Dr Rebecca Mawson shares 10 top tips on diagnosing and managing patients with acne
Read this article to learn more about:
- identifying those who are at greatest risk of severe acne
- why some patients may show poor response to treatment
- why monotherapy with antibiotics should be avoided.
This top tips article on acne management is based on a combination of different resources, and focuses on primary care management only, with onward referral to secondary care. In the UK, approximately 3% of GP consultations with patients aged 13–25 years are related to acne.1 In 2000, UK GPs wrote 2.6 million prescriptions for acne, which included 0.7 million prescriptions for topical antibiotics, and 1 million for oral tetracyclines.2
1 Make the correct diagnosis-identify high-risk patients
Early diagnosis and careful clinical assessment of acne can help to deliver best practice in a number of ways. Some patients will be destined to develop more severe disease and/or respond less well to treatment. It is important that primary care clinicians recognise poor prognostic factors:3
- early age of onset for acne in both sexes; and in girls, relatively earlier menarche and higher levels of dehydroepiandrosterone
- early presentation with mid-facial lesions, predominantly comedones
- marked seborrhoea (greasy skin)
- truncal acne
- strong family history of acne and/or scarring
- development of scarring
- psychological issues as a result of acne.
A careful history and examination will identify at-risk individuals. Assessment and recognition of specific lesions and the degree of seborrhoea will inform management and selection of therapies that target the specific clinical presentation as well as aetiological factors. Acne is associated with an increased likelihood of psychiatric morbidity so it is important to assess mental status.4 Early intervention and counselling may reduce mental health decline and the isolation associated with acne.5
2 Understand the pathogenesis in order to tailor treatment
The pathogenesis of acne is complex and centres on the pilosebaceous unit.
Factors involved in the pathophysiology include:6,7
- an androgen-dependent increase in sebum production
- abnormal follicular differentiation with hyperkeratinisation within the intrafollicular duct
- colonisation with gram-positive anaerobic Propionibacterium acnes (P. acnes)
- early peri-follicular inflammation prior to any microbial colonisation
- later inflammation as a result of P. acnes colonisation; this is characterised by a cell-mediated immune response.
3 Know the basics of common topical therapies
The British National Formulary8 has over 20 different acne treatments, but making a rational choice is difficult because of a limited evidence base.8 For further information on the use of topical therapies, see the PCDS Acne-primary care treatment pathway (Figure 1, below).9
4 Review response to treatment
Approximately 20% of patients will show a poor response to treatment. The reasons behind this include:3
- the wrong diagnosis—symptoms could be that of rosacea, not acne (see the top tips article on rosacea for further information)
- inadequate adherence to therapy—topical treatments are inconvenient and time-consuming for patients
- inappropriate assessment of overall acne severity by the prescribing practitioner (e.g. only examining face and not the trunk)—the acne may be much more severe than initially identified
- side-effects or intolerance of therapy—the patient may have stopped treatment because of irritation
- P. acnes resistance to treatment
- unusual underlying conditions (e.g. congenital adrenal hyperplasia, polycystic ovary syndrome [PCOS])
- anabolic steroid use-be aware of this, especially in young gym-going men.
5 Warn patients of side-effects of retinoids9
In most cases, topical retinoids will irritate the skin when first applied. Practitioners should ensure that they warn patients of this side-effect, as some patients may stop treatment due to the unexpected irritation and skin dryness.
Patients should be encouraged to first cleanse the skin, and then apply a small amount of the retinoid, avoiding the eyes and lips. The retinoid should be left on for 15–30 minutes, and then washed off and moisturiser applied.10 The patient should slowly increase the time the retinoid is left on the skin to build tolerance, ultimately aiming to leave the retinoid on overnight. The patient will know the retinoid is effective when the skin loses it shine; however, it may take 6 weeks from start of treatment for the acne formation to decrease. A similar approach can be taken when using benzoyl peroxide topically.
6 When to refer
Most individuals with acne can be managed in primary care. NICE advises referral to a specialist service if a patient:5
- has a very severe variant such as fulminating acne with systemic symptoms (acne fulminans)
- has severe acne or painful, deep nodules or cysts (nodulocystic acne) and could benefit from oral isotretinoin
- has severe social or psychological problems, including a morbid fear of deformity (dysmorphophobia)
- is at risk of, or is developing, scarring despite primary care therapies
- has moderate acne that has not responded to treatment, which should include several courses of both topical and systemic treatment over a period of at least 6 months; failure is probably best based on a subjective assessment by the patient
- is suspected of having an underlying endocrinological cause for the acne that needs assessment.
7 Take a stepwise approach
Often it is difficult to know where to start with acne treatments. First, you should decide if the acne is comedonal predominant or pustular/nodular predominant. Second, consider whether the acne covers a small area such as the chest or face, which can be treated topically, or if it is widespread and not practical to treat topically. See Figure 2 (below).11
8 Avoid monotherapy with antibiotics
Oral antibiotics in acne must only be used when indicated and should never be used as monotherapy because of the increasing emergence of antibiotic resistance. Oral antibiotics are indicated for patients with extensive disease, which includes truncal acne and moderate to severe papulopustular acne.12
Antibiotics commonly used for acne are shown in Figure 2 (above).11 Doxycycline and lymecycline should be selected in preference to minocycline and oxytetracycline because they have a superior side-effect profile and result in better patient adherence to therapy.13 Benzoyl peroxide should be used alongside antibiotics to reduce the likelihood of bacterial resistance emerging.7
Antibiotics are essential for maintenance and treatment of some patients with acne but should be reviewed every 2–3 months. Many patients' symptoms will clear in 3 months but some may require life-long antibiotic treatment.
