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Acne vulgaris
COMMON DERMATOSES
Acne vulgaris
Key points
Anjali Mahto
C
Acne is a disorder of the pilosebaceous unit and typically affects areas with a high density of sebaceous follicles
Abstract
C
Acne presents as comedones, papules, pustules, nodules and cysts
C
Severe acne can lead to permanent scarring of the skin
C
Diagnostic investigations may be required in an adult woman with signs of hyperandrogenism
C
There are multiple methods of treatment to achieve acne control, including topical and oral agents in addition to light and laser therapies
Acne vulgaris is a chronic skin condition caused by blockage or inflammation of the hair follicles and their associated sebaceous glands e together known as the pilosebaceous units. It typically affects areas with the highest density of sebaceous follicles; this includes the face, upper chest and back. Although all age groups can be affected, it is primarily a disorder of adolescence. It can present as non-inflammatory comedones (blackheads, whiteheads), inflammatory papules, pustules, nodules and cysts, or a mixture of lesions. This can result in symptoms of local tenderness and erythema. Acne is extremely common and thought to affect most people at some point in their lives. Twenty per cent progress to severe acne, which can lead to permanent scarring. The condition can be associated with significant psychosocial complications including low self-esteem, altered body image, social isolation and depression. The aims of treatment are to prevent long-term complications.1
stimulates inflammation via a number of proinflammatory mediators, including interleukins-12 and -8 and tumour necrosis factor.3
Keywords Acne; antibiotics; contraceptive pill; diet; isotretinoin; light and laser therapies; spironolactone
Other causes A small number of other causes that have been implicated in the pathogenesis of acne. These include cosmetic agents and hair pomades, medications (corticosteroids, lithium, iodides), hyperandrogenism and mechanical occlusion with headbands, shoulder pads and backpacks.
Epidemiology Acne accounts for more than 3.5 million general practitioner appointments per year.2 It affects 80% of people at some point between 11 and 30 years of age. During adolescence, acne is more common in male than female patients. Acne can also occur in adults and is more prevalent in women. It can develop for the first time over the age of 25 years and is thought to affect up to 20% of women and 8% of men. Of those suffering with the disease, 20% have severe disease that is likely to lead to scarring.
Diagnosis
Acne develops from a complex interplay between multiple factors. Genetics are thought to play an important role, as the number and size of sebaceous glands and their activity is inherited. Twin studies show that the concordance rate for the prevalence and severity of acne is extremely high. The heritability of acne is almost 80% in first-degree relatives. Sebaceous gland activity is under the influence of hormones, in particular the androgen dihydrotestosterone. During adolescence, the body produces androgen hormones from the gonads and adrenal glands. These hormones act directly on the sebaceous gland to increase sebum production and excretion. Increased sebum combined with abnormal follicular hyperkeratinization results in ‘sticky’ keratinocytes blocking the pilosebaceous duct, and comedo formation. Bacterial colonization with the anaerobic Propionibacterium acnes can follow. P. acnes
History A patient with acne usually presents with a history of ‘spots,’ most commonly affecting the face, back, chest and shoulders. Systemic symptoms are often absent, but the patient may describe local symptoms of pain, erythema or tenderness. Additionally, acne can have a psychological impact, regardless of the severity of disease. When taking a history, it is important to enquire about the duration of symptoms, aggravating factors, any over-the-counter preparations that have been tried, and the psychosocial impact of the disease, particularly at work or school. In female patients, consider whether acne could be secondary to hyperandrogenism, and enquire about irregular menstrual cycles, hirsutism, androgenic alopecia, premenstrual flaring of acne lesions or suddenonset severe acne. Psychosocial factors are often overlooked but must not be taken lightly. Acne can have a severe negative impact on a person’s life and is often underestimated by healthcare professionals. Validated quality-of-life scoring systems such as the Cardiff Acne Disability Index can be used to monitor psychological state. Individuals in whom acne is having a marked psychosocial impact may need more aggressive treatment or early referral to a specialist.
Anjali Mahto MBBCh BSc MRCP is a Consultant Dermatologist at the Cadogan Clinic, London, UK. Competing interests: none declared.
Examination Acne is characterized by comedones, papules, pustules, nodules and cysts, as follows.
