and differentiation. P acnes droplets. Gradually the fol- microenvironment of the fol-
3. Propionibacterium acnes licular duct becomes licle that is important (not
colonisation of the pilo- clogged with lipids, bacte- the skin surface per se),
sebaceous follicle. ria and skin cell fragments. which encourages increased
4. Inflammation. Follicle 4. Inflammation With an accumulation of colonisation by P acnes,
Understanding the once blockage — these elements, a visible which then leads to inflam-
causative factors in the dis- 2. Abnormal comedo forms lesion — the comedone — mation.
ease is important, as therapy keratinisation forms.
should target as many We do not know exactly Inflammation
causative factors as possible, what causes the abnormal After a microcomedone has
and combination treatment is follicular desquamation. formed, CD4 lymphocytes
often useful. 1. Increased Several mechanisms are invade and disrupt the
thought to be involved — pilosebaceous follicular
Increased sebum Sebaceous gland changes in lipid composi- wall, then neutrophils
production tion, androgens and local migrate there. Rupture of
In acne, the size of the seba- inflammatory cytokines. the follicular wall then dis-
ceous gland and the number Changes in sebum lipid gorges keratinocytes, lipids,
of lobules per gland is level being constant. For and non-hormonal therapies composition may irritate the bacteria and cellular debris
increased. This is due to example, it may explain that reduce sebum produc- follicular keratinocytes, into the dermis.
androgenic stimulus and why facial oil glands are tion may be helpful in acne which then release inflam- More inflammatory medi-
results in increased sebum affected by acne but why oil management. matory cytokines such as ators then act via the
excretion. Some sebaceous glands on the leg are not interleukin 1α (IL-1α), immune response to pro-
glands display ‘end-organ affected. Abnormal follicular which in turn leads to duce inflammation and, in
hyper-responsiveness’, as Although androgens lead growth and abnormal desquamation severe cases, lesions that
not all sebaceous glands are to increased sebum produc- differentiation and inflammation. will ultimately scar. It is
affected equally. tion, most people with acne In normal skin cell turnover, likely that the host’s
This explains why acne do not have significant the keratinocytes lining the Colonisation of the response to the inflamma-
may occur in different sites endocrine abnormalities. sebaceous duct are shed as pilosebaceous follicle tion caused by P acnes is
despite the serum androgen However, both hormonal single cells into the duct P acnes is a bacterium that what is important.
Clinical manifestations and classification
ACNE may be broadly classified The psychological Figure 2: Mild acne. Figure 3: Moderate acne. Figure 4: Severe acne.
according to disease severity, such as
mild, moderate and severe. This clas- effects of the skin (Image courtesy of Dr Kurt Gebauer.)
sification is somewhat subjective, as a lesions are important
patient with only a few spots may
feel that theirs is a severe case. to assess.
Mild acne has few lesions that
are usually superficial (figure 2).
They are open (blackheads) and
closed (whiteheads) comedones.
There may be the occasional
inflammatory papule or pustule.
Moderate acne is characterised
by more inflammatory lesions that
are pink or red (figure 3). They are
papules, pustules and the occasional ated with hirsutism, menstrual Figure 5: Hormonal acne. Figure 6: Infantile acne.
nodule or deeper lesion. irregularity and signs of polycystic (Image courtesy of Dr Maureen Rogers.)
Severe acne features many deeper ovary syndrome.
lesions that are inflammatory nod-
ules and cysts (figure 4). This form Infantile acne
has a tendency to scar. Infantile acne occurs from six
The psychological effects of the months to three years of age as
skin lesions are important to assess; comedones and inflammatory
this will be discussed later. lesions on the cheeks, forehead and
chin (figure 6). The lesions usually
Hormonal or post-adolescent settle after a few months; however,
acne in women scarring can occur with inflamma-
Hormonal acne can appear in a tory and deeper lesions.
mild, moderate or severe clinical
form (figure 5). It occurs in post- Acne scarring
adolescent women and may con- Acne scarring results from moder-
Figure 7: Acne scarring.
tinue into the 40s age group. There ate or severe inflammatory acne
(Image courtesy of Dr Greg Goodman.)
is often a history of an acne flare lesions that heal with the formation
premenstrually, typically one week of fibrous tissue (figure 7). As
before the menses; another time is inflammatory lesions heal there are
during ovulation. colour changes of purple, red and
Lesions are usually inflammatory pink which gradually fade with
and can be deep; patients describe time, as well as hypo- and hyperpig-
them as ‘blind’ pimples that can last mentation. Scars may be depressed
for weeks. They often have a char- and pit-like (termed ‘ice pick’) or
acteristic distribution on the lower flat, thin atrophic scars. Other scars
third of the face, along the jawline are thick and lumpy and are hyper-
and the neck. They may be associ- trophic or keloid in nature.
