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Practice nursing basics: management of acne

Annabel Smoker
RGN BNSc(Hons) PGDipEA MA
Lecturer
School of Nursing and Midwifery
University of Southampton
E:A.L.Smoker@soton.ac.uk

Acne vulgaris is a common disorder of the sebaceous glands affecting 80-90% of adolescents. In the majority of cases the condition resolves spontaneously after 4-5 years; however, 7% of sufferers will endure the problem beyond 25 years of age.(1) The visibility of the disease can create profound psychological distress, yet patients are often reluctant to seek advice for a condition that is seen as part of growing up. Early intervention is therefore key to minimising both permanent scarring and negative self-image.
Acne management forms part of the principal dermatological workload in primary care, accounting in 2001 for three million GP consultations and 50,000 specialist referrals.(2) Over £30m is spent annually by the NHS on prescription drugs.(3) Nurses are well placed to offer help to sufferers; however, the author's own study of practice nurses revealed that they infrequently gave advice about acne, and indeed many felt they lacked the confidence to do so.(4) Respecting that care should move closer to the patient, the experiences and knowledge of expert practitioners and patient support groups can be used to shape services in general practice and enhance the quality of frontline care.

Clinical presentation
Types of lesions include noninflammatory open comedones (blackheads), closed comedones (whiteheads), and inflammatory papules and pustules. In severe disease, nodules and cysts can lead to extensive residual depressed (ice-pick) or hypertrophic keloid scarring.
 
Aetiology
A combination of four interrelated physiological factors cause acne.(5,6) The first, raised sebum production, is due to increased sebaceous gland sensitivity to androgens, particularly testosterone. With few exceptions, the level of testosterone (derived from the ovaries, testes and adrenals) is within normal parameters. The excess sebum leaves the skin feeling "greasy". The second physiological factor, pilosebaceous occlusion, occurs because dead epithelial cells accumulate within the duct and become impacted. Blockage can also result from the use of cosmetics, oils or tar-based products. The third factor, sebum trapped in the follicle, provides nutrition for the commensal bacteria, Propionibacterium acnes, encouraging proliferation and the release of free fatty acids. These in turn produce the fourth factor, an inflammatory response, leading to the development of pustules and, in severe disease, nodules. Blackheads arise if blockage occurs at the orifice; whiteheads are indicative of deeper occlusion.
Typically acne is classified as mild, moderate or severe, inflammatory or noninflammatory. It can occur on any area of the body where sebaceous glands are prolific. Upon examination there may be a marked variation in severity across different areas of the body. It may be confined to the forehead and cheeks or affect the whole face, upper chest and back. Less common variants include acne conglobata, acne fulminans, Gram-negative folliculitis, infantile acne, pyoderma faciale and acne excoriée. Differential diagnosis should exclude rosacea, drug eruptions, and contact and perioral dermatitis.

Assessment
The initial assessment should provide comprehensive, multidimensional data. To achieve this, the nurse needs to be able to gain the patient's/parent's confidence.(7) The focus should not be restricted solely to minimising physical disfigurement, given the evidence of associated psychological problems such as low self-esteem and difficulty forming interpersonal relationships.(8) There is evidence of a link to poor academic performance, bullying, increased incidence of unemployment, anxiety, depression and, in some rare instances, suicidal thoughts.(9)
Practitioners should explore factors that might contribute to or exacerbate acne. When hormone levels fluctuate during the menstrual cycle, in the first trimester of pregnancy and three months postpartum, acne may get worse. Other factors include the use of progestogen-only contraceptives (mini-pill or Depo-Provera injections [Pharmacia]) and underlying hyperandrogenetic syndromes, such as polycystic ovary syndrome (characterised by hirsutism, abnormal periods and weight gain). Stress influences testosterone activity and can exacerbate acne. Oil-based cosmetics, iodides and certain drugs such as lithium and corticosteroids also trigger flare-ups.(5) Seasonal variations may play a role;(10) white people often  notice an aggravation in hot, humid climates associated with increased perspiration.(6)
It is important to elicit when the acne started, whether it has spread, and any associated pain or pruritus. The Leeds Acne Grading System is, with the exception of atypical presentation, a simple pictorial tool for assessing acne severity on the face, chest and back and monitoring individual responsiveness to treatment.(11) The severity of associated tenderness or pain should also be recorded on a simple scale of +++ for severe to +/- for intermittent discomfort. The extent of psychological disability can be measured using the Assessment of the Psychological and Social Effects of Acne (APSEA).(8) This may help identify those who might benefit from counselling, cosmetic camouflage and aggressive treatment. Obsessive- compulsive picking should be controlled to minimise infection and scarring, although this condition, known as acne excoriée, may be a sign of underlying dysmorphophobia.
All prescription treatments, over-the-counter (OTC) products and alternative therapies should be identified, with an indication of the level of compliance and the patient's thoughts on what they think aggravates or alleviates the problem. A thorough assessment should reveal how much the patient understands about their condition, treatments and any misconceptions held. There are many myths, and contradictory advice serves only to confuse.
 
