Acne

Prevalence

• 50% of adolescents will have acne.
• 10% will have severe acne.
• 10-20% of cases persist into adulthood.

Definition

• Chronic inflammatory disease of the pilosebaceous unit.

Common Demographics

• Adolescents and young adults.
• Males tend to resolve in early twenties.
• Females can persist into 30s/40s.

Pathogenesis

• Abnormal sebum production (due to androgens).
• Abnormal skin cell development and desquamation.
• Infection by Propionibacterium acnes (P. acnes).
• Inflammation.

Causes

• Familial/genetic tendency.
• Androgenic hormones and hormonal changes during puberty.
• Acne bacteria (P. acnes).
• Occlusive/comedogenic products.
• Polycystic Ovary Syndrome (PCOS).
• Drugs (e.g., steroids, hormones, anticonvulsants).
• High environmental humidity.
• Possible dietary factors (dairy/high GI foods).

Aggravating Factors

• Drugs.
• Topical products.
• Hormonal changes.
• Consider PCOS if hirsutism, obesity, or menstrual irregularity present.

Differential Diagnoses

• Folliculitis.
• Keratosis pilaris.
• Milia.
• Miliaria.
• Neonatal cephalic pustulosis.

Severity Classification

Mild Acne

• Primarily composed of noninflammatory lesions or comedones (blackheads or whiteheads).
• Some papules (red pimples) may also be present.

Moderate Acne

• Contains both noninflammatory comedones and inflammatory lesions, including papules and a few pustules (pimples with a white top).

Moderate to Severe Acne

• Characterized by numerous comedones, pustules, and papules.
• A few cysts (large pus-filled inflammatory lesions >5 mm in diameter) or nodules (cysts that have ruptured) may also be present.

Severe Acne

• Characterized by both inflammatory and noninflammatory symptoms as described above, but with the presence of numerous nodules and/or cysts.
• Nodules and cysts are often painful and found on the face, neck, and upper trunk, and sometimes extend to the waistline.

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Treatment

1. Assessing Acne Severity

• Based on lesion type, distribution, and inflammation:
  • Mild: Comedones with occasional inflammatory lesions.
  • Moderate: Multiple inflammatory papules/pustules ± nodules.
  • Severe: Nodulocystic lesions, scarring, significant psychosocial impact.
• Severity guides treatment selection.

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2. Pre-Treatment Considerations

• Androgenisation in Women:
  • Evaluate for hirsutism, obesity, menstrual irregularity.
  • Consider hormonal work-up (e.g., PCOS).
• Occupational or Environmental Exposures:
  • Exacerbating agents: halogens, industrial oils, heat, humidity.
  • Recommend avoidance or protective measures.
• Medication Review:
  • Cease/change acnegenic drugs (e.g. steroids, lithium, phenytoin).
• Cosmetic Use:
  • Advise non-comedogenic, oil-free skin products and sunscreens.
• Patient Education:
  • Debunk myths (e.g., diet, hygiene alone).
  • Clarify realistic treatment timelines (up to 6–12 weeks).

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3. Psychosocial Assessment

• Acne can lead to:
  • Social withdrawal
  • Reduced self-esteem
  • Depression, anxiety, suicidal ideation
• Explore with open-ended questions, regardless of severity.
• Address body image and emotional wellbeing directly.

General Principles

• Stop acne-exacerbating agents.
• Ensure skin care products are suitable.
• Consider anti-androgenic COCP in appropriate female patients.
• Avoid concurrent use of oral + topical antibiotics (↑ resistance, ↓ efficacy).

Treatment by Severity

Severity	First-Line Treatments
Mild	– Topical retinoids (e.g., adapalene, tretinoin) – Benzoyl peroxide (BPO) – Topical antibiotics (e.g., clindamycin) – Keratolytics (e.g., salicylic acid) – Azelaic acid, niacinamide
Moderate	– Oral antibiotics (e.g., doxycycline, minocycline) – COCP and/or spironolactone (females) – Always combine with topical retinoid or BPO
Severe	– Refer for oral isotretinoin if: – Scarring or nodulocystic acne – Resistant or recurrent disease – Significant psychosocial impact

Specific Pharmacological Therapies

Topical Agents

• Benzoyl Peroxide (BPO)
  • 2.5–5% preferred; antibacterial & keratolytic
  • Bleaches fabrics, may irritate
• Topical Retinoids
  • Adapalene 0.1%: daily at night
  • Tretinoin 0.025%: start low, titrate
  • Trifarotene 0.005%: approved for truncal acne
  • Start alternate nights → nightly
  • Teratogenic; avoid in pregnancy
• Clindamycin 1% or Erythromycin
  • Less effective as monotherapy due to resistance
  • Combine with BPO for synergy