26 | Australian Doctor | 5 June 2009 www.australiandoctor.com.au
Assessment — history and examination
IT is important to realise that you an idea of which treat- moderate or severe. It is
Summary: history and
many patients have actually ments have failed and the important to assess whether
had acne for months or years patient’s perceptions of treat- the lesions are inflammatory,
before their visit to the doctor. ment. For example, they that is, pink or red, as treat- History
They have often already tried may be unwilling to use a ment with a topical or oral • How long have you had
many over-the-counter treat- topical treatment because of antibiotic is useful in these pimples for?
ments and they may feel that perceived irritation or they cases. • Are there any triggers?
there is very little you can may not want to take oral Sometimes palpation of a • Is there a family history?
offer them. There is also a medications because of con- lesion is helpful to fully appre- • What treatments have you
feeling that they may be cerns about safety.) ciate the depth of a nodule or had? How long did you
responsible for their pimples • What treatment has worked cyst; this may then alert you follow each treatment?
because of poor hygiene or best and why did you stop to consider an oral form of • What was the most
poor diet. it? (Many patients do not therapy rather than topical effective treatment? Why
Acne is not infectious, and understand that they may treatment. did you stop it?
touching the spots will not require maintenance therapy After you have determined • How do you feel about
spread them. These miscon- sity? (This question often to suppress acne rather than the acne severity, look for evi- your skin? Does it stop
ceptions need to be dispelled. uncovers what the patient just treat a flare. Others dence of scarring. Acne scars you from doing anything?
Many parents are concerned feels is the real cause of the simply ‘run out ’of their pre- take many forms and acne Examination
about the potential side effects problem and it may be one scription, so they need to scarring has been shown to be • Assess the severity and
of oral treatment, so the treat- of the acne myths such as know what is an acceptable a major concern in patients whether there is any
ing doctor needs to under- poor hygiene.) time frame for using a treat- presenting for treatment. scarring.
stand the efficacy and safety • Is there a family history of ment.) Consider the psychological • Determine any
of medications to reassure the acne in siblings or parents • How do you feel about your impact that acne has on your psychological impact.
patient and their parents. and, if so, is there any evi- skin and does it stop you patient. Do they lack self-con-
To successfully evaluate the dence of acne scarring or did from doing anything? (This fidence or seem withdrawn?
patient with acne, the follow- your relative need oral gives you an understanding Are they going to reliably
ing tips in history and exami- isotretinoin? (This will often of the impact of acne on the ‘stick’ with the treatment regi-
nation may be helpful. warn you that this patient patient’s quality of life; it men you are going to provide?
may respond poorly to treat- may give you a clue as to Will they understand the need
History ment or may be at risk of the impact if the patient is to take your proposed treat-
Ask the patient: scarring.) always wearing make-up to ment and be willing to come
• How long have you had • What treatments have you cover up or possibly avoid- back for review?
pimples for? (If patients had and for how long did ing social situations such as Acne is a clinical diagnosis;
have had acne for years they you use each treatment? going to school or social however, it is important to
may be at an increased risk (This is important, as some events.) consider the following differ-
of scarring.) patients do not give the ential diagnoses:
• If you have acne flares, does treatment a realistic time The examination • Rosacea.
anything trigger them, such frame in which to work and Look at the face and trunk • Perioral dermatitis.
as stress, for example, exam- they may not be true non- and determine the severity of • Acneiform drug eruption.
inations at school or univer- responders. Also it will give the active acne spots — mild, • Folliculitis on the trunk.
