Key learning points:
- Acne is a vey common skin condition, virtually universal in young people, with 50% who have moderate to severe disease
- Assessment should include physical examination (face, back and chest), psycho-social assessment and review of past and current treatment and skin care
- Treatment should be matched to acne severity: mild, moderate or severe, following evidence-based clinical guidelines. All treatment should be applied or taken for two months, to fully assess therapeutic effect
Primary care nurses will meet patients with acne on a daily basis. However, do primary care nurses see acne care as part of their professional role? Do primary care nurses think acne care is for dermatology specialists only? Hopefully, primary care nurses do not dismiss acne as simply ‘teenage spots’ that the young person will outgrow?
This article seeks to outline best practice in acne care and promote that acne care should be embraced by all primary care nurses.
How common is acne?
Acne is virtually universal in young people; many will experience mild physiological acne. The trigger for the emergence of acne is often hormonal with the surge of androgens at puberty important in males, and pre-menstrual flares and anti-androgen-responsive acne in females explained by hormonal factors. A study of UK teenagers, aged between 14-16 years found and examined prevalence of examined acne in 50%; and moderate to severe acne in 11% (1).
Acne is not exclusively a teenage disease, acne, in females aged 20-30 is not uncommon and affects approximately 5% of females in this age group, and acne can also be seen in infants (transient infantile acne) and occasionally older people (comedonal acne) (2).
What is the pathophysiology of acne?
Acne is a skin condition of the sebaceous glands, occurs at sites with the greatest density of sebaceous glands: face, chest and back. At puberty the androgen glands increases and stimulate the sebaceous glands to produce sebum. Hypercornifaction of the cells lining the pilosebaceous ducts of the sebaceous glands is also under the control of androgens; this causes partial or total obstruction of the ducts (3).
The obstructed pilosebaceous ducts are colonised by bacteria including propionibacterium acnes, staphylococcus epidermidis and pityrosporum ovale. Propionibacterium acnes have the ability to break down triglycerides in sebum to free fatty acids producing lipase (3). Cytokines as inflammatory mediators are also released.
The release of inflammatory mediators causes inflammation and polymorph and lymphocyte infiltration results in pus formation. Rupture of the ducts contributes to large inflammatory pustules, nodules and cysts (3).
How to assess and classify acne?
Acne assessment should be considered within a holistic skin assessment. Acne may be considered mild, moderate or severe. Comedones and inflammatory lesions are usually considered separately (see Table 2 for description of acne lesions).
It is very important to examine the face, chest and back, as a patient may present with mild facial acne but have severe nodular-cystic acne under their clothes. The key principles to consider when conducting assessing a patient with acne are:
- View the acne lesions with a good light and grade severity.
- Always examine the face, back and chest.
- Look for the classical acne lesions, open and closed comedones, papules, pustules and nodules; and record distribution.
- Ask about experience and success with past and current treatments, including over the counter (OTC) preparations.
- Assess and record psychological concerns and social effects for the patient (The Cardiff Acne Disability Index (CADI) and Assessment of psychological and Social Effects (APSEA) are useful tools) (5).
Acne often has an enormous psycho-social burden for the sufferer. A study comparing psychiatric co-morbidly in atopic dermatitis, alopecia areata, acne and psoriasis highlight the importance of recognising depression, among dermatology patients (6). The study also indicates that in some instances even clinically mild to moderate disease such as non-cystic facial acne can be associated with significant depression and suicidal ideation (6).
How is acne treated?
Acne is treatable; early recognition of mild acne progressing to moderate acne forms is essential, as adequate progression of treatment, can prevent severe acne and acne scarring. Acne scarring will occur in 30% of those with moderate to severe acne and early treatment at every stage is the key to prevention (3).
Mild acne can usually be controlled with a topical preparation. Moderate acne usually requires a topical preparation and some form of oral therapy. Patients with severe acne should be referred to a dermatology specialist for management. The European Dermatology Forum Guidelines provides an evidence-based treatment pathway for acne (7).
The National Institution for Health and Care Excellence (NICE) Clinical Knowledge Summaries provide UK guidance based on the European guidelines; on treating people with acne from 12 years onwards (8).
Mild acne can usually be treated with OTC preparations; however most are not recommended due to lack of evidence (8). NICE recommend topical retinoids for comedones; and benzoyl peroxoide (2.5%-10%) for papules are recommended first line treatments.
