This site is intended for health professionals only

Why nurses should be treating acne patients

Alison Bowser
Chief Executive
Acne Support Group

Ask any nurse how they manage their patients with acne and many will reply, "I don't see them, they usually see the GP." Not only is it worrying to think that nurses don't consider themselves the "first port of call", but it in no way reflects patients' preference. In a survey of Acne Support Group (ASG) members, almost a third said they would prefer to consult a nurse about their acne, rather than their GP.(1) Reasons cited by ASG members for preferring to see a nurse included:

  • It is easier to talk to a nurse (39%).
  • They give more sympathy (38%).
  • They have more time (36%).   
  • I feel more comfortable with a nurse (30%).
  • There is less waiting time (20%).

What was most interesting from this survey was the impression ASG members have that nurses are relaxed and able to give more time. While this may be true for some, we know only too well that the pressures of working in a practice probably keep nurses as busy, if not busier, than the GP! Perhaps the clue to such positive answers also lies behind the qualifying part of this question, which was: "If they had identical training on acne, which would you prefer to see ...?" Do you feel that you have had identical training in acne management, causes and so on to your GP colleagues? Don't worry if you don't think you have - the chances are that most doctors would have had little specific acne training, and perhaps none at all!
The good news is that there are now many courses offering training in dermatology, with specific modules on acne. Some of these are being offered through distance learning. In addition, the ASG has started to run training courses aimed specifically at nurses, with great results. The primary aim of learning about acne causes and treatments is to keep the information useful and practical at every stage.
Myths about acne causes still circulate, not only in the school playground but in the workplace, at home and within the field of medicine. Well-meaning but misleading advice can cause more problems than it solves. For example, many people believe that toothpaste is a good emergency treatment for spots. While this might help some people, using proven ingredients such as benzoyl peroxide and salicylic acid on a regular basis will help to avoid the spots appearing in the first place.
Other myths include:

  • Poor diet - too much chocolate, chips or greasy fried foods are often blamed for spots, yet not one of these has been proven to cause acne. There are some theories that women who experience premenstrual flares could be craving chocolate, which, in turn, may be blamed for the acne flare, rather than the slight hormone fluctuations. It is worth mentioning that, although the greasy food cause is a myth, eating a balanced diet including plenty of fresh fruit and vegetables can help to maintain healthy skin.
  • Poor hygiene - washing is important to remove surface dirt and bacteria but will not prevent what is happening in the pilosebaceous unit, the root of the acne problem.
  • Acne is contagious - it is likely that someone with spots around their mouth may appear unappealing to kiss, but no evidence exists to prove that it can be contagious.

Other myths include some bizarre references to sexuality, sexual behaviour or sexual fantasies. Suffice to say, only teenagers tend to believe these!

Getting it right
Giving confident advice based on facts, not myths, is the simple key to helping patients. Your confidence will allow them to understand that acne is both very common and very treatable. This information is vital, especially to someone who is feeling depressed and despondent with treatments they will claim have been "useless".
Take the time to explain how increased sebum is triggered by a sensitivity to circulating testosterone, causing the formation of a tiny blockage (the microcomedone), which comes from dead skin cells that proliferate and block the hair follicle surface. Bacteria usually present on most people's skin thrive in this extra oily environment and can result in inflammation and redness, resulting in the typical pus-filled spot.

[[NIP24_box1_23]]

Review
Ask what treatments they have already used? This might evoke a fairly typical response of "I've tried them all - they have all failed!" However, often upon asking a few questions it might be revealed that it was the patient that had failed to use their treatments correctly.

Checklist of questions

How long did you use your treatment for?
It is easy to believe marketing that promises results in a few days. The natural lifespan of a spot is only a few days, so this marketing speak is sadly misleading. Any treatment for acne (with the exception of Dianette [Schering Health Care] and isotretinoin) should be used for a minimum of two months. At this time, the skin should be reviewed for signs of any noticeable improvement. Ask the patient to return for a review at this time.

How often did you apply/use it?
Using a spot cream as and when you remember is not going to allow it to work to its full capacity. For example, you wouldn't expect to get away without fillings if you only brushed your teeth when you saw bits of food stuck on your gums - therefore using a spot treatment only when a spot appears is not going to be helpful. Spots usually start forming for a few days below the surface of the skin, out of sight, before they "pop up". Therefore the aim of treatment is to stop new spots forming. Use treatments as directed. Conversely, slapping on twice as much cream as is necessary will not help patients' spots clear up twice as fast.

What were the treatments?
Some of the most useful antiacne ingredients available over the counter include benzoyl peroxide, salicylic acid and nicotinamide. However, some products available on the spot care shelves of chemists or supermarkets will do very little to help more inflamed, persistent acne and may possibly be quite useless even for mild acne. Others are often very harsh and may make the problem worse. Some patients may have tried prescription treatments but failed to stick with them (see the two-month rule above), and it may be useful to point out the  benefit of sticking with a treatment to allow it to have a fair chance of working.

Assess
Make notes on the types of treatments tried then ask your patient where they most commonly get acne outbreaks. Acne usually appears on the face and neck, but the chest, shoulders and back are also commonly affected. You should ask the patient to show you all the sites and note any signs of scarring to help give a clearer historical record.

Grading acne
Using a fairly simple grading scale consisting of mild, moderate or severe is usually the easiest way of recording acne severity. Fortunately severe acne is rare and will often require fast-tracked referral.(4) The Leeds Grading Scale of Acne can be a useful tool to share with your acne patients.(5) Get them to grade their acne themselves and together agree a realistic outcome - that is, from grade 5 to grade 3 within two months.

Treatments
A variety of treatments are available for helping with various aspects of acne, such as Dianette to suppress androgen activity or antibiotics to help target the Propionibacterium acnes. It is estimated that there are up to 100 combinations of treatments that are currently prescribed for acne, so next time your patient says they have tried them all, challenge them to name some!

References

  1. Acne Support Group. Members survey. 2003. Unpublished.
  2. Goulden V, Clark SM, Cunliffe WJ. Post-adolescent acne: a review of clinical features. Br J Dermatol 1997;136:66-70.
  3. Acne Support Group. Members survey. 1993. Unpublished.
  4. NICE. Referral advice ref N0041. Available from URL: http://www.gp-training.net/protocol/misc/niceref.pdf
  5. Leeds General Infirmary. The Leeds grading scale of acne. J Dermatol Treat 1998;9:215-20.

Resources
Acne Support Group
The ASG received charitable status in 1992 and continues to provide an independent service to anyone affected by acne. For further information on training courses that can count towards continuing professional development (CPD), please contact the office T:01872 553003 Remember to pass on our details to your patients for further support and membership benefits T:0870 870 2263 W:www.stopspots.org

Further reading
At your fingertips: acne.
Dudley B, Mitchell T. London: Class Publishing; 2002