THERE are two situations in which as well as LFTs should be performed severe acne to a dermatologist for testosterone, sex-hormone-binding
ordering laboratory tests may be in all patients. If the patient is female oral isotretinoin. globulin (SHBG) and dehydro-
required: as baseline tests before of childbearing age, a serum beta- If hormonal acne is suspected epiandrosterone sulphate (DHEAS).
and during oral isotretinoin ther- human chorionic gonadotrophin and (underlying polycystic ovary syn- If a diagnosis of polycystic ovary
apy, and for assessing hormonal urinary pregnancy test should be drome is often the cause), the fol- syndrome is being considered, a
acne in post-adolescent women. done to make sure the patient is not lowing tests are done: luteinising transvaginal ultrasound may be
Before oral isotretinoin treatment, a pregnant. These tests can be helpful if hormone (LH), follicular stimulat- considered.
fasting cholesterol and triglyceride test you plan to refer the patient with ing hormone (FSH), oestradiol, free cont’d next page
HOW TO TREAT Acne
THE key to successful man- enhancing efficacy by treating
Table 1: Topical retinoids Table 2: Oral contraceptive therapy for acne
agement is to show empathy more causative factors. The
for patients’ concerns and be Topical retinoid Brand name Brand names Composition duration of treatment is a min-
able to offer patients safe and imum of 6-8 weeks and ide-
effective therapy. From the Adapalene Differin topical gel and cream Brenda-35 ED, Diane-35 ED, Ethinyloestradiol + ally for no longer than three
start they need to have realistic Estelle-35 ED, Juliet-35 ED cyproterone actetate months.
expectations of how long it Adapalene + benzoyl Epiduo gel Some patients cannot toler-
will take for the treatment to peroxide Marvelon Ethinyloestradiol + ate other therapies and when
become effective and often desogestrel effectiveness is seen with oral
Isotretinoin Isotrex gel
their treatment may need to be antibiotics, therapy can be con-
Valette Ethinyloestradiol + dienogest
modified if they are not tinued for a longer period of
Tretinoin Retin-A, ReTrieve cream, Stieva-A
responding well or if their Yasmin, Yaz Ethinyloestradiol + time with caution. If long-term
grade of acne worsens. Tazarotene Zorac cream drospirenone therapy is required, it may be
When patients understand helpful to use benzoyl peroxide
how their treatment works, for a minimum of 5-7 days
how to use it and how long it Tips for antibiotic whiteheads. As there are only Topical retinoids work by nodules. The surface area of between antibiotic courses to
takes to become effective and therapy a few inflammatory spots, normalising follicular desqua- involvement may be increased reduce the risk of resistance.
see results, their compliance antibiotic therapy is not mation and having an anti- and include the face, neck, Always ask about allergies to
improves. It is important to • Do not use topical and needed. This is usually the first inflammatory role. Benzoyl chest and back. antibiotics and warn of poten-
establish a follow-up appoint- oral antibiotics at the stage of acne and is seen in the peroxide is an antimicrobial Because of the more wide- tial side effects.
ment after the initial consulta- same time younger patient. that reduces the P acnes count spread involvement, topical Doxycycline is a first-line
tion so that both the treating • Use oral antibiotics for a As the spots are superficial and has some anti-inflamma- treatment becomes less effec- antibiotic for acne and is used
doctor and patient can assess 6-12-week course only, topical treatment is rec- tory action. The mechanism of tive and oral therapy is used at a dose of 50-100mg daily.
the efficacy of treatment, • If a longer course of oral ommended. Many patients azelaic acid is unclear. often in conjunction with top- Some prescribers use 200mg
establish a management plan antibiotics is required, use may have already tried over- When more inflammatory ical treatments. Oral antibio- daily for the first two weeks
for maintenance therapy or benzoyl peroxide for a the-counter products by the papular and pustular lesions tics and oral anti-androgenic and then 100mg daily there-
change treatments if the week between courses time they present. These prod- occur but in total there are few medications such as the oral after.
patient is a poor or non- • Warn of side effects of ucts often contain benzoyl per- lesions, a topical antimicrobial contraceptive, spironolactone There is controversy as to
responder. antibiotic therapy, oxide or salicylic acid. is usually added. Combination or cyproterone acetate may be whether minocycline should
Treatment should be contin- particularly Use of a topical retinoid products may enhance compli- considered in women. be used first line, due to
ued for at least six weeks, so photosensitivity with (table 1) is recommended, ance, as they reduce the Oral antibiotics have been reports of liver abnormalities.
assessment can be made and doxycycline applied nightly to all areas of number of products used and the mainstay of acne therapy There have also been cases of
therapy altered. In every con- the affected face, not just the applications required. for decades but there are increased skin and nail pig-
sultation, the issues of skin spots. As irritation can occur, As the lesions are still super- growing concerns about side mentation with long-term use.
