Acne Vulgaris

Clinical

·         Open [blackheads],  closed [whiteheads], papules [inflamed], pustules, nodules or cysts [deeper]

·         Scars from deep nodules [keloid, ice pick scars…]

·         If before puberty, need to exlude adrenal pathology.

Treatment  [review all in 6 weeks]

·         Blackhead or whitehead with few papules or papulopustular

·         Topical retinoid with benzoyl peroxide – Epiduo – apply thinly once daily in the evening.  DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY.  Can cause skin irritation, use thinly.

·         Azelaic acid 15% [alternative to above, less irritating] – apply twice daily, stop after 1 month if not better.

·         Papules and some pustules

·         Benzoyl peroxide & clindamycin 1% – Duac – apply once daily in the evening.  CAN STAIN CLOTHING. Can cause initial skin irritation – this will likely improve within 1-2 weeks.

·         Zinc acetate & erythromycin [if above fails] – Zineryt – apply twice daily.

·         Marked pustular [combination therapy]

·         Topical retinoid ON – Isotrex – apply thinly once daily in the evening.  DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY.  Can cause skin irritation, use thinly.

·         Benzoyl peroxide OM – benzoyl peroxide 4% – apply once daily in the morning.  CAN STAIN CLOTHING. Can cause initial skin irritation – this will likely improve within 1-2 weeks.

·         Oral antibiotics

·         Marked pustular @ risk of scarring or widespread – Oral antibiotic

·         1st – tetracycline 500mg BDfor 3m, then reduced to 250mg twice daily for 3m.  DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY.   [alternative Oxytetracyline 500mg BD, Lymecycline 408mg OD]

·         2nd – Doxycycline 100mg OD – DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY.

Erythromycin 500mg BD for 3 months then 250 mg bd for 3 months – Only one licensed for use in pregnancy. Less effective as high degree of resistance against P. acnes.

·         Continue for at least 4-6m [maintain on topical] – should reduce by 30-50% @ 3m.

Dianette

·         Not indicated for use solely as an oral contraceptive – higher risk of VTE

·         Indication – Severe acne that has not responded to oral antibiotic or moderately severe hirsutism

·         Withdraw 3-4 cycles after condition treated

Referral criteria – for trimethoprim, dapsone, oral isotretinoin [LFT, fasting Lipid, FBC]

·          Moderate acne or nodular lesions fails responding with >=2 3m courses antibiotic

·         Psychological distress

·         Severe or severe nodulocystic acne

·         Are at risk of, or are developing, scarring despite primary care therapies

Information sheet: http://www.patient.co.uk/health/acne