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Diagnosis and management of acne in primary care

Siobhan Hicks
RGN BSc
Nurse Practitioner in Primary Care
Lecturer in Public Health and Primary Care
London

Acne vulgaris is an extremely common complaint thought to affect 90% of us at some stage of our lives that, but if effectively managed, will usually improve. It is a chronic skin condition generally associated with puberty, although not exclusively, as infants and older people may also be affected. The usual symptoms are recurring painful red spots or blackheads; greasy irritated skin; nodules and pustules. The face and occasionally the neck and back are most affected due to a disorder of the pilosebaceous follicles found in these areas.
The patient's perception of the severity of their condition does not always reflect the clinician's objective assessment, and therefore the patient should always be treated sympathetically as the impact acne has on their lives can have profound psychosocial ramifications.
Treatment of acne should be started early to prevent scarring and the choice of treatment should be dependent on age, severity and whether the acne is inflammatory or comedonal.

Different types of acne
Comedones are the primary noninflammatory lesions associated with mild-to-moderate acne. These are caused by the skin at the top of the pores becoming thick and blocked with dead skin cells, which shed into the pores causing plugs. There are many different categories of comedones - the most common being blackheads and whiteheads (see Box 1).

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Moderate-to-severe acne presents with inflamed lesions that can be superficial or deep; these usually arise from noninflamed lesions, with superficial papules (inflamed) and pustules (containing pus) being the most common. At puberty androgens such as testosterone and androsterone increase production of sebum from enlarged sebaceous glands. This causes the glands to become blocked and infected with anaerobic bacteria - Propionibacterium acnes and Propionibacterium granulosum - that cause an inflammatory reaction.(2) This reaction causes the skin to become red and spots may become large and filled with pus, sometimes forming cysts and nodules that can be very disfiguring. When healed the skin may be discoloured for many months (postinflammatory hyperpigmentation). It is also common for small pitted scars to form at the site of an infected spot. Variants of acne that may require specialist treatment are seen in Box 2.

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Polycystic ovary syndrome is a condition in women where excess male hormone is secreted in the ovary or adrenal gland. As well as acne symptoms include thinning of scalp hair, hirsutism and irregular periods. It is therefore prudent to test for androgens in women with acne resistant to treatment. Investigations may include total and free testosterone, and luteinising hormone/follicle-stimulating hormone ratio.

Investigations and diagnosis
Acne is self-evident - the patient presents with spots affecting the face, neck or back and is often an adolescent or young adult. No investigations are usually necessary but as discussed measurement of androgens may be appropriate. Nonetheless, sensitive questioning and examination will enable the practitioner to build a rapport with the patient and plan an effective way forward. Some useful questions to ask are:(4)

  • How long have you had acne?
  • What treatments have you tried - prescribed or over-the-counter?
  • What impact is the condition having on your life?
  • Are there any causative factors, ie, medication such as lithium, progestogen-only pill, steroids?
  • Are there any environmental or cosmetic factors?
  • Could there be a hormonal cause?
  • Have you altered your diet, with any success?

On examination, the objective findings may include the following (try and assess the face neck and back in order to form a complete assessment of the problem, this is often embarrassing for the patient so should be dealt with sensitively)(4)

  • Does the patient look withdrawn, is there a lack of direct eye contact?
  • Are there inflammatory papules, pustules, closed and open comedones?
  • Is the skin and hair greasy?
  • Are nodules inflamed and painful to touch?
  • Is there evidence of previous scarring/hyperpigmentation?

As with every condition it is important to rule out any differential diagnosis. Acne rosacea is sometimes confused with acne vulgaris, but it usually affects older patients in the 40-70 age range, and symptoms include papules, pustules, redness, and also blepharitis of the eyes, all usually exacerbated by sunlight and often limited to the head.

Current treatment
Prodigy guidelines currently recommend that topical treatments are the firstline choice for mild acne (see Box 3 and Resources).

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Topical antibiotics are an alternative which are especially useful when inflammatory lesions are present. Due to concerns about antibiotic resistance it is suggested they be reserved for use with benzoyl peroxide in moderate acne.(6)
Topical treatments are still recommended as the initial treatment of choice for moderate acne (see Box 4).

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Oral antibiotics should be considered in the following situations:(4)

  • Topical treatment has failed or is not tolerated.
  • Moderate acne of back or shoulders, due to difficulty in reaching these areas.
  • Significant risk of scarring.

