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