care and diet need to be patients should be advised to ficial, oral antibiotics are not effects with long-term treat- Oral erythromycin tends
addressed and the acne myths apply a thin layer to a cool dry needed but should be consid- ment courses and antibiotic not to be used because of gas-
and concerns addressed (see face. If they have sensitive skin, ered if topical therapy fails or resistance in the community. trointestinal side effects and
box, page 30). The treatment they can start using it every if the inflammatory lesions For optimal treatment oral the increasing antibiotic resist-
algorithm below has been pro- second night then, as tolerance become greater in number or antibiotics should not be used ance in the community.
posed as a simple guideline increases, apply it nightly. deeper. as monotherapy or combined Bactrim is a second-line anti-
(figure 8). Results should be seen by with a topical antibiotic. It is biotic that may be used in
6-8 weeks and the patient may Treating moderate acne best to use them in combina- chronic acne.
Treating mild acne be able to use topical retinoid Moderate acne is characterised tion with a topical retinoid or The oral contraceptive is an
In mild acne, lesions are few therapy for months, even as by increasing numbers of benzoyl peroxide. Using com- excellent choice for women
or they tend to be largely maintenance therapy after inflammatory lesions — bination therapy minimises with hormonal acne who also
superficial blackheads and their active lesions disappear. papules, pustules and deeper antibiotic resistance as well as cont’d page 30
Figure 8: Acne treatment algorithm.
MILD MODERATE SEVERE
Comedonal Papular/pustular Papular/pustular Nodular2 Nodular/conglobate
Topical retinoid Oral antibiotic Oral antibiotic Oral isotretinoin3
1st choice1 Topical retinoid + topical antimicrobial + topical retinoid + topical retinoid
+/- benzoyl peroxide + benzoyl peroxide
Alt. topical retinoid Alt. topical antimicrobial Alt. oral antibiotic High-dose oral antibiotic
or agent + alt. topical retinoid + topical retinoid
Alternatives1 azelaic acid* + alt. topical retinoid +/- benzoyl peroxide
alt. oral antibiotic
+ alt. topical retinoid
+ benzoyl peroxide
+/- benzoyl peroxide/azelaic
salicylic acid azelaic acid*
Oral antiandrogen5 Oral antiandrogen5
Alternatives See 1st choice See 1st choice + topical retinoid/azelaic + topical retinoid High-dose oral antiandrogen5
for females1,4 acid* +/- oral antibiotic + topical retinoid
+/- topical antimicrobial +/- alt. antimicrobial +/- alt. topical antimicrobial
Maintenance Topical retinoid Topical retinoid +/- benzoyl peroxide
therapy 1. Consider physical removal of comedones. 2. With small nodules (>0.5-1cm). 3. Second course in case of relapse. 4. For pregnancy, see text. 5. See text. *There was not consensus on this alternative
recommendation, however, in some countries azelaic acid prescribing is appropriate practice.
This algorithm was published in Gollnick H, et al; Global Alliance to Improve Outcomes in Acne. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. Journal of the
American Academy of Dermatology 2003; 49(1 Suppl): S1-S37. Copyright Elsevier 2003. Reproduced with permission.
28 | Australian Doctor | 5 June 2009 www.australiandoctor.com.au
HOW TO TREAT Acne
from page 28 Isotretinoin is an oral Features of oral isotretinoin treatment fractionated laser systems. Myths and controversy
require contraception. Con- retinoid that targets all patho- Individual pitted scars can be
traindications may include a physiological factors in acne • For patients with severe acne treated with punch grafting, • Acne is not infectious —
history of blood clots, cigarette and therefore makes it an • For patients unresponsive to conventional therapy subcision or even excision for P acnes colonises the
smoking and breast cancer. extremely effective agent. It • For acne patients experiencing psychological distress larger scars. Atrophic scars pilosebaceous follicle.
