HOW TO TREAT 49 cessation , his acne returns . Because of the propensity of this acne type to cause long-lasting scarring , Sven is again started on oral isotretinoin 20mg daily . He remains on oral isotretinoin two years after disease reoccurrence with a plan for weaning . Sven continues to receive intralesional triamcinolone injections for keloid scarring .
ausdoc . com . au 17 NOVEMBER 2023
HOW TO TREAT 49 cessation , his acne returns . Because of the propensity of this acne type to cause long-lasting scarring , Sven is again started on oral isotretinoin 20mg daily . He remains on oral isotretinoin two years after disease reoccurrence with a plan for weaning . Sven continues to receive intralesional triamcinolone injections for keloid scarring .
This case highlights the need for prompt specialist referral , even early in the acne disease process , if scarring is present . This is because of the possibility of lifelong disfigurement if prompt effective treatment is not provided . While it is usually prudent to wait three months to review treatment efficacy , severe cases may warrant early intervention with isotretinoin . As a result , there is no PBS mandated minimum time to start treatment . Relapse rates after oral isotretinoin therapy vary but are estimated to occur in one third of patients . 36 The peak time to relapse is 6-18 months after treatment cessation , with early discontinuation and low cumulative doses identified as risk factors for relapse . 36 Patients may need a second course of oral isotretinoin , or maintenance therapy with topical agents to ensure sustained results .
Case study two
Archie , a 16-year-old male with Fitzpatrick type III skin presents to the dermatologist with a three-year history of nodulocystic acne . He had been trialled on multiple courses of topical benzoyl peroxide and retinoid therapies with little benefit . He had started oral doxycycline the previous week .
On examination , Archie has severe nodular acne limited to the face but with the presence of icepick scars . After screening and education , he is promptly started on oral isotretinoin 10mg daily with concomitant oral erythromycin 400mg bd . Erythromycin is stopped after three months . The isotretinoin is increased to 20mg daily after three months , then further increased to
20mg weekdays / 40mg weekends at five months . At five months mild improvement is seen , although active nodulocystic lesions are still present ( see figure 3 ). Intralesional triamcinolone 2.5mg / mL injections and manual extraction are employed as adjuncts on active lesions , with good results . After 15 months of treatment , Archie does not experience further active lesions , although icepick scarring and post-inflammatory erythema remain ( see figure 11 ). He tolerated treatment well , although a mild raise in transaminases was detected on monitoring blood tests . The dose
How to Treat Quiz . of isotretinoin was subsequently reduced to 10mg daily .
As demonstrated in both of these cases , erythromycin is a useful adjunct when starting oral isotretinoin in patients with severe disease . Tetracyclines are not prescribed concomitantly with isotretinoin due to the risk of pseudotumour cerebri , that is , idiopathic intracranial hypertension . A flare of acne may be expected approximately 6-8 weeks after starting isotretinoin treatment , and this usually resolves by three months . Under dermatology guidance , systemic glucocorticoids may be used to counteract an initial flare ; however ,
GO ONLINE TO COMPLETE THE QUIZ ausdoc . com . au / how-to-treat
1 . Which ONE commensal pathogen is most commonly implicated in the pathogenesis of acne ? a Staphylococcus aureus . b Staphylococcus epidermidis . c C . acnes . d Pseudomonas aeruginosa .
2 . Which THREE have been implicated in the pathogenesis of acne lesions ? a Hyperandrogenism . b Low BMI . c Increased sebum production . d Skin flora activating local inflammatory pathways .
3 . Which ONE is NOT a direct complication of acne vulgaris ? a Scarring . b Post-inflammatory erythema . c Secondary infection . d Weight gain .
4 . Which TWO are recommended before starting treatment for acne ? a A change in the patient ’ s diet . b Review of medications . c Starting vitamin supplementation . d Screening for features of associated diseases .
5 . Which THREE of the following indicate a follicular occlusion syndrome in conjunction with acne conglobata ? a Dissecting cellulitis . b Hidradenitis suppurativa . c Acne keloidalis nuchae . d Pilonidal sinus .
6 . Which THREE of the following features may indicate hyperandrogenism as the cause of acne ? a Weight loss . b Acne in prepubertal children . c Irregular menses . d Hirsutism .
7 . Which THREE are appropriate as a first-line treatment for mild acne ? a Oral isotretinoin . b Topical benzoyl peroxide . c Combined oral contraceptive pill . d Topical adapalene .
EARN CPD OR PDP POINTS
• Read this article and take the quiz via ausdoc . com . au / how-to-treat
• Each article has been allocated one hour by the RACGP and ACRRM .
• RACGP points are uploaded every six weeks and ACRRM points quarterly . they are used uncommonly because of their side effect profile . For persistent or painful lesions , intralesional steroid injections and / or manual extