Acne

Acne affects approximately 85% of teenagers but can occur in most age groups and can persist into adulthood. The extent and severity of the disease is hugely variable and extends from oily skin and a couple of spots to extensive pustular and cystic acne that can result in significant pain, discomfort and scarring

Hormonal changes around puberty increase both oil production in glands in the skin and the stickiness of skin cells within the pores of the skin. These changes result in an oily appearance to the skin and the development of blackheads and whiteheads (collections of oil trapped within the pores of the skin). These pores can in turn become inflamed and infected resulting in the appearance of pimples and papules. If the pores rupture into the skin larger inflamed and tender cysts can develop.

Acne typically involves some or all of the following sites: face, neck, chest and back

For many people acne is much more that a nuisance and a minor cosmetic blemish. The papules, pustule and cysts are sore and cause significant tissue damage often resulting in social isolation and life-long scarring. With modern treatment virtually all cases of acne can be effectively treated with early intervention

Acne treatments are determined by the type, location, severity and extent of the disease.

Gentle cleanser (use with irritating topical therapy such as benzyl peroxide preparations or topical retinoids (panoxyl 5 or 10% gel, duac gel, differin gel, epiduo gel or isotex gel)              

Salacylic acid cleanser (use alone, with less irritating topical preparations such as topical antibiotics or azelaic acid and/ or with oral medications such as oral antibiotics, the contraceptive pill or anti-androgens)

Comedonal acne retinoid gel or azelaic acid gel apply at night

Papulopustular acne benzyl peroxide gel alone or in combination with topical retinoid or topical antibiotic and retinoid preparation (topical antibiotics should not be used alone as antibiotic resistance is significant problem)

If topical therapy is causing irritation reduce frequency of application of topical gel or cream

If a moisturiser is necessary use a lotion which is not comedogenic ie. Effaclar H by La Roche Posay)

Comedonal

Topical Retinoid or Fixed combination with retinoid > BPO or Azelaic Acid Salicylic Acid

Papular/pustular

Fixed Combination or BPO or Topical Retinoid or Azelaic Acid

Papular/pustular

Fixed Combination preferred

±

Hormonal therapy and/or Oral Antibiotics

Moderately Severe – Severe

Fixed Combination + Oral Antibiotics preferred

Or + Oral Isotretinoin

Or + Oral Hormonal Therapy

If patient responds, treats until clear or almost clear

Actions if Response is Poor

Males

Oral Osotretinoin

or

Fixed Combination + Oral Antibiotics

Females

Oral Isotretinoin + anti-androgenic hormonal therapy

or

Fixed Combination + Oral Antibiotics

(consider high dose) and/or oral anti-androgenic hormonal therapy

If patient responds, treats until clear or almost clear

Actions if Response is Poor

Take with food reduces stickiness of skin, reduces oil production

Adverse effects

Dry mouth and lips, dry skin and dermatitis, nose bleeds

Potential problems with wound healing so no elective surgery, waxing or ablative laser (non-ablative laser or IPL is fine)

Flare of acne in first weeks of treatment – treat with topical steroid, steroid injections and / or Amoxil po for 2 weeks

Interaction with alcohol; don’t drink on roaccutane

May effect concentration – avoid around exams if possible

Potential liver inflammation – check liver blood tests @ 4 weeks

Depression is rare, thought to occur at an incidence of 1 in 5000, if mood changes, stop treatment

Headache (stop if headache occur, particularly early morning headaches)

Pregnancy (Roaccutane is associated with severe birth defects if taken whilst pregnant therefore all female patients require contraception and a negative pregnancy test before each prescription is issued; male is not an issue

Sexual active couples are advised to use 2 forms of contraception

Combination therapy

low dose roaccutane can be safely combined with either a 650 microsecond Nd-Yag laser or an intense pulsed light device to reduce side effects and simultaneously treat acne scarring.

Highly effective, safe and well tolerated

Represents an effective compromise solution for patients and parentsworried about the effects of acne and acne scarring by simultaneously both aspects of the disease whilst also minimizing potential side effects

Colour

Red (erythematous)

Pale

Pigmented

Amount of collagen

Excessive

hypertrophic (keloid)

Diminished

atrophic (ice pick, box car and rolling scars)

Surface Profile

Proud of skin

elevated

Indented

depressed

Current management of scars attempts to minimise appearance of scars by addressing all of the above and trying to return the scar appearance to as close as possible to normal skin

Erythematous

Intense pulsed light and / or  Nd-Yag Laser

Pale

Fraxel (Erbium glass laser)

Pigmented

Intense pulsed light and /or Fraxel