Acne Vulgaris

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Acne vulgaris (pimples or spots) is a common chronic inflammatory skin disorder involving the hair follicle and sebaceous gland which presents mainly in adolescence. A variety of spots appear mostly on the face and other parts of the body. Severe acne may require evaluation to exclude an underlying hormonal disorder. This condition may induce some psychological  disturbances. The choice of treatment depends on age, severity, and whether the acne is predominantly inflammatory or comedonal.

Cause

  • Increased sebum secretion
  • Abnormal keratinisation of the hair follicles (hereditary)
  • Increased sensitivity of the sebaceous glands to male hormones 
  • Propionibacterium acnes
  • Prolonged use of systemic and topical steroids e.g. Anabolic steroids such as danazol, stanozolol and nandrolone 
  • Use of pomades, especially products that contain lanolin, petrolatum, vegetable oils, butyl stearate, lauryl alcohol and oleic acid
  • Contraceptive agents: medroxyprogesterone injection, implanted or intrauterine progesterone, and oral contraceptives
  • Pregnancy 
  • Polycystic ovarian syndrome
  • Adrenal disorders

Symptoms

  • Pimples (on the face and occasionally on the trunk, chest and shoulders)
  • Greasy skin
  • Facial disfigurement

Signs

  • Comedones (blackheads and whiteheads)
  • Papules 
  • Cysts
  • Scars
  • Nodules
  • Pustules
  • Hirsutism (suggest excess androgens) 

Investigations

  • Usually none 
  • Serum testosterone (in females with accompanying hirsutism and virilising features)
  • Pelvic ultrasound (in females to exclude polycystic ovaries if hirsutism present)

TreatmentTreatment Objectives

  • To improve cosmetic appearance
  • To prevent complications particularly scarring
  • To reassure patient
  • To identify and avoid any causative or contributing factors

Non-pharmacological treatment

  • Counselling of patients

Pharmacological treatment 

See sections below

Referral CriteriaRefer patients not responding to treatment to a dermatologist. Suspected underlying endocrine conditions should be referred to an endocrinologist.

For mild to moderate acne

Evidence Rating: [A]

  • Benzoyl peroxide 5% lotion, topical, apply daily (avoiding mouth, eyes and the mucous membranes) 

And

  • Clindamycin, 1% lotion or gel, topical, apply daily

Or

  • Tretinoin 0.01% gel, topical, apply nocte (avoiding the sun, eyes, nostrils, mouth, mucous membrane and broken skin)

Caution: Retinoids (Tretinoin) are contraindicated in pregnancy

Or

  • Adapalene 0.1% cream or gel, topical, apply thinly once daily (at night before sleep) 

For moderate to severe acne (or where topical therapy is ineffective or not tolerated)

Evidence Rating: [B]

Topical treatment as for mild to moderate acne above

And

  • Doxycycline, oral,

Adults

100 mg daily for 6 weeks-6 months (depending on response to treatment)

Children

Not recommended

Or

  • Tetracycline, oral, 

Adults

250-500 mg 12 hourly for 6 weeks-6 months (depending on response to treatment)

Change medication to erythromycin after 4 months if response is  poor  

Children

> 12 years; same dose as for adults above

< 12 years; not recommended

Or

  • Erythromycin, oral,

Adult

500 mg 12 hourly for 6 weeks-6 months

Children

>12 years; 500 mg 12 hourly for 6 weeks - 6 months 

1-12 years; 125 mg 12 hourly Or 250 mg once daily for 6 weeks-6 months