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                                                                                                                                                                             and classification

                                                                                                                                                                             Assessment —
                                                                                                                                                                             history and



                                                                                                                                                                             The author

 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

 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                                                 
 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

 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

                                                                                                                                                                   Oral isotretinoin
                                         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
                                         or                                      or
                                                                                                                                                                   +/- 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                                                           

 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              
 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             
 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   
 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                                                                              
                                                           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                                                 

     GP’s contribution
                                           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.

                                  How to Treat Quiz                                                                Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
                                                                                                                   by post or fax.
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                                  Acne — 5 June 2009                                                                ONLINE ONLY
                                                                                                           for immediate feedback

 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

 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 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                                                  

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