Pathogenesis
MEDICINE --:-
1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003
COMMON DERMATOSES
Comedones are the most basic acne lesion and can be open or closed. Closed comedones (whiteheads) are small plugged follicles whose contents are not exposed to the skin surface. Open comedones (blackheads) are small follicles with dilated openings onto the skin. The black colour results from oxidation of the debris within the follicle. Papules are small, usually red, raised elevations of the skin. Pustules resemble papules but have a central pocket of pus. Nodules and cysts are larger painful swellings usually more than 5 mm in size. Examination can reveal other skin lesions that have developed as a consequence of the acne. These include atrophic or pitted scars, post-inflammatory erythema or hyperpigmentation, and keloids. The latter two are more common with darker skin. When making a clinical assessment, an attempt should be made to categorize disease severity. There are multiple acne severity grading systems, largely developed for use in clinical trials, that may not be entirely suitable for daily clinical practice. However, expert opinion is that separating disease status into mild, moderate and severe categories can help guide management (Table 1).
Differential diagnosis C C C C C C
Rosacea Folliculitis Perioral dermatitis Pityrosporum folliculitis Demodex folliculitis Milia
Table 2
that many adult women with an androgen drive to their acne do not have elevated circulating hormone concentrations.
Management Topical treatments4 Retinoids: these agents are derived from vitamin A. They correct abnormal follicular hyperkeratinization and inhibit new comedone formation. The most commonly used topical retinoids include tretinoin, adapalene and isotretinoin. Skin irritation and redness can occur in the early phase of treatment. These agents thin the stratum corneum and can increase photosensitivity; patients should therefore be given advice regarding sun protection.
Differential diagnoses The diagnosis of acne is usually straightforward. Table 2 offers a list of conditions that can mimic it.
Benzoyl peroxide: benzoyl peroxide is a bactericidal agent with the ability to reduce P. acnes populations in the sebaceous follicles. It is useful for both inflammatory and non-inflammatory acne lesions, and is not associated with bacterial resistance. Products containing benzoyl peroxide are available over the counter or by prescription, and are used once or twice daily.
Investigations Diagnostic investigations are not typically required in acne as the diagnosis is clinical. However, in female patients with signs of hyperandrogenism, hormonal investigations can be required to exclude conditions such as polycystic ovarian syndrome (PCOS) and congenital adrenal hyperplasia.1 Usual screening blood tests include total and free testosterone luteinizing hormone, follicle-stimulating hormone, dehydroepiandrosterone, 17-hydroxyprogesterone, prolactin, 21b-hydroxylase. These should be checked in the luteal phase of the menstrual cycle, that is, just before the onset of menses. To improve accuracy, patients should be asked to stop oral contraceptives 1 month before testing. It is also worth bearing in mind
Antibiotics: topical antibiotics, commonly clindamycin, are often used for their activity against P. acnes. There is a risk of bacterial resistance with these agents so they are not used as monotherapy. Topical antibiotics are usually combined with either retinoids or benzoyl peroxide. Topical antibiotic usage should if possible be limited to no more than 12 weeks. Azelaic acid: this can be used as a second-line option for acne if other treatments are unsuitable or not tolerated. There are fewer scientific data on this agent, and results are mixed.
Assessing acne severity Severity
Description
Mild
Open and closed comedones and few inflammatory lesions Comedones with occasional inflammatory papules and pustules that are confined to the face Many comedones with small and large inflammatory papules and pustules; more extensive Many comedones and inflammatory lesions with nodules and cysts tending to coalesce; face and truncal involvement, evidence of scarring
Mild/moderate
Moderate
Severe
Oral treatments Antibiotics: these have anti-inflammatory properties and activity against P. acnes. Oral antibiotics can be successfully combined with topical retinoids or benzoyl peroxide in moderate acne. First-line agents include tetracycline, oxytetracycline, doxycycline and lymecycline. There is good evidence that these agents can reduce inflammatory lesion counts and severity. Other antibiotics used include erythromycin, azithromycin and trimethoprim. Tetracycline antibiotics should not be used during pregnancy, but erythromycin is a safe alternative in this situation. Average treatment time is about 12 weeks. Hormonal therapies: the combined oral contraceptive pill can be used to control acne in women requiring contraception. Oestrogen in the contraceptive pill reduces sebum production. It also reduces ovarian production of androgens by suppressing
Table 1
MEDICINE --:-
2
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003
COMMON DERMATOSES
Diet: the relationship between diet and acne has been controversial. Given current data, no specific dietary changes are recommended in isolation to treat acne. There is, however, emerging evidence that high glycaemic index diets can be associated with the condition. There is also limited evidence that some dairy products (particularly skimmed milk) can also have a role.