Topical Combinations

• BPO + Adapalene: comedonal acne
• BPO + Clindamycin: inflammatory acne
  • Cease once inflammation settles

Oral Antibiotics

• Doxycycline: 50–100 mg daily
  • Common choice; photosensitivity, GI upset
• Minocycline: 50–100 mg daily
  • Check LFTs at baseline, then yearly (risk of liver toxicity)
• Erythromycin: 250–500 mg BD
  • Use if tetracyclines contraindicated (e.g., pregnancy)
• Duration:
  • Review at 6–8 weeks
  • Stop after control; continue topicals 3–6 months
• Caution:
  • Avoid tetracyclines in pregnancy and children <8 years
  • Do not co-prescribe with topical antibiotics

Hormonal Treatments (Females)

• Combined Oral Contraceptive Pills (COCP)
  • Cyproterone preferred for anti-androgenic effect
  • Alternatives: drospirenone, desogestrel, gestodene
  • May take 3–6 months for full effect
  • Can be combined with antibiotics or spironolactone
• Spironolactone
  • Anti-androgen; start at 25–50 mg/day → titrate to 100 mg/day
  • Combine with COCP for contraception and SE control
  • Monitor: BP, renal function, LFTs (6-monthly)
  • Side effects: breast tenderness, irregular menses, hypotension
  • Pregnancy category D – contraindicated

Oral Isotretinoin

• Indications:
  • Severe, nodulocystic, scarring, or refractory acne
  • Major psychosocial distress
• Dose:
  • Start at 0.5 mg/kg/day → increase up to 1 mg/kg/day
  • Typical course 6–9 months
• Teratogenic – strict pregnancy prevention needed
• Not contraindicated in history of depression; monitor mental health
• Common side effects:
  • Dry lips/skin, cheilitis, epistaxis, sun sensitivity, myalgia
• Less common side effects:
  • Dyslipidaemia, paronychia, hair loss, night vision issues, rectal bleeding

Antibiotic Stewardship

• Avoid prolonged use (>3 months) of oral antibiotics.
• Combine with BPO to reduce resistance.
• Do not use oral and topical antibiotics simultaneously.
• Rotate antibiotics if inadequate response at 6–8 weeks.

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Information for patients with acne

✅ Common Myths About Acne – Busted

• “Acne is caused by poor diet.”
  ❌ False. Diet does not directly cause acne. However, high glycaemic index foods and dairy may make acne worse in some individuals. If you notice a particular food triggers breakouts, it’s reasonable to reduce or avoid it.
• “Acne is caused by hormone problems.”
  ❌ Usually false. Most people with acne have normal hormone levels. Their skin is just more sensitive to natural hormones like androgens. A small group (e.g., those with PCOS) may have true hormone imbalances contributing to acne.
• “Acne is caused by poor hygiene.”
  ❌ False. Acne is not due to dirty skin. In fact, over-washing or scrubbing can irritate the skin and make acne worse. Gently wash your face twice daily with a mild cleanser.
• “Everyone gets acne, so it doesn’t matter.”
  ❌ False. Around 50% of teenagers get acne, but that doesn’t mean it shouldn’t be treated. Acne can impact self-esteem, social life, and mental health—your concerns are valid.

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✅ Important Facts About Acne

• Acne is very common and can begin as early as age 8.
• It can lead to emotional distress, including anxiety and depression.
• Oil-based skincare products and makeup can clog pores and worsen acne.
• Heat and humidity, such as in saunas, can aggravate acne.
• Some people continue to have acne into adulthood.
• Untreated or severe acne may cause permanent scarring.
• Medications are available that can significantly improve acne.

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💊 How to Treat Acne Effectively

• Follow your treatment plan every day, unless your doctor tells you otherwise.
• Apply creams or gels to the whole affected area (e.g., entire forehead or cheeks), not just to individual spots.
• Use oil-free (non-comedogenic) or water-based moisturisers, cosmetics, and sunscreens.
• Try not to pick or squeeze pimples—this can lead to scarring or worsen inflammation.
• Acne treatment takes time to work. Most options take 6–12 weeks to show visible results—be patient and consistent.

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Special Considerations

Infantile Acne

• Can occur after 3 months of age.
• Needs comedones, papules, and pustules.
• Usually mild and resolves by 12 months.
• Treatment options include benzoyl peroxide, topical antibiotics, and topical retinoids.

Neonatal Cephalic Pustulosis

• Variant of neonatal acne.
• Eruption on the face and/or scalp of newborn babies, usually around 3 weeks of age.
• No comedones present.
• Associated with Malassezia colonization.
• Usually resolves without treatment.
• Can use topical antifungals, e.g., Ketoconazole 2% BD for 3 days.