Severe acne should be treated with oral antibiotics. Tetracyclines are recommended as firstline treatment. However, they may cause severe adverse effects and are therefore not suitable for all. The choice of tetracycline depends on side-effect profile and convenience (how often taken). Minocycline is now used with caution because it has several adverse effects that are rare but severe. Erythromycin is an alternative when firstline treatment is not tolerated or contraindicated. Topical retinoids may help prevention of new comedones while taking antibiotics and benzoyl peroxide may delay or prevent antibiotic resistance occurring especially if oral antibiotics are being used for more than two months. Topical antibiotics and oral antibiotics are not recommended for use together as this is thought to be ineffective and may encourage resistance.(7) It is important to note that additional contraceptive barrier method will be required if initiating long-term antibiotics.
Hormonal treatment can be prescribed if it is known or suspected that a woman has acne aggravated by high androgen levels. Combined oral contraceptives are often effective due to the oestrogen content.(5) Progestogen-only pills may worsen acne.
Co-cyprindiol (Dianette; Schering Healthcare) is a combination of ethinylestradiol and cyproterone (an anti-androgen) that is licensed for use in the treatment of severe acne, although it may take two to six months to work. Although an effective contraceptive, it is not licensed for treating acne alone and should be discontinued three to four menstrual cycles after the acne has resolved. Dianette has been found to be associated with an increased risk of venous thromboembolism (VTE). Research suggests that there is a 2-4-fold increase in the risk of VTE when compared with standard combined oral contraceptive,(8) but it is possible that women with androgen-related conditions might have an inherently increased cardiovascular risk.(9)
Pregnancy may either improve or worsen acne, and several drugs used to treat acne are contraindicated in pregnant women. Oral retinoids are highly teratogenic and should never be used; topical retinoids should also be avoided.(10)
Treatment for scarring acne is highly effective but must be initiated in secondary care due to toxicity. Oral isotretinoin is a synthetic form of vitamin A. It can cause dry skin, lips and eyes; raise lipids; cause muscular aches and pains; cause acne to flare-up; cause mood swings and thin hair. As mentioned previously, isotretinoin is harmful in pregnancy, even up to one month post-treatment, and so two forms of contraception are essential in female patients up to one month after stopping treatment.
Laser treatment works by targeting P acnes in the sebaceous glands. This treatment is very expensive and trials are limited.
Surgical and medical techniques can aid by incision and drainage of pus; comedo extraction removes entire comedones; corticosteroid injections reduce inflammation and lesion size; and dermabrasion may be performed by plastic surgeons.

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Follow-up
Review your patient after six weeks; it is a good opportunity to discuss compliance and provide reassurance. If treatment has been effective, continue for the recommended duration of the drug. However, if the improvement has been poor, consider the following options:

  • For topical formulations consider changing the formulation or type of topical drug.
  • Increase strength of the product - if not already at maximum.
  • Combine topical formulations.
  • If no response to antibiotic, suspect resistance after three months.
  • Consider adding oral antibiotic.
  • Consider hormonal cause.
  • Consider referral to secondary care (see Box 5).(11)

Can acne be prevented?
In order to help patients continue with treatment it is important to help them understand how to use their medication and to be aware of side-effects. The likely timescale for improvement and duration of treatment should be explained - at least six weeks or more.
It is important to give your patient sensible advice on personal hygiene and to dispel myths. It is generally accepted that acne is not caused by poor hygiene; in fact overzealous washing can aggravate the skin and picking/squeezing causes scarring. There may be a link between stress and acne, especially because unsightly lesions can aggravate stress, but there is no evidence to support this. Acne is not infectious, P acnes is naturally present in the skin but colonises in the follicles. Diet has little or no effect on acne and there is no evidence to suggest sunlight is beneficial.(12)
Dispelling these myths and explaining current best practice will enable and motivate your patient to adhere to their treatment plan and eradicate potentially harmful behaviour.

References:

  1. Simpson NB, Cunliffe WJ. Disorders of the sebaceous glands. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's textbook of dermatology. 7th ed. Oxford: Blackwell Science; 2004.
  2. Healy E, Simpson N. Acne vulgaris. BMJ 1994;308:831-3.
  3. 3. Wolf JE. Acne and rosacea: differential diagnosis and treatment in the primary care setting. Medscape 2002. Available from: http://www.medscape.com
  4. 4. Brown SK, Shalita AR. Acne vulgaris. Lancet 1998;351:1871-6.
  5. James WD. Acne. N Engl J Med 2005;352:1463-72.
  6. ICSI. Health care guideline: acne management. 2003. Available from: http://www.icsi.org
  7. Dreno B. Topical antibacterial therapy for acne vulgaris. Drugs 2004;64:2389-97.
  8. CSM. Cyproterone acetate (Dianette): risk of venous thromboembolism (VTE). Curr Prob Pharmacovigilance 2002;28:9-10.
  9. Seaman HE, de Vries CS, Farmer RDT. The risk of venous thromboembolism in women prescribed cyproterone acetate in combination with ethinyl estradiol: a nested cohort analysis and case control study. Hum Reprod 2003;18:522-6.
  10. Berson DS, Marchant M. Topical retinoids in primary care. Medscape. 2003. Available from: http://www.medscape.com
  11. NICE. Referral advice - a guide to appropriate referral from general to specialist services. London: NICE; 2001. Available from: http://www.nice.org
  12. Prodigy. Clinical knowledge summaries. Available from: www.prodigy.nhs.uk

Resources:
Acne Support Group
W: www.m2w3.com/acne
W: www.stopspots.org
British Association of Dermatologists
W:: www.bad.org.uk
Dermatology Resource
W: www.dermnetnz.org
Prodigy knowledge
W: www.prodigy.nhs.uk