Myths
A popular myth is that acne is contagious and occurs as a result of poor personal hygiene. The blackhead is due to the oxidation of sebum and the accumulation of melanin within the pore. It is deeply impacted and therefore cannot be washed away. Aggressive overcleansing may cause localised dryness and irritation. The relationship between diet and acne is contentious and tenuous, with the exception of excessive dietary iodides found in vitamin supplements, seaweed diets and some desalinated drinking water, which are thought to exacerbate acne.(5) The evidence suggests the critical determinant is genetic predisposition rather than the consumption of chocolate, fatty foods or a tendency to constipation. Nevertheless, as with all patients, individuals should be encouraged to adopt a healthy, balanced diet. Sexual activity per se, which may coincide with puberty, does not contribute to the development of acne.

Management of acne
Drug treatment
Both clinical presentation and the level of psychological disability influence the choice of therapy (see Table 1). Patients naturally expect early improvement; however, in reality it may take several months before there is a visible difference. Treatments are often long-term, and some may initially provoke a mild erythema and peeling. These side-effects could be interpreted as a deterioration of the condition and thereby affect compliance.

[[NIP11_table1_31]]

Mild-to-moderate acne
Topical treatments fall into three categories - anticomedonal, anti-inflammatory and combined preparations. Anticomedonal agents such as retinoids (tretinoin, isotretinoin and adapalene) are effective in blackhead-type acne. Skin irritation and photosensitivity following application may necessitate a temporary suspension in treatment; retinoids are not well tolerated by atopic patients whose skin is naturally hypersensitive. Benzoyl peroxide 2.5-10% and azelaic acid have both anticomedonal and antimicrobial properties, which means they are suitable for inflamed and noninflamed lesions. Again, mild irritation, peeling and scaling may occur with residual hypo- or hyperpigmentation depending on skin type. Topical antibiotics (erythromycin, tetracycline and clindamycin) should be considered when patients do not respond to benzoyl peroxide. Antibiotic-resistant P acnes is increasingly a problem for patients on oral erythromycin; the combination of benzoyl peroxide and topical and/or systemic antibiotics can reduce this.(12,13) Progress should be reviewed after 4-8 weeks.

Moderate-to-severe acne
Moderate-to-severe acne requires oral antibiotics and, in severe nodulocystic and scarring acne, isotretinoin, a vitamin A derivative. The same antibiotic should be used when combining topical and systemic therapies. Hormone therapy (co-cyprindiol) is an alternative for female patients. Increasingly, acquired antibiotic resistance associated with long-term use makes isotretinoin a favoured option.(14) Isotretinoin can be prescribed only by specialists because of its potentially serious side-effects. In most instances, improvements take 2-3 months. To achieve maximum compliance and reduce adverse reactions, patient education is critical.
While the majority of patients can be effectively managed in primary care, there are those who will require referral to specialist services (see Table 2).(15) Intralesional injections, cautery, cryotherapy, dermabrasion and laser resurfacing may lessen residual scarring in severe cases. Dermabrasion is less commonly used, and laser resurfacing, rarely available on the NHS, may offer a very limited cosmetic improvement. It is vital to highlight the restricted choices of treatments for scarring to keep patient expectations realistic.

