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Acne Vulgaris - Coggle Diagram
Acne Vulgaris
Management: Primary Care
Avoid oil-based comedogenic skin care products, make up and sunscreens, and remove make up at the end of the day
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Mild - Moderate 12 week course of the following first line: A fixed combination of topical adapalene with topical benzoyl peroxide (0.1% or 0.3% adapalene with 2.5% benzoyl peroxide), A fixed combination of topical tretinoin with topical clindamycin (0.025% tretinoin with 1% clindamycin) or A fixed combination of topical benzoyl peroxide with topical clindamycin (3% or 5% benzoyl peroxide with 1% clindamycin).
Give advise and information tailored to their needs including: possible reasons for acne, treatment options, including unsuitability of some treatment options in pregnancy and need for contraceptive use, benefits/drawbacks of treatment, impact of acne, adherence to treatment and relapses.
Moderate - Severe : 12 week course of one of the following first line; A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening, A fixed combination of topical tretinoin with topical clindamycin to be applied once daily in the evening, A fixed combination of topical adapalene with topical benzoyl peroxide to be applied once daily in the evening, together with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily or Topical azelaic acid (15% or 20%) applied twice daily, with either oral lymecycline 408 mg or oral doxycycline 100 mg once daily.
Consider topical benzoyl peroxide as monotherapy as an alternative if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic.
Creams or lotions may be preferable for people with dry or sensitive skin and less greasy gels may be preferable for people with oily skin.
Concentration or application frequency of topical treatments may need to be reduced or lowered if skin irritation occurs.
Do not use: monotherapy with topical antibiotic, monotherapy with an oral antibiotic or a combination of a topical and oral antibiotic for treatment of acne.
Consider topical benzoyl peroxide as monotherapy as an alternative if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic (oral or topical).
Combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women.
Acne-related scarring: discuss concerns and provide information of reason for scarring, ongoing treatment, possible treatment options for scarring and psychological distress.
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Diagnosis: History
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Exacerbating factors such as flares with menstruation, contraceptives, cosmetics, face creams or hair products
Duration, type and distribution of lesions
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Family history including endocrine disorders, polycystic ovarian syndrome, acne and other skin conditions.
Drug history - androgens, corticosteroids, isoniazid, ciclosporin and lithium can cause or exacerbate.
Hyperandrogenism — may present with irregular periods, androgenic alopecia or hirsutism in women.
Look for clinical features of acne such as non-inflammatory comedones and inflammatory papules, pustules, nodules and scarring. Comedones must be present for a diagnosis of acne to be made. If not present, consider alternative diagnoses.
Look for signs of other disorders that can present with acne such as hyperandrogenism or Polycystic ovarian syndrome.
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Management: Referral
Consider referral to mental health services if a person with acne experiences significant psychological distress or a mental health disorder, including those with a current or past history of suicidal ideation or self-harm, a severe depressive or anxiety disorder or body dysmorphic disorder.
Consider referral for - mild-moderate that has not responded to two courses of treatment, moderate-severe which has not responded to treatment that includes an oral antibiotic, acne scarring, acne with persistent pigmentary changes or acne of any severity/scarring contributing to persistent psychological distress or a mental health disorder.
Consider condition-specific management of referral to an appropriate specialist if a medical disorder or medication (including self-administered anabolic steroids) is likely to be contributing to a person's acne.
Refer to consultant dermatologist-led team - if diagnostic uncertainty, acne conglobata or nodulo-cystic acne.
Urgently refer those with acne fulminans on the same day to on-call dermatology team for assessment within 24 hours
Management: Follow up
Oral antibiotic - Completely cleared — consider stopping the antibiotic but continuing the topical treatment or Improved but not completely cleared — consider continuing the oral antibiotic, alongside the topical treatment, for up to 12 more weeks.
If acne fails to respond adequately - review severity and offer further treatment option appropriate to severity. Moderate to severe - If oral antibiotic therapy not included offer treatment that includes this.
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If acne has cleared advise maintenance therapy is not always necessary, consider maintenance in those who have frequent relapse (fixed combination of topical adapalene and topical benzoyl peroxide), review maintenance after 12 weeks to decide if it should be continued.
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Management: Relapse
If acne relapses after an adequate response to oral isotretinoin (prescribed under specialist care) and is currently: Mild to moderate — offer an appropriate treatment option, Moderate to severe — offer either: 12 week course of appropriate treatment or re-referral
If acne relapses after a second course of oral isotretinoin (prescribed under specialist care) and is currently moderate to severe, further care should be decided by the consultant dermatologist-led team. Re-referral if required.
If acne responds adequately to a course of an appropriate first-line treatment but then relapses, consider either: further 12 week course of the same treatment or an alternative 12 week treatment
Investigations
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Consider appropriate investigations/referral to endocrinology for people presenting with clinical features of polycystic ovary syndrome (such as menstrual irregularity and hirsutism), or other endocrinopathy.
Acne vulgaris is a chronic inflammatory skin condition which mainly affects the face, back and chest. It is characterised by blockage and inflammation of the pilosebaceous unit (hair follicle, hair shaft and sebaceous gland). It presents with inflammatory or non-inflammatory lesions, or a mixture of both. Non-inflamed lesions are known as comedones which may be open (blackheads), closed (whiteheads) or microcomedones (clinically invisible).Inflammatory acne lesions include papules and pustules (5 mm or less in diameter) — in more severe disease these can develop into larger deeper pustules and nodules. Acne can be mild, moderate or severe.