Acne
Pharmacological Treatments
Non-Pharmacological Treatments
Clinical Features
Common chronic disorder affecting the hair follicle and sebaceous gland, in which there is expansion and blockage of the follicle and inflammation
Prevalent in adolescents and young adults but, may sometimes occur in children and adults of all ages
Open and closed uninflamed comedones (blackheads and whiteheads)
Inflamed papules and pustules
Severe acne: nodules and pseudocysts
Post-inflammatory erythematous or pigmented macules and scars
Adverse social and psychological effects
Causes - combination of factors
Familial tendency
Endogenous and exogenous androgenic hormones (esp. during puberty)
Acne bacteria
Innate immune activation with inflammatory mediators
Distension and occlusion of the hair follicles
Severity
Mild
Moderate
Severe
Presence of non-inflammatory lesions (i.e. comedones). Some inflammatory lesions (pustules or papules) may be present, but generally <10-15, total lesions <30
Multiple comedones (10 – 40) and inflammatory lesions (10 – 40). Nodules may occasionally be present, and there may be some limited scarring. Lesions may also be present on the trunk. Total lesions 30-125
Widespread presence of nodules and cysts, and/or a large number of inflamed pustules and papules. Scarring is likely to be present. Nodulocystic acne is a particularly severe form of acne characterised by multiple inflamed nodules and scarring, usually including the trunk. Total lesions >125
Sunlight (short-term) treatment = anti-inflammatory
Lasers (and other light systems)
Cryotherapy
Intralesional steroid injections
Cautery or diathermy (electrosurgery) = removes comedones
Low glycaemic, low protein, low dairy diet with lots of fresh fruit and vegetables; stop smoking; minimising application of oils and cosmetics to the affected skin.
Mild
Benzoyl peroxide
General sale; 2.5%, 5%, 10% Gel
Antiseptic - kills skin surface bacteria (does not cause bacterial resistance) that cause acne and softens and removes outer layers of the skin; reduces redness, soreness and inflammation and it helps to unplug blocked pores (reduces no. of comedones)
Adverse effects: skin irritation; dryness; hypersensitivity reactions
Dose: initially apply once daily removing after 2h for 3 days, then apply once daily at night and leave overnight for 3 days, then apply twice daily if necessary; start treatment with lower-strength preparations
Monitoring: redness or burning sensation of skin, dry skin or peeling = use it less often and use an oil-free moisturiser (for dryness + peeling); blisters = stop using benzoyl peroxide and see your doctor or pharmacist
Education points: avoid excessive exposure to sunlight; avoid medicated, abrasive or alcohol-based soaps/cosmetics; may bleach fabrics or hair; ensure skin is clean and dry before applying; avoid contact on eyes, nose, lips, sensitive areas of neck
Adapalene
Prescription; 0.1% Cream or Gel
Retinoid analogue - regulates epithelial proliferation and differentiation, reduces follicular occlusion, has dermal anti-inflammatory properties, and may reduce sebum production and size of sebaceous glands (which also inhibits growth of bacteria)
Moderate
Severe
Dose: apply thinly once daily in the evening to clean and dry skin; review treatment after 3 months
Adverse effects: local reactions; drug-induced photosensitivity reactions; acne flare
Monitoring: contact dermatitis, acne flare, swelling of face or eyelids, conjunctivitis, hypersensitivity reactions = tell doctor or pharmacist immediately
Education points: protect your skin from sunlight - do not use sunbeds; avoid contact on eyes, nose, lips; avoid abrasive cleaners, astringent cosmetics (such as those containing alcohol), and other preparations to treat acne; allow peeling (resulting from other irritant treatments) to subside before using a topical retinoid; do not donate blood during treatment with adapalene and for at least 4 weeks after discontinuing therapy
Tretinoin
Doxycycline
COCP (cyproterone)
Isotretinoin
Salicylic acid
Keratolytic; helps slow down shedding of the cells inside the follicles, preventing clogging and also helps break down blackheads and whiteheads.
Uses visible light wavelengths; effect may be enhanced by the use of a photosensitising agent (photodynamic therapy)
May be used to control new nodules.
Used to shrink older nodules and pseudocysts.
Microdermabrasion (mild acne)
Prescription; 0.025%, 0.05% Cream
Retinoid analogue - refer to Adapalene
Dose: apply once daily at night to clean dry skin; on first night apply for 5 mins before washing off, on second night apply for 10 mins, then increase treatment time by 30 mins every night until 2h application time reached, thereafter leave on overnight
Adverse effects + Education points: same as Adapalene
Monitoring: may cause irritation or dryness, especially when used concomitantly with other topical acne medication; if excessive irritation occurs, decrease dose or discontinue use
Adverse effects: experience moderate or severe skin irritation (esp. if not present before use of this medicine), flushing, unusually warm skin and reddening of skin = tell doctor or pharmacist
Surgical procedure; skin resurfacing technique that is used to treat facial scarring
Prescription; 5mg, 10mg, 20mg, 30mg, 40mg capsules
Retinoid analogue - synthetic stereoisomer of tretinoin (vit. A derivative) - refer to Adapalene
Adverse effects: dryness of skin, lips, eyes, pharyngeal and nasal mucosa; headache; myalgia; arthralgia; raised plasma-triglyceride conc, serum-cholesterol conc, blood-glucose conc and serum-transaminase conc; haematuria; proteinuria; thrombocytopenia; thrombocytosis; neutropenia; anaemia; mood changes
Dose (severe nodulo-cystic and conglobate acne resistant to other therapy): initially 500 micrograms/kg daily (in 1–2 divided doses) for 2–4 weeks, increased if necessary to 1 mg/kg daily, for 16–24 weeks (repeat treatment course after a period of at least 8 weeks if relapse after first course); maximum cumulative dose 150 mg/kg per course
Dose (Moderate acne unresponsive to topical therapy or with scarring): 10–20 mg daily until all acne lesions have resolved (usually 3–5 months), then reduce to half the daily treatment dose for a further 4 months to avoid relapse and scarring
Monitoring: blood testing of pregnancy (effective contraception must be used - highly teratogenic), serum lipids, liver function; mood changes (esp. depression)
Education points: avoid concurrent use with tetracyclines (increased risk of intracranial hypertension), vit. A, topical keratolytic or exfoliative antiacne agents and the mini-pill; protect skin from sunlight - don't use sunbeds; take with or just after food, or a meal; avoid wax epilation (risk of epidermal stripping), dermabrasion, and laser skin treatments (risk of scarring) during treatment and for at least 6 months after stopping; may experience decreased night vision so use caution if driving or operating any vehicle at night; don't donate blood during treatment nd for at least 1 month after discontinuing therapy
Prescription; 50mg, 100mg tablets
Tetracycline antibiotic - primarily bacteriostatic, inhibits bacterial protein synthesis by binding to the 30S ribosomal subunit
Dose: 50–100 mg once daily
Adverse effects: nausea, vomiting, diarrhoea, dysphagia, oesophageal irritation
Monitoring: skin rash, fever, swelling, or other ‘allergic-type’ reaction; sharp pain while swallowing, or pain in your throat or chest; a pulsing headache, ringing in the ears, or feel dizzy = tell doctor or pharmacist immediately
Education points: take with food; swallow whole with plenty of fluid, while sitting or standing. Remain sitting upright or standing for at least 30 minutes afterwards; don't take indigestion remedies, or medicines containing iron, calcium, or zinc, 2h before or after; protect your skin from sunlight - don't use sunbeds; don't use if pregnant or under 12 yrs