The combined oral contra- works by decreasing the size • Extremely effective, as it targets all causes of acne can be ‘filled’ with injectable Antibiotic treatment is
ceptive has many modes of and secretion of the oil gland, • Duration of treatment and daily dose are individualised fillers, while thickened scars largely used as an anti-
action for improving acne, and normalising follicular keratin- • Low starting dose is used that may be gradually increased, as can be treated with topical or inflammatory agent.
many oral contraceptives on isation and inhibiting P acnes tolerated intralesional steroids or sili- • Acne is not due to poor
the market have well-demon- growth, and it has an anti- • Side effects are usually manageable cone dressings. hygiene. There is no
strated benefits in acne treat- inflammatory effect. It is • Warn of mood changes and the potential risk of depression evidence to show that
ment (see table 2, page 28). unique in that it targets all the • Warn about contraception and teratogenicity Treating the acne psyche frequent washing
Patients should be advised factors causing acne. Being positive about the improves acne, and
of the possible side effects of Patients need counselling effectiveness of medical acne certainly overly vigorous
the oral contraceptive, such as when considering isotretinoin are usually discontinued can relapse after oral treatments is important for washing and scrubbing
nausea, headache, weight gain treatment. They need to because of a risk of raised isotretinoin treatment, and the patient’s adherence, as many aggravate
and breast tenderness and understand that, while it is a intracranial pressure with con- patients need to be advised of many patients have tried inflammatory lesions.
enlargement. Other concerns highly effective medication, comitant use of oral tetracy- this. treatments that have not Gentle washing twice
that patients have are melasma there are side effects that are clines. Vitamin supplements Many patients are denied worked. They often present daily is recommended. An
and effects on mood and usually manageable. that contain vitamin A should oral isotretinoin because of to you after years of having acne wash containing
libido. Patients require education be stopped, as this may fear and ignorance. Doctors pimples and having ‘tried salicylic acid or benzoyl
It is important that they about the possible side effects, increase side effects. need to understand that with everything’. What may not peroxide may be useful.
have realistic expectations of which are often dose related, Common side effects of oral good counselling, effective be immediately apparent to • The role of diet is
how quickly the treatment will the need for contraception in isotretinoin include: contraception and vigilance you are their inner feelings. currently the most
show a positive effect, and this women of childbearing age, • Dry, chapped lips. regarding mood changes, Patients with acne have been controversial issue, as
is usually after three cycles of and the risk of depression. • Dry skin. they can provide effective known to experience depres- most people believe that
treatment. They should also be The patient needs to under- • Dry, gritty eyes. treatment. Patients need to sion, anxiety and dysmor- it has a major role;
warned that their hormonal stand that the therapy is a • Secondary bacterial infec- be reassured that they may phophobia. however, there has been
acne may recur when they stop course of treatment and that tion. not experience any negative very little scientific
the oral contraceptive. laboratory investigations are • Muscle aches. mood changes. In fact, many Physical therapy evidence to support this
If the oral contraceptive is needed before and during • Headaches. studies show that the qual- Some practitioners use come- widespread belief. Recent
partially effective or ineffective, therapy. These can be usually treated ity-of-life index is improved done extractors, which are studies show that dairy
an androgen blocker such as The duration of treatment symptomatically or resolve with effective treatment. available from the chemist, products may contribute
spironolactone or cyproterone may be four to six months or during the course of treatment. There are also concerns as a means of removing the via hormones contained
acetate can be added. Daily even longer. The length of However, any patient with about long-term teratogenic- blackheads. If whiteheads are within milk products.
doses of spironolactone of 50- treatment and daily dosages severe headache, decreased ity, and male patients need present, they may need to be Other recent studies cite
100mg (and, rarely, up to are individualised by the der- night vision or mood change reassurance that it does not treated with light hyfreca- the benefit of a low-
200mg) have been used. matologist according to the should stop taking the medica- affect spermatogenesis. There tion, incision with a large- glycaemic-index diet and
Cyproterone acetate can be patient’s weight, tolerance of tion immediately. is no increased risk of fetal gauge needle or tip of a weight reduction as
added at a dose of 50mg for treatment and response to As oral isotretinoin is a deformity for women who scalpel blade or treated with helpful adjunctive
days 5-15 of the menstrual treatment. There is no ‘stan- potent teratogen, therapy have taken oral isotretinoin a topical retinoid for a few treatment. More research
cycle. For patients who have dard’ dosage. must not start until a negative previously and have not weeks before comedone is required to substantiate
polycystic ovary syndrome, The starting dosage may be pregnancy test is obtained, become pregnant until at least extraction. diet as a true causative
metformin has also been used. 0.5mg/kg/day or less. A low and contraception is essential one month after stopping the Light chemical peel with factor.
