48 HOW TO TREAT : ACNE VULGARIS
48 HOW TO TREAT : ACNE VULGARIS
8 DECEMBER 2023 ausdoc . com . au
Figure 7 . Postinflammatory hyperpigmentation in papulopustular acne .
Figure 8 . Postinflammatory erythema in papulopustular acne with icepick scarring .
Figure 9 . Icepick ( small , round ) and boxcar ( wide , flat ) scarring .
Figure 10 . Keloid scarring post-acne . the literature . Energy-based therapies may have a role in patients who are intolerant of oral or topical treatments , demonstrate poor compliance to treatment , or as an adjunct to prevent recurrence . Because of the relatively novel use of these treatments , the cost may be prohibitive to patients .
COMPLICATIONS OF ACNE
THE sequelae of acne have the potential to be permanently disfiguring , although most will eventually resolve with treatment of the disease itself .
PIH , characterised by patches of darkly pigmented skin relative to its surroundings , can occur at the site of resolved inflammatory acne lesions ( see figure 7 ). The mainstay treatment of PIH includes consistent sun protection , and selection of a topical agent that targets both active
Table 3 . Light and laser therapies used in the treatment of acne vulgaris Treatment Infra-red laser , radio frequency
Blue light therapy , including Kleresca laser ( LED light with biophotonic photoconverter gel ), red light therapy
Intense pulsed light , pulsed dye laser
acne lesions and the hyperpigmentation , such as azelaic acid or a topical retinoid . Topical hydroquinone 4 % can be used as a depigmenting agent once the acne has been treated . Conversely , post-inflammatory erythema ( see figure 8 ) may not respond to these treatments and require specialist input for laser therapies .
Post-acne scarring may occur in various forms including atrophic ( icepick , rolling , or boxcar subtypes , see figure 9 ) or hypertrophic ( keloid )
Proposed mechanism of action Thermal damage to sebaceous glands
types ( see figure 10 ). Patients with darker skin types are particularly prone to developing hypertrophic scarring . 34 Refer patients with acne scarring for specialist input ; they are likely to require a combination of laser therapies and minor surgical procedures .
Do not underestimate the distressing nature and social stigma of acne , as this often results in morbidity and lowered quality of life . 3 , 35 Provide early psychological support to these patients .
Bactericidal effect on C . acnes by inducing reactive free radicals
Thermal damage to sebaceous glands , bactericidal effect on C . acnes by inducing reactive free radicals
CASE STUDIES
Case study one
SVEN , a 19-year-old male with Fitzpatrick type II skin presents to his GP with a two-year history of nodulocystic acne . He had previously tried two-month courses each of adapalene 0.1 % and topical benzoyl peroxide . In addition he has been taking oral doxycycline for the past six weeks with minimal improvement in disease severity .
On examination , Sven has severe nodulocystic acne distributed over his cheeks , anterior chest , and back ; both atrophic and keloid scarring are present . Given the presence of scarring and his previous treatment history , the GP refers Sven to a dermatologist .
After careful screening , the dermatologist initiates 10mg oral isotretinoin daily . Oral erythromycin 400mg bd is added to reduce the severity of expected disease flare on starting treatment ; this is discontinued after two months . After three months the isotretinoin is increased to 20mg daily , and Sven tolerates this dose with no adverse events . He has no further new acne lesions after eight months of treatment and it is ceased after a total of 14 months , having reached his cumulative weight-based dose for this treatment period . During this time , his keloid scars are treated with intralesional triamcinolone injections , with modest improvement .
Thirteen months after treatment