gonadotropin release. Finally, oral contraceptives increase hepatic synthesis of sex hormone-binding globulin (SHBG), resulting in an overall decrease in free testosterone. Spironolactone can be used off-label in the UK by specialists in the treatment of acne. It has a number of antiandrogenic properties. The drug binds to the androgen receptor and reduces androgen production. It also increases SHBG concentrations, resulting in less free circulating testosterone. Pregnancy must be avoided as there is a risk of feminization of the male fetus. Spironolactone has a useful role against acne in adult women, especially in the context of PCOS.
Intralesional corticosteroid injections: intralesional injections of corticosteroids, usually triamcinolone acetamide diluted to 5 mg/ml or less, can be used to flatten nodules or cysts within 48 e72 hours. Injections can be useful for isolated cysts where a quick response is required and should only be performed by a specialist as there are a number of potential adverse effects, including atrophy and infection. In addition to recognized medical treatments, patients should be given basic skincare advice to manage their acne. The skin should be gently cleansed twice daily, and comedogenic creams and cosmetics should be avoided. A
Isotretinoin: isotretinoin is a systemic retinoid that is highly effective in severe, recalcitrant acne vulgaris. It also has a role in acne that is resistant to treatment with other agents, relapses quickly after completion of antibiotic therapy, or is having a profound psychological impact. In the UK, it can only be prescribed under the supervision of a dermatologist. Isotretinoin acts as an anti-inflammatory agent, reduces sebum production and corrects abnormal epidermal differentiation. Treatment is usually deemed complete when a cumulative dose of 120e150 mg/kg has been reached. The drug is teratogenic so female patients of childbearing age are required to take oral contraception in conjunction with it. Common adverse events include dry mucous membranes, myalgia, photosensitivity and headaches. There have also been reported and well-publicized cases of mood disorders in association with isotretinoin. Although no clear cause-and-effect relationship has been definitively established, patients should be warned of this potential link.5
KEY REFERENCES 1 Zaenglein A, Pathy A, Schlosser B, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016; 74(5): 945e73. 2 National Institute for Health and Care Excellence. Acne vulgaris. London: NICE, 2014. 3 Rao J. Acne vulgaris. Emedicine 2016, http://emedicine.medscape. com/article/1069804-overview (accessed 22 October 2016). 4 Nast A, Dreno B, Bettoli V, et al. European evidence based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol 2012; 26(suppl 1): 1e29. 5 Goodfield M, Cox N, Bowser A, et al. Advice on the safe introduction and continued use of isotretinoin in acne in the UK. Br J Dermatol 2010; 162: 1172e9.
Light and laser treatments: there is growing interest in new non-invasive therapies for acne. Light and laser therapies (photodynamic therapy, blue light, intense pulsed light) are commercially available, particularly in the private sector. A recent Cochrane review of these treatments concluded that highquality evidence for these treatments is lacking. However, some of these treatments appear promising, and additional studies are required to fully assess their true clinical effect.
TEST YOURSELF To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the end of the issue or online here.
Question 1
Question 2
A 15-year-old boy presented with ‘spots’ on his face.
An 18-year-old woman presented with severe acne. She had had acne for 5 years, but topical treatment had had only had a modest effect. She was becoming increasingly distressed by her appearance and was considering not taking up her university place, where she felt her appearance would be commented on by many people. Her drug treatment had included topical retinoids, benzoyl peroxide and oral antibiotics.
On examination, what are the earliest characteristic changes in acne? A Comedones B Pustules C Erythema D Pigmentation E Papules
MEDICINE --:-
What is the most appropriate treatment for her now? A Oral isotretinoin
3
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003
COMMON DERMATOSES
B C D E
Oral contraceptive pill Photodynamic therapy Oral spironolactone Oral antibiotics
What is the most important advice to give when commencing this treatment? A Consider an oral contraceptive to avoid pregnancy B Use factor 8 sunblock when exposed to the sun C Be aware that psychosis is a possible unwanted effect D Avoid vigorous exercise E Apply an emollient skin cream
Question 3 A 21-year-old woman had severe acne unresponsive to topical treatments. She was advised to take oral isotretinoin.