Some of the benefits of using antibiotics comes from the anti-inflammatory effects, rather than the antimicrobial effects alone.14
9 Consider hormonal therapy
Hormonal therapies can be a useful option in the management of acne in women. All combined oral contraceptives (COC) have the potential to reduce acne through their oestrogenic effects.15 One cyproterone acetate/ethinylestradiol preparation has a licence for the treatment of severe acne, but is not licensed as a contraceptive agent in the UK.16
Third-generation COCs contain less androgenic progesterone (e.g. gestodene, desogestrel), but have an increased risk of venous thromboembolism (VTE) compared with second-generation pills containing progesterone (e.g. levonorgestrel). The risk of a VTE is highest for first-time users and during the first year a woman uses the combined pill.17
Careful selection and counselling of patients is required when prescribing a COC for acne, and healthcare professionals should be mindful of the adverse effect profile.
Retinoids are not recommended in pregnancy due to teratogenicity and therefore patients should ideally be on contraception if sexually active. The combined pill offers a potentially beneficial effect on acne whereas progesterone only contraception (e.g. progesterone only pill, contraceptive implant) may worsen acne.15
Current advice from the Faculty of Sexual and Reproductive Healthcare states that no additional contraception is needed during or after a course of non-enzyme inducing antibiotics (NB rifampicin is an enzyme inducer).18
10 Direct the patient to useful resources
Patients who come to see you about their skin have usually tried over-the-counter medications and researched online. Some useful resources to direct patients to include:
- Acne Academy—a website developed by Harrogate Hospital, which has helpful myth busters and advice for patients as well as parents
- British Association of Dermatologist patient leaflet on acne.
- Purdy S, Langston J, Tait L. Presentation and management of acne in primary care: a retrospective cohort study. Br J Gen Pract 2003; 53 (492): 525–529.
- Coates P, Vyakrnam S, Eady E et al. Prevalence of antibiotic-resistant propionibacteria on the skin of acne patients: 10-year surveillance data and snapshot. Br J Dermatol 2002; 146 (5): 840–848.
- Layton A, Eady E, Zouboulis C. Acne. Part 8, Chapter 90 in: Griffiths C, Barker J, Bleiker T et al, editors. Rook's textbook of Dermatology. 9th Edition. Wiley-Blackwell, 2016.
- Sundstrom A, Alfredsson L, Gerden B et al. Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study. BMJ 2010; 341: c5812.
- NICE. Acne vulgaris. Clinical Knowledge Summaries. NICE, 2014. Available at: cks.nice.org.uk/acne-vulgaris (accessed 31 August 2016).
- Ramli R, Aamir S, Ahmad F et al. Review. Acne analysis, grading and computational assessment methods: an overview. Skin Res Technol 2012; 18 (1): 1–14.
- Williams H, Dellavalel R, Graner S. Acne vulgaris. Lancet 2012; 379 (9813): 361–372.
- British National Formulary. Available at: www.medicinescomplete.com (accessed 24 August 2016).
- Primary Care Dermatology Society. Acne-primary care treatment pathway. PCDS, 2015. Available at: www.pcds.org.uk/ee/images/uploads/general/Acne_Treatment_2015-web.pdf
- Veraldi S, Barbareschi M, Benardon S, Schianchi R. Short contact therapy of acne with tretinoin. J Dermatolog Treat 2013; 24 (5): 374–376.
- Primary Care Dermatology Society. Acne vulgaris. PCDS, 2011 (last updated 2016). Available at: www.pcds.org.uk/clinical-guidance/acne-vulgaris
- Hoover W, Davis S, Fleischer A, Feldman S. Topical antibiotic monotherapy prescribing practices in acne vulgaris. J Dermatolog Treat 2014; 25 (2): 97–99.
- European Dermatology Forum. Guideline for the treatment of acne. EDF Guidelines Committee, 2016. Available at: www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne
- Scottish Antimicrobial Prescribing Group. Long term antibiotic use for acne, rosacea and other dermatology conditions. SMC, 2015. Available at: www.scottishmedicines.org.uk/files/sapg/Advice_on_antibiotic_use_in_acne_and_rosacea_November_2015.pdf
- Arowojolu A, Gallo M, Lopez L. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev 2009; 8 (3): CD004425.
- Bayer plc. Dianette. Summary of product characteristics. Available at: www.medicines.org.uk/emc/medicine/1814/SPC/dianette (accessed 31 August 2016).
- Mayor S. European evaluation concludes third generation pills are associated with a small increase in risk of venous thromboembolism. BMJ 2001; 323: 828.
- Faculty of Sexual and Reproductive Healthcare. Drug interactions with hormonal contraception. FSRH: 2011, updated 2012. Available at: www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdfG