AcneAcneDr Stephen ChadwickDr Stephen Chadwick

GPsWIGPsWI

AcneAcne

Very commonVery common Most teenagers will have some acneMost teenagers will have some acne Tends to resolve by late teens or early Tends to resolve by late teens or early

twenties, but can persisttwenties, but can persist Late onsetLate onset 10% will have acne in thirties10% will have acne in thirties 6% in forties6% in forties

FeaturesFeatures

Comedones (open and closed)Comedones (open and closed) GreaseGrease Red papules and pustulesRed papules and pustules Nodules and cystsNodules and cysts ScarringScarring Pain and tendernessPain and tenderness Low self esteem and confidenceLow self esteem and confidence

CauseCause

Disorder of pilosebaceous follicleDisorder of pilosebaceous follicle Excess of oilExcess of oil Dead skin not shed properly and blocks Dead skin not shed properly and blocks

the pores with blackheadsthe pores with blackheads Microcomedones and comedonesMicrocomedones and comedones Pockets of oil form ideal breeding ground Pockets of oil form ideal breeding ground

for Propionibacterium acnesfor Propionibacterium acnes Inflammation leads to red papules and Inflammation leads to red papules and

pustules.pustules.

AssessmentAssessment

Previous treatmentsPrevious treatments Compliance and side effectsCompliance and side effects How bad does the patient feel it is ?/10How bad does the patient feel it is ?/10 Objective assessment of severityObjective assessment of severity Mild/moderate/severe and face/chest/backMild/moderate/severe and face/chest/back Comedones, papules and pustulesComedones, papules and pustules Nodules and cystsNodules and cysts ScarringScarring

TreatmentTreatment

Do not pick or squeezeDo not pick or squeeze Ask about inappropriate emollient useAsk about inappropriate emollient use Oil-free make-up, non-comedogenicOil-free make-up, non-comedogenic Use mild soap or gentle cleanserUse mild soap or gentle cleanser Expect topical treatments to dry or irritate, Expect topical treatments to dry or irritate,

and manage thisand manage this At least 2 months to assess any treatmentAt least 2 months to assess any treatment

ComedonalComedonal

ComedonalComedonal

Topical retinoidTopical retinoid E.g. Tretinoin 0.025% gel applied nocte, or E.g. Tretinoin 0.025% gel applied nocte, or

Adapalene 0.1% gel/creamAdapalene 0.1% gel/cream

Or Or Azelaic AcidAzelaic Acid E.g. Skinoren 20% creamE.g. Skinoren 20% cream

Mild papulo-pustularMild papulo-pustular

Topical Retinoid and Topical AntimicrobialTopical Retinoid and Topical Antimicrobial E.g.tretinoin gel nocte and antimicrobial marne E.g.tretinoin gel nocte and antimicrobial marne

(?BPO, or Duac), or possibly Epiduo gel (?BPO, or Duac), or possibly Epiduo gel (adapalene + BPO)(adapalene + BPO)

Or Or Azelaic Acid + Topical AntimicrobialAzelaic Acid + Topical Antimicrobial E.g. Zineryt lotionE.g. Zineryt lotion

Moderate Papulo-pustularModerate Papulo-pustular

Oral antibiotic + Topical Retinoid +/- BPOOral antibiotic + Topical Retinoid +/- BPO E.g. Lymecycline od, or Erythromycin 500mg bd, E.g. Lymecycline od, or Erythromycin 500mg bd,

+ Tretinoin gel nocte +/- BPO marne+ Tretinoin gel nocte +/- BPO marne

OrOr Alt. oral antibiotic + alt. retinoid/azelaic Alt. oral antibiotic + alt. retinoid/azelaic acid +/- BPOacid +/- BPO

E.g. Trimethoprim 300mg bd + adapalene +/- E.g. Trimethoprim 300mg bd + adapalene +/- BPOBPO

Or Or Females, ? Add DianetteFemales, ? Add Dianette

Nodulo-cysticNodulo-cystic

Oral antibiotic + topical retinoid +/- BPOOral antibiotic + topical retinoid +/- BPO ? High Dose, eg Lymecycline bd or ? High Dose, eg Lymecycline bd or

Trimethoprim 300mg bd Trimethoprim 300mg bd

Or Or Oral Isotretinoin Oral Isotretinoin

Or Females, Or Females, Dianette + topical retinoid +/- oral Dianette + topical retinoid +/- oral antibioticantibiotic

Severe, includes any scarringSevere, includes any scarring

Severe, includes any scarring Severe, includes any scarring

Oral IsotretinoinOral Isotretinoin

Or Or High Dose Oral Antibiotic + Topical High Dose Oral Antibiotic + Topical Retinoid + BPORetinoid + BPO

Or Females, Or Females, Dianette + topical retinoid Dianette + topical retinoid +/- oral antibiotic+/- oral antibiotic

Maintenance TreatmentMaintenance Treatment

Use Oral Antibiotics for 6-12 months Use Oral Antibiotics for 6-12 months minimum, minimum, continue topical retinoid continue topical retinoid (azelaic acid) long term(azelaic acid) long term

For moderate-severe cases, ?topical For moderate-severe cases, ?topical retinoid +/- BPO long termretinoid +/- BPO long term

How to reduce referrals?How to reduce referrals?

Manage expectations, compliance and Manage expectations, compliance and side effectsside effects

Use PILs e.g. Use PILs e.g. www.bad.org.ukwww.bad.org.uk

Use more Use more Topical RetinoidsTopical Retinoids and combine and combine them with Topical or Oral Antibiotics +/- them with Topical or Oral Antibiotics +/- BPOBPO

When to referWhen to refer

Refer early if scarring, or severe casesRefer early if scarring, or severe cases

Mild-moderate cases not responding to Mild-moderate cases not responding to standard treatments regimesstandard treatments regimes

Females for ?Ro-accutane, discuss Females for ?Ro-accutane, discuss contraception prior to referralcontraception prior to referral

Questions?Questions?