. starting dosage minimises before, during and for one medication. glycolic, salicylic and lactic
Treating severe acne potential side effects and the month after therapy. Ideally acids can also be useful, espe- the minority of patients who
Severe acne is treated with risk of a flare. It can then be treatment should start on the Treating acne scarring cially in the presence of post- are unwilling or unable to
oral antibiotics or oral increased at the follow-up second or third day of the Acne scars should be treated inflammatory hyperpigmen- undertake other forms of
isotretinoin. If patients have visit, depending on the menstrual cycle. when there are no or few tation. medical treatment.
not improved significantly patient’s tolerance. The course Oral isotretinoin can pro- active lesions. There is no one The role of light, photo-
with a 12-week course of oral ends when an acceptable duce changes in mood and it ‘best’ treatment, as the scars dynamic and laser therapy is When to refer
antibiotics or relapse quickly cumulative dose is achieved is possible for significant may vary in morphology and controversial. They are not • Moderate to severe acne
after effective treatment with and the patient has been rela- mood changes such as depres- thus require different tech- indicated as first-line treat- unresponsive to therapy.
oral antibiotics, referral to a tively acne free for 2-3 sion to occur. This should be niques. Make-up and camou- ments because of cost, uncer- • Severe acne that has a ten-
dermatologist for isotretinoin months. discussed with patients before flage are simple methods. tainty of remission length dency to scar.
should be considered. Patients Topical treatments that can they start the medication and Dermabrasion is gradually and protocols regarding best • Psychological distress,
who are experiencing signifi- cause dryness are often discon- should be asked about during becoming less popular, as wavelength and treatment including dysmorphophobia.
cant emotional distress may tinued, as isotretinoin has each subsequent visit. laser resurfacing increases in duration and intervals. They • Suspected underlying
also benefit from isotretinoin. drying effects. Oral antibiotics As with all treatments, acne popularity with the newer may provide an option for endocrinological problem.
Author’s case study Evidence-based practice
Recommendation Strength of Level of evidence
JANE, a 28-year-old accountant, presents recommendation
with a 12-month history of inflammatory
Topical antibiotics A I
papules and the occasional pustule on her
lower cheeks. She is “sick and tired” of Topical benzoyl
having pimples for years, has “tried every- A I
thing” and spent a “small fortune”. She
started her new job a year ago, which has Topical retinoids A I
been stressful, and she is otherwise well. Oral antibiotics A I Online resources
Jane first developed mild acne in her teens • All about acne:
but this settled with a benzoyl peroxide wash Oral contraceptive A I www.acne.org.au
and a topical retinoid. During her final year • The Australasian College
of school, she had a flare of her pimples, Oral isotretinoin A I of Dermatology:
with many inflammatory lesions on her face Herbal treatments B II www.dermcoll.asn.au/
and trunk, but this settled initially with a public/a-z_of_skin-
three-month course of oral antibiotics. Effect of diet B II acne.asp
While at university she suffered deeper option. She is also not keen on the oral con- • DermNet NZ:
*This information is based on the American Academy of Dermatology
nodules on her face and chin and was pre- traceptive, as she has heard that she may put Guidelines of Care for Acne Vulgaris Management (see Online www.dermnet.org.nz/acne/
scribed a six-month course of oral retinoids. on weight. You counsel her about this and, resources). index.html
Her acne cleared but recurred within a year when you place her on the oral contracep- A = consistent and good-quality patient-oriented evidence • American Academy of
and she underwent a second course of oral tive, her acne clears in four months. B = inconsistent or limited-quality patient-oriented evidence Dermatology. Guidelines
I = good-quality patient-oriented evidence
retinoids two years later. Since then topical Jane’s case shows how the severity of acne II = limited-quality patient-oriented evidence
of Care for Acne Vulgaris
treatments and further courses of oral anti- can change over time and that at different Management:
biotics have been ineffective. stages there may be different treatment www.aad.org/research/_
options. Hormonal acne should be consid- doc/ClinicalResearch_
Management ered in a woman who has had several Acne%20Vulgaris.pdf
Jane is now non-responsive to many treat- courses of oral retinoids, is unresponsive to
ments. She is considering yet another course conventional therapy and has inflammatory
of oral retinoids but is not keen on this lesions on the lower third of her face. cont’d page 32
30 | Australian Doctor | 5 June 2009 www.australiandoctor.com.au
HOW TO TREAT Acne
and in particular to Andrew’s skin is clear. He is When the dose is increased, or Have there been trials of the
isotretinoin, which could have still taking antidepressants but a change in mood detected, the use of isotretinoin for acne
“grave side effects”. I delivered it is likely that he will be stop- patient will require more regu- rosacea? Is the dose required
a short ‘lecture’ on the risks of ping that soon as well. He is lar surveillance. for rosacea different from
scarring, infections and social mixing with some new friends that for cystic acne?