MEDICINE --:-
4
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003
Acne vulgaris
Key points
Anjali Mahto
C
Acne is a disorder of the pilosebaceous unit and typically affects areas with a high density of sebaceous follicles
Abstract
C
Acne presents as comedones, papules, pustules, nodules and cysts
C
Severe acne can lead to permanent scarring of the skin
C
Diagnostic investigations may be required in an adult woman with signs of hyperandrogenism
C
There are multiple methods of treatment to achieve acne control, including topical and oral agents in addition to light and laser therapies
Acne vulgaris is a chronic skin condition caused by blockage or inflammation of the hair follicles and their associated sebaceous glands e together known as the pilosebaceous units. It typically affects areas with the highest density of sebaceous follicles; this includes the face, upper chest and back. Although all age groups can be affected, it is primarily a disorder of adolescence. It can present as non-inflammatory comedones (blackheads, whiteheads), inflammatory papules, pustules, nodules and cysts, or a mixture of lesions. This can result in symptoms of local tenderness and erythema. Acne is extremely common and thought to affect most people at some point in their lives. Twenty per cent progress to severe acne, which can lead to permanent scarring. The condition can be associated with significant psychosocial complications including low self-esteem, altered body image, social isolation and depression. The aims of treatment are to prevent long-term complications.1
stimulates inflammation via a number of proinflammatory mediators, including interleukins-12 and -8 and tumour necrosis factor.3
Keywords Acne; antibiotics; contraceptive pill; diet; isotretinoin; light and laser therapies; spironolactone
Other causes A small number of other causes that have been implicated in the pathogenesis of acne. These include cosmetic agents and hair pomades, medications (corticosteroids, lithium, iodides), hyperandrogenism and mechanical occlusion with headbands, shoulder pads and backpacks.
Epidemiology Acne accounts for more than 3.5 million general practitioner appointments per year.2 It affects 80% of people at some point between 11 and 30 years of age. During adolescence, acne is more common in male than female patients. Acne can also occur in adults and is more prevalent in women. It can develop for the first time over the age of 25 years and is thought to affect up to 20% of women and 8% of men. Of those suffering with the disease, 20% have severe disease that is likely to lead to scarring.
Diagnosis
Acne develops from a complex interplay between multiple factors. Genetics are thought to play an important role, as the number and size of sebaceous glands and their activity is inherited. Twin studies show that the concordance rate for the prevalence and severity of acne is extremely high. The heritability of acne is almost 80% in first-degree relatives. Sebaceous gland activity is under the influence of hormones, in particular the androgen dihydrotestosterone. During adolescence, the body produces androgen hormones from the gonads and adrenal glands. These hormones act directly on the sebaceous gland to increase sebum production and excretion. Increased sebum combined with abnormal follicular hyperkeratinization results in ‘sticky’ keratinocytes blocking the pilosebaceous duct, and comedo formation. Bacterial colonization with the anaerobic Propionibacterium acnes can follow. P. acnes
History A patient with acne usually presents with a history of ‘spots,’ most commonly affecting the face, back, chest and shoulders. Systemic symptoms are often absent, but the patient may describe local symptoms of pain, erythema or tenderness. Additionally, acne can have a psychological impact, regardless of the severity of disease. When taking a history, it is important to enquire about the duration of symptoms, aggravating factors, any over-the-counter preparations that have been tried, and the psychosocial impact of the disease, particularly at work or school. In female patients, consider whether acne could be secondary to hyperandrogenism, and enquire about irregular menstrual cycles, hirsutism, androgenic alopecia, premenstrual flaring of acne lesions or suddenonset severe acne. Psychosocial factors are often overlooked but must not be taken lightly. Acne can have a severe negative impact on a person’s life and is often underestimated by healthcare professionals. Validated quality-of-life scoring systems such as the Cardiff Acne Disability Index can be used to monitor psychological state. Individuals in whom acne is having a marked psychosocial impact may need more aggressive treatment or early referral to a specialist.
Anjali Mahto MBBCh BSc MRCP is a Consultant Dermatologist at the Cadogan Clinic, London, UK. Competing interests: none declared.
Examination Acne is characterized by comedones, papules, pustules, nodules and cysts, as follows.
