44 HOW TO TREAT : ACNE VULGARIS
44 HOW TO TREAT : ACNE VULGARIS
8 DECEMBER 2023 ausdoc . com . au acne vulgaris varies widely . While there is no single standard definition of acne severity , mild acne can be loosely defined as scattered comedonal or papulopustular acne lesions limited to one or a few body parts and the absence of nodules . Some post-inflammatory changes may be present , but patients with significant scarring or psychological distress should not be classified as having mild acne . Moderate to severe acne encompasses multiple inflamed comedones and pustules and / or the presence of nodules over multiple body parts . Scarring , post-inflammatory changes , and psychological distress may be present .
DIAGNOSIS
ACNE vulgaris is largely a clinical diagnosis . Screen all patients for the use of acne-promoting medications ( see box 2 ), comedogenic topical preparations and occlusive occupational face garments . If possible , change to alternatives . Also screen all patients with features of high androgen levels ( see box 3 ) to rule out an underlying pathology . Failure to identify and treat an underlying pathology will result in persistent or recurrent acne after adequate treatment .
Screen all patients with features of high androgen levels .
Many other conditions may present with acneiform lesions that mimic acne vulgaris . Papulopustular rosacea can be differentiated from acne vulgaris by the presence of telangiectasias , the absence of comedones , and the papules and pustules arranged predominately around the mid-face . In periorificial ( perioral ) dermatitis , the papules are limited to the perioral , periocular or perinasal region . On the limbs , keratosis pilaris presents with flesh-coloured or erythematous keratotic follicular papules resembling mild acne .
TREATMENT
THE choice of treatment for acne is dependent on the type and severity of acne , the presence of sequelae , which include scarring , post-inflammatory hyperpigmentation ( PIH ) and erythema , and psychological distress .
Conservative treatment
Do not overlook the importance of a consistent , simple skincare routine . Advise patients to use a gentle , low pH , soap-free cleanser and oil-free moisturiser twice daily , in addition to a non-comedogenic sunscreen for daytime . Remind all patients , but particularly those with darker skin types , to reduce sun exposure to avoid darkening of PIH . Advise patients to discontinue comedogenic skincare and make-up products , such as those containing oils . Note that trauma to the skin caused by picking and squeezing acne and scrubbing of the skin while cleansing can promote the development of further lesions via transfer of bacteria , and should be discouraged .
Treatment of mild acne
In the patient with mild acne , a topical treatment may be used as a firstline adjunct once causative factors
Box 1 . Presentation of acne
• Comedonal acne :
• Comedonal acne consists of small non-inflammatory papules .
• In the case of closed comedones , or ‘ whiteheads ’, papules are smooth and white- or flesh-coloured .
• Open comedones , or ‘ blackheads ’ have a central follicular opening filled with brown , grey or black material ( see figure 1 ).
• Papulopustular acne :
• Papulopustular acne consists of small , inflamed papules and pustules on an erythematous base ( see figure 2 ).
• Nodular / nodulocystic acne :
• Nodular or nodulocystic acne presents with large , inflamed pustules or nodules ( see figure 3 ).
• Lesions are usually tender and deep-seated , with patients often noting these lesions ‘ never come to a head ’.
• Subtypes : — Certain patterns of acne vulgaris may present in the following patient groups and indicate various subtypes . — These often require more considered treatment and specialist input :
• Severe , nodular acne in young men particularly involving the chest , back and buttocks may indicate acne conglobata ( see figure 4 ).
• The sequelae of this disease include sinus tracts and severe scarring .
• Acne conglobata can be seen in conjunction with other conditions relating to follicular occlusion , such as hidradenitis suppurativa ( see figure 4 ), dissecting cellulitis ( see figure 5 ), and pilonidal sinuses .
• Scarred , eroded lesions with otherwise relatively mild comedonal or pustular acne may indicate acne excorie , a condition in which the patient obsessively scratches lesions until scarring occurs .
• A concurrent psychiatric disorder may be present .
and proper skin care have been addressed . Counsel patients that treatment benefits are slow , and they should adhere to treatment for at least three months to assess the efficacy of the regimen . Encouraging patients to keep a photo diary of their skin can help to reassure them of the gradual improvement in lesion severity over time .
The choice of topical treatment depends on the type of acne and the presence of any post-inflammatory changes ( see table 1 ). If the acne is predominately comedonal with little to no inflammatory component , agents with a prominent keratolytic effect ( that is , they encourage the removal of keratin debris ) will likely have the most benefit . Keratolytic agents include azelaic acid , topical retinoids and alpha and beta hydroxy acids . The latter are found in many over-the-counter preparations or at higher strengths in chemical peels performed by dermal therapists ; however , patients should be cautious of the risk of over-sensitisation if they are already using a potentially irritating topical treatment .
Azelaic acid is both keratolytic and has antimicrobial properties against C . acnes , overall reducing inflammation . 13 In addition , because of suppression of tyrosine kinase ( a key factor in the development of hyperpigmentation ) azelaic acid is effective at concurrently treating PIH . A marked reduction in the severity of PIH has been shown in patients of Asian descent , so consider this product in those darker skin types . 14
Topical retinoids are derived from vitamin A and , much like
Figure 1 . Comedonal acne . Closed comedones (‘ whiteheads ’) are present in the lower half of the figure ; open comedones (‘ blackheads ’) are present in the top right corner .
Box 2 . Medications that can promote acne
• Oral corticosteroids .
• Anabolic steroids .
• Progestogen-only hormonal contraception ( including hormonal implants and IUDs ).
• Antiepileptics ( phenytoin ).
• Antidepressants ( lithium ).
• Ciclosporin .
• Azathioprine .
• Vitamin B2 , B6 and B12 .
Box 3 . Features that may prompt screening for hyperandrogenism
• Acne in preadolescents .
• Hirsutism .
• Oligomenorrhoea .
• Early features of virilisation in preadolescents .
azelaic acid , act via multiple mechanisms to reduce acne . Retinoids reduce hyperkeratinisation to inhibit comedone formation and have an anti-inflammatory effect . 15 Their anti-tyrosinase effect also benefits patients who have coexisting PIH . 16 Multiple preparations of retinoids are available via prescription , including tretinoin at a 0.025 % or 0.05 % strength , and adapalene 0.1 %. In patients with acne who have no other comorbidities , adapalene 0.1 % was better tolerated compared with tretinoin PAGE 46