If the mild acne does not respond after two months, to these preparations, then topical retinoids, benzoyl peroxide or azalaic acid should be prescribed in primary care(8).
In moderate acne, topical combination therapy with antibiotics (e.g. benzoyl peroxide 5% and clindamycin 1% or tretinoin 0.025% and erythromycin 4%) or retinoids, if comedones present (Adapalene and benzoyl peroxide) (7).
Oral antibiotics should be considered if moderate acne does not respond to topical treatments (tetracycline, oxytetracyline, doxycyline or lymecyline are first-line options8); and for practical purposes such as treating the chest and back, correct administration is crucial to success.
Antibiotics need to be prescribed for at least three months, as therapeutic effects are generally not observed until six to eight weeks; concomitant use of different topical and systemic antibacterial is not recommended, to prevent development of bacterial resistance (8).
Combined oral contraceptives are recommended for females; as there is good evidence that they reduce lesion count (7,8). Anti-androgen therapy (cyproterone acetate with ethinylestradiol) should only be prescribed for a short course (three to four cycles), when topical or systemic therapy fail, following a safety review by the European Medicines Agency (EMA), the Medicines and Healthcare Products Regulatory Agency (MHRA), which identified a higher risk of venous thromboembolism with anti-androgen therapy (9).
Patients with severe acne should be referred to a dermatology specialist; as the majority of patients will be treated with oral isotretinoin (8). Alternative options include, high dose oral antibiotics for six months or longer or oral anti-androgens for females (8).
Acne skin care advice
Patients with acne need support and advice on general skin care. There are several acne myths, which should be dispelled; see Table 3. The rule of acne treatment is that any treatment can take time to work; so any treatment must be continued for two months, for therapeutic effects. If after two months, the lesions have reduced by 50% and resolving; continue with treatment. If the same amount of lesions remain, then the treatment pathway should be reviewed (10).
Advise washing with an acne wash and lukewarm water, and warn that over cleaning and using facial scrubs can increase sebum production. Females will appreciate advice on make-up, non-comedogenic make-up (these products are oil-free) recommended, there is no evidence that this type of make-up worsens or causes acne (10).
Why primary care nurses need to address acne care?
Support patients with information on acne, dispelling myths, skin care and practical advice on treatments is an essential role for primary care nurses.
Acne is an undertreated skin condition, which can cause immense psychological distress. Mild and moderate acne can be successfully treated; with good outcomes; and all patients with severe acne need referral to dermatology specialists (8). Primary care nurses, particularly those who work with young people, should develop skills in managing acne, which will improve quality of life for their patients.
1. Smithard A, Glazebrook C, Williams HC. Acne prevalence, knowledge about acne and psychological morbidity in mid adolescent: a community based study. British Journal Dermatology 2001;145: 274-9.
2. Schofield JK, Grindlay D, Williams HC. Skin conditions in the UK: a health care needs assessment. Centre of Evidence Based Dermatology 2009; 6: 92.
3. Layton A. Disorders of the sebaceous glands. In Burns T, Breathnach S, Cox N, Griffiths C (eds). Rook’s Textbook of Dermatology. 8th edn. 2010;2(42): 1-68.
4. Ballanger F, Baudry P, Guyen JN et al. Heredity: a prognostic factor for acne. Dermatology 2006; 212(2): 145-8.
5. Motley RJ, Finlay AY. Practical use of a disability index in the routine management of acne. Clinical and Experimental Dermatology 1992;
6. Gupta MA, Gupta AK . Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. British Journal of Dermatology 1998; 139(5): 846-50.
7. Nast A, Dreno B, Bettoli V et al. European evidence-based (S3) guidelines for the treatment of acne. Journal of European Academy of Dermatology and Venereology 2012; 26(1):1-29.
8. NICE. Clinical Knowledge Summary – Acne Vulgaris. 2014. Available at: http://cks.nice.org.uk/acne-vulgaris [accessed 18 February 2015]
9. MRHA. Drug Safety Update: Cyproterone acetate with ethinylestradiol (co-cyprindiol): balance of benefits and risks remains positive. 2013. Available at: https://www.gov.uk/drug-safety-update/cyproterone-acetate-with-ethinyles... [accessed 18 February 2015]
10. Bowser A. Acne and Rosacea – the complete guide. Chatham:
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