problems with untreated acne and enjoying the challenges of Myalgias have been reported The trials for oral
and suggested another consul- his HSC year. in a significant number of isotretinoin use in rosacea
tation with Andrew alone. patients as a side effect of oral were small and done many
DR RENATA CHAPMAN I saw Andrew on his own Questions for the author isotretinoin. There have been years ago. The medication is
Chatswood, NSW the following week. He admit- After five weeks of therapy What is the postulated mecha- concerns about cartilage used off-label for resistant
ted to feeling lonely, depressed Andrew experienced an nism of depression with degeneration and bone rosacea, particularly in
Case study and lacking confidence. He did acneiform eruption on the face isotretinoin therapy? In damage with their use. Could antibiotic-resistant cases or
ANDREW was 17 when he not like his school, had no and a flare of his eczema. He Andrew’s case was there a you comment on this issue? patients who cannot stop
saw me for the first time. close friends and hated his was very ashamed of his looks place for preventive therapy Cases of myalgia have been taking oral antibiotics to
Accompanied by his mother appearance. On the K-10 scale and admitted to increased anx- with SSRIs when starting reported and patients should control papulopustular dis-
and very quiet during the con- he scored 45 out of 50. He iety, with panic attacks and isotretinoin? be warned about strenuous ease.
sultation, he hardly looked at wanted to be treated. worsening mood. He was dis- The mechanism of depres- exercise. Non-steroidals such
me and let his mother answer I spoke to his mother again. playing suicidal ideation and, sion with oral isotretinoin is as paracetamol often help and There is a significant inflam-
all my questions. I clearly explained the possi- although these ideas were pres- unknown. It is thought to be very often the myalgias are matory component in the
He had very severe papulo- ble side effects of isotretinoin ent even before starting uncommon and idiosyncratic. short term. aetiology of acne lesions.
pustular and comedonal acne, therapy and wrote two refer- isotretinoin, he was now pre- There was a case for early The cases of cartilage Why do steroids, with their
as well as cystic acne in a few rals — one to a dermatolo- pared to carry them out. SSRI treatment and, in an ideal degeneration and bone anti-inflammatory abilities,
patches. There was evidence gist and another to a good After a multidisciplinary world, Andrew’s mood should damage were reported in actually tend to worsen
of early scarring on his face. psychologist. conference, Andrew was have been stabilised or patients not using oral acne?
Surprisingly, his mother was Andrew’s baseline investi- admitted to a psychiatric assessed before treatment with isotretinoin for acne but for Anabolic steroids and cor-
only seeking treatment for his gations were all normal. He ward. He was started on flu- isotretinoin. disorders of keratinisation, ticosteroids used at high dose
dyshidrotic foot eczema. was started on a small dose oxetine but, rather than stop- When there is concern the dosages were higher than or long term boost androgen
I asked about the acne, and of 20mg daily for two weeks ping isotretinoin, its dose was about a patient’s psychologi- those used for acne and were production, stimulating seba-
Andrew’s mother told me that and then the dose was halved. He was discharged cal state, low-dose therapy is also used for extended peri- ceous glands. However, at
they were trying different increased to 20mg twice home after four weeks. His often used, such as 20mg daily ods of time. Doctors need to small doses and used short
herbal and over-the-counter daily. He was given support- skin and his mood had in this case for many weeks, be aware of these facts when term, corticosteroids can be
preparations, and they were ive treatment for his skin improved significantly. even for 6-8 weeks before a reading the patient informa- anti-inflammatory and sup-
opposed to any “chemicals” and mucous membranes. Eight months later, gradual increase in dosage. tion for this product. press acne flares.