[[NIP11_table2_32]]

Practical advice
Guidance should focus on skincare practices. The twice-daily use of a pH 5.5 "balanced" soap or nonsoap face wash should be encouraged, especially postexercise. Recommend a soft paper towel to pat the skin dry. Daily moisturisation and weekly exfoliation can improve the skin's condition. Patients should opt for "noncomedogenic" products. Topical treatments should be applied after cleansing and at least 15 minutes before moisturisers or makeup. Help may be required to apply treatments to the back. If it is unlikely the patient will apply topical treatments to all areas affected as directed (for example, in the case of a student away from home), systemic therapy may be more appropriate.
It is natural to want to squeeze spots, despite the potential for scarring. Where this is a known or suspected activity, the "Traffic light guide to squeezing spots" can advise on damage limitation (see www.stopspots.org).(2) Further confidential support and information can be obtained direct from the Acne Support Group or OCD Action, the latter for those with obsessive-compulsive disorder or dysmorphophobia.

Conclusion
The agenda for the modernisation of the NHS offers an exciting opportunity to develop primary care nurse-led acne services.(16,17) Practical training and supervision are pivotal to securing the knowledge and competencies required to fulfil this role. Initiatives such as the "Expert Patient" encourage the promotion of self-management skills through tailored education,(18) and as such primary care practitioners are well positioned to make a positive impact on the patient's ability to cope with a highly visible condition.

Practice pointers

  • Early intervention can significantly reduce physical and psychological trauma
  • Recognise when you may be able to offer practical advice and support, as not all sufferers may self-refer. Consider bringing up the subject if the patient does not
  • The patient assessment should be multidimensional and facilitate evaluation. Do not assume the level of psychosocial disability will mirror disease severity. Dysmorphophobia may be present in very mild cases
  • Acne referral practice guidelines should be used to expedite specialist involvement
  • Reinforce advice with written information

References

  1. Cunliffe WJ. Looking back to the future - acne. Dermatology 2002;204:167-72.
  2. Mitchell T, Dudley A. Acne at your fingertips. London: Class Publishing; 2002.
  3. Coates P, Eady AE, Cove JH. Complementary therapies for acne (Protocol for a Cochrane Review). In: The Cochrane Library. Issue 4. Oxford: Update Software; 2002.
  4. Smoker AL. The role of the practice nurse in the care of people with skin conditions. Br J Dermatol Nurs 1999;3(2):5-7.
  5. Fulton JE. Acne: its causes and treatments. Int J Cosmet Surg Aesthet Dermatol 2002;4(2):95-105.
  6. Hunter JA, Savin JA. Dahl MV. Clinical dermatology. 2nd ed. Oxford: Blackwell Science; 1995.
  7. Cunningham M. Effective acne treatment. Br J Dermatol Nurs 2000;4(4):12-5.
  8. Layton AM, Seukeran D, Cunliffe WJ. Scarred for life. Dermatology 1997;195(Suppl):S15-21.
  9. Acne Support Group. Acne Support Group survey. Middlesex: Acne Support Group; 1997.
  10. Sardana K, Sharma RC, Sarkar R. Seasonal variation in acne vulgaris - myth or reality. J Dermatol 2002;29:484-8.
  11. O'Brien SC, Lewis JB, Cunliffe WJ. The Leeds revised acne grading system. J Dermatological Treatment 1998;9:215-20.
  12. Webster GF. Acne vulgaris. BMJ 2002;325:475-9.
  13. Cunliffe WJ. Acne: when, where and how to treat. Practitioner 2000;244(1615):865-6, 868, 870-1.
  14. Layton AM. Acne - what's new? Dermatol Pract 1999;7(1):16-18.
  15. National Institute for Clinical Excellence. A guide for appropriate referral from general to specialist services. London: NICE; 2001. p. 7-8.
  16. Rolfe G. A nurse-led acne, psoriasis and eczema initiative in Northants. Dermatological Nurs 2002;1(4):18-20.
  17. Action on Dermatology. Dermatology good practice guide. London: Department of Health; 2003.
  18. Department of Health. The expert patient: a new approach to chronic disease management for the 21st century. London: The Stationery Office; 2001.

Resources
Acne Support Group
PO Box 9
Newquay TR9 6WG    
T:0870 870 2263
W:www.stopspots.org

British Association of Dermatologists
W:www.bad.org.uk

British Dermatological Nursing Group
19 Fitzroy Square
London WIP 5HQ
T:020 7383 0266
W:www.bdng.org.uk

OCD Action
Aberdeen Centre
22-24 Highbury Grove
London N5 2EA
T:020 7226 4000
W:www.ocdaction. org.uk

Skincare Campaign
W:www.skincarecampaign.org