Pathogenesis
MEDICINE --:-
1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003
COMMON DERMATOSES
Comedones are the most basic acne lesion and can be open or closed. Closed comedones (whiteheads) are small plugged follicles whose contents are not exposed to the skin surface. Open comedones (blackheads) are small follicles with dilated openings onto the skin. The black colour results from oxidation of the debris within the follicle. Papules are small, usually red, raised elevations of the skin. Pustules resemble papules but have a central pocket of pus. Nodules and cysts are larger painful swellings usually more than 5 mm in size. Examination can reveal other skin lesions that have developed as a consequence of the acne. These include atrophic or pitted scars, post-inflammatory erythema or hyperpigmentation, and keloids. The latter two are more common with darker skin. When making a clinical assessment, an attempt should be made to categorize disease severity. There are multiple acne severity grading systems, largely developed for use in clinical trials, that may not be entirely suitable for daily clinical practice. However, expert opinion is that separating disease status into mild, moderate and severe categories can help guide management (Table 1).
Differential diagnosis C C C C C C
Rosacea Folliculitis Perioral dermatitis Pityrosporum folliculitis Demodex folliculitis Milia
Table 2
that many adult women with an androgen drive to their acne do not have elevated circulating hormone concentrations.
Management Topical treatments4 Retinoids: these agents are derived from vitamin A. They correct abnormal follicular hyperkeratinization and inhibit new comedone formation. The most commonly used topical retinoids include tretinoin, adapalene and isotretinoin. Skin irritation and redness can occur in the early phase of treatment. These agents thin the stratum corneum and can increase photosensitivity; patients should therefore be given advice regarding sun protection.
Differential diagnoses The diagnosis of acne is usually straightforward. Table 2 offers a list of conditions that can mimic it.
Benzoyl peroxide: benzoyl peroxide is a bactericidal agent with the ability to reduce P. acnes populations in the sebaceous follicles. It is useful for both inflammatory and non-inflammatory acne lesions, and is not associated with bacterial resistance. Products containing benzoyl peroxide are available over the counter or by prescription, and are used once or twice daily.
Investigations Diagnostic investigations are not typically required in acne as the diagnosis is clinical. However, in female patients with signs of hyperandrogenism, hormonal investigations can be required to exclude conditions such as polycystic ovarian syndrome (PCOS) and congenital adrenal hyperplasia.1 Usual screening blood tests include total and free testosterone luteinizing hormone, follicle-stimulating hormone, dehydroepiandrosterone, 17-hydroxyprogesterone, prolactin, 21b-hydroxylase. These should be checked in the luteal phase of the menstrual cycle, that is, just before the onset of menses. To improve accuracy, patients should be asked to stop oral contraceptives 1 month before testing. It is also worth bearing in mind
Antibiotics: topical antibiotics, commonly clindamycin, are often used for their activity against P. acnes. There is a risk of bacterial resistance with these agents so they are not used as monotherapy. Topical antibiotics are usually combined with either retinoids or benzoyl peroxide. Topical antibiotic usage should if possible be limited to no more than 12 weeks. Azelaic acid: this can be used as a second-line option for acne if other treatments are unsuitable or not tolerated. There are fewer scientific data on this agent, and results are mixed.
Assessing acne severity Severity
Description
Mild
Open and closed comedones and few inflammatory lesions Comedones with occasional inflammatory papules and pustules that are confined to the face Many comedones with small and large inflammatory papules and pustules; more extensive Many comedones and inflammatory lesions with nodules and cysts tending to coalesce; face and truncal involvement, evidence of scarring
Mild/moderate
Moderate
Severe
Oral treatments Antibiotics: these have anti-inflammatory properties and activity against P. acnes. Oral antibiotics can be successfully combined with topical retinoids or benzoyl peroxide in moderate acne. First-line agents include tetracycline, oxytetracycline, doxycycline and lymecycline. There is good evidence that these agents can reduce inflammatory lesion counts and severity. Other antibiotics used include erythromycin, azithromycin and trimethoprim. Tetracycline antibiotics should not be used during pregnancy, but erythromycin is a safe alternative in this situation. Average treatment time is about 12 weeks. Hormonal therapies: the combined oral contraceptive pill can be used to control acne in women requiring contraception. Oestrogen in the contraceptive pill reduces sebum production. It also reduces ovarian production of androgens by suppressing
Table 1
MEDICINE --:-
2
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003
COMMON DERMATOSES
Diet: the relationship between diet and acne has been controversial. Given current data, no specific dietary changes are recommended in isolation to treat acne. There is, however, emerging evidence that high glycaemic index diets can be associated with the condition. There is also limited evidence that some dairy products (particularly skimmed milk) can also have a role.
gonadotropin release. Finally, oral contraceptives increase hepatic synthesis of sex hormone-binding globulin (SHBG), resulting in an overall decrease in free testosterone. Spironolactone can be used off-label in the UK by specialists in the treatment of acne. It has a number of antiandrogenic properties. The drug binds to the androgen receptor and reduces androgen production. It also increases SHBG concentrations, resulting in less free circulating testosterone. Pregnancy must be avoided as there is a risk of feminization of the male fetus. Spironolactone has a useful role against acne in adult women, especially in the context of PCOS.