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Acne — 5 June 2009 ONLINE ONLY
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1. Which TWO statements about acne are are superficial and few in number, first-line spots only, being careful to avoid the with hormonal acne who require
correct? treatment is a topical retinoid plus an oral surrounding skin contraception
a) Acne affects up to 30% of people antibiotic c) If a patient has sensitive skin, they can start
b) Infantile acne may occur between six c) In moderate papular/pustular acne, by using a topical retinoid every second 9. Which TWO statements about side effects
months and three years of age monotherapy with oral antibiotics is the night with oral isotretinoin are correct?
c) Hormonal acne is a variant of acne only optimal treatment d) Patients may use topical retinoid therapy for a) Supplements containing vitamin A can be
occurring in adolescent girls d) Referral to a dermatologist for oral months safely continued during oral isotretinoin
d) Acne may persist for decades in some cases isotretinoin should be considered for therapy
patients with severe acne who are 7. Which TWO statements about oral b) Concomitant use of oral tetracyclines with
2. Which THREE of the following are key unresponsive to conventional therapy antibiotics for the treatment of acne are oral isotretinoin carries no increased risk of
causative factors in acne? correct? adverse effects
a) Increased sebum production 5. Which TWO statements about physical a) Oral antibiotics are best used in combination c) Oral isotretinoin can produce significant mood
b) Abnormal follicular growth and differentiation therapies in the management of acne are with a topical antibiotic changes such as depression
c) Poor personal hygiene correct? b) Using oral antibiotics in combination with a d) Any patient with severe headache, decreased
d) Propionibacterium acnes colonisation of the a) Comedone extractors may be used as a topical retinoid or benzoyl peroxide night vision or mood change should stop
pilosebaceous follicle means of removing the blackheads enhances efficacy taking oral isotretinoin immediately
b) Before comedone extraction, whiteheads c) The minimum duration of treatment is six
3. Which TWO statements about the may need to be treated with light months 10. Which TWO statements about treatment
management of acne are correct? hyfrecation, incision with a large-gauge d) Doxycycline is a first-line antibiotic for acne, with oral isotretinoin are correct?
a) Vigorous cleaning of the skin is needle or a topical retinoid for a few weeks but patients need to be warned of side a) Contraception is essential before, during and
recommended for inflammatory lesions c) Chemical peels with glycolic, salicylic and effects, particularly photosensitivity for one month after therapy with oral
b) Acne washes containing salicylic acid or lactic acids should be avoided, particularly in isotretinoin
benzoyl peroxide may be useful the presence of post-inflammatory 8. Which TWO statements about hormonal b) A pregnancy test is not essential before
c) Patients should be advised to follow a low- hyperpigmentation acne are correct? starting oral isotretinoin therapy, provided the
fat high-carbohydrate diet d) Light, photodynamic and laser therapy are a) In hormonal acne, flares may occur around patient has been using contraception
d) Treatments should be continued for at least first-line treatments for acne the time of ovulation beforehand
six weeks b) In hormonal acne, lesions are c) Male patients should be warned that oral
6. Which THREE statements about topical characteristically distributed on the forehead, isotretinoin affects spermatogenesis
4. Which TWO statements about the retinoids for acne are correct? around the nose, and on the upper back d) There is no increased risk of fetal deformity
hierarchy of acne treatment are correct? a) Topical retinoids normalise follicular c) Women with hormonal acne do not require for women who have taken oral isotretinoin
a) For mild comedonal acne use of a topical desquamation and have an anti- any investigations previously and have not become pregnant
retinoid is recommended inflammatory effect d) In the absence of contraindications, the oral until at least one month after stopping the
b) In mild papular/pustular acne where lesions b) Topical retinoids should be applied to the contraceptive pill is a good option for women medication
CPD QUIZ UPDATE
The RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. You
can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post HOW TO TREAT Editor: Dr Wendy Morgan
or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online. Co-ordinator: Julian McAllan
Quiz: Dr Wendy Morgan
NEXT WEEK Pain occurs in most patients with advanced cancer, but this can be controlled. The next How to Treat reviews management of cancer pain in palliative care. The authors are Dr Amy Waters,
clinical research fellow in palliative medicine, Royal North Shore Hospital, St Leonards, and locum staff specialist in palliative medicine, St George Hospital, Kogarah; Dr Charles Brooker, director of chronic
and cancer pain, Pain Management and Research Centre, Royal North Shore Hospital, St Leonards; and Dr Josephine M Clayton, staff specialist and head of department, palliative care, Royal North Shore
Hospital, St Leonards; Cancer Institute NSW clinical research fellow, Centre for Medical Psychology & Evidence-based Decision-making; and senior lecturer, faculty of medicine, University of Sydney, NSW.
32 | Australian Doctor | 5 June 2009 www.australiandoctor.com.au