Intralesional corticosteroid injections: intralesional injections of corticosteroids, usually triamcinolone acetamide diluted to 5 mg/ml or less, can be used to flatten nodules or cysts within 48 e72 hours. Injections can be useful for isolated cysts where a quick response is required and should only be performed by a specialist as there are a number of potential adverse effects, including atrophy and infection. In addition to recognized medical treatments, patients should be given basic skincare advice to manage their acne. The skin should be gently cleansed twice daily, and comedogenic creams and cosmetics should be avoided. A
Isotretinoin: isotretinoin is a systemic retinoid that is highly effective in severe, recalcitrant acne vulgaris. It also has a role in acne that is resistant to treatment with other agents, relapses quickly after completion of antibiotic therapy, or is having a profound psychological impact. In the UK, it can only be prescribed under the supervision of a dermatologist. Isotretinoin acts as an anti-inflammatory agent, reduces sebum production and corrects abnormal epidermal differentiation. Treatment is usually deemed complete when a cumulative dose of 120e150 mg/kg has been reached. The drug is teratogenic so female patients of childbearing age are required to take oral contraception in conjunction with it. Common adverse events include dry mucous membranes, myalgia, photosensitivity and headaches. There have also been reported and well-publicized cases of mood disorders in association with isotretinoin. Although no clear cause-and-effect relationship has been definitively established, patients should be warned of this potential link.5
KEY REFERENCES 1 Zaenglein A, Pathy A, Schlosser B, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016; 74(5): 945e73. 2 National Institute for Health and Care Excellence. Acne vulgaris. London: NICE, 2014. 3 Rao J. Acne vulgaris. Emedicine 2016, http://emedicine.medscape. com/article/1069804-overview (accessed 22 October 2016). 4 Nast A, Dreno B, Bettoli V, et al. European evidence based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol 2012; 26(suppl 1): 1e29. 5 Goodfield M, Cox N, Bowser A, et al. Advice on the safe introduction and continued use of isotretinoin in acne in the UK. Br J Dermatol 2010; 162: 1172e9.
Light and laser treatments: there is growing interest in new non-invasive therapies for acne. Light and laser therapies (photodynamic therapy, blue light, intense pulsed light) are commercially available, particularly in the private sector. A recent Cochrane review of these treatments concluded that highquality evidence for these treatments is lacking. However, some of these treatments appear promising, and additional studies are required to fully assess their true clinical effect.
TEST YOURSELF To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the end of the issue or online here.
Question 1
Question 2
A 15-year-old boy presented with ‘spots’ on his face.
An 18-year-old woman presented with severe acne. She had had acne for 5 years, but topical treatment had had only had a modest effect. She was becoming increasingly distressed by her appearance and was considering not taking up her university place, where she felt her appearance would be commented on by many people. Her drug treatment had included topical retinoids, benzoyl peroxide and oral antibiotics.
On examination, what are the earliest characteristic changes in acne? A Comedones B Pustules C Erythema D Pigmentation E Papules
MEDICINE --:-
What is the most appropriate treatment for her now? A Oral isotretinoin
3
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003
COMMON DERMATOSES
B C D E
Oral contraceptive pill Photodynamic therapy Oral spironolactone Oral antibiotics
What is the most important advice to give when commencing this treatment? A Consider an oral contraceptive to avoid pregnancy B Use factor 8 sunblock when exposed to the sun C Be aware that psychosis is a possible unwanted effect D Avoid vigorous exercise E Apply an emollient skin cream
Question 3 A 21-year-old woman had severe acne unresponsive to topical treatments. She was advised to take oral isotretinoin.
MEDICINE --:-
4
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mahto A, Acne vulgaris, Medicine (2017), http://dx.doi.org/10.1016/j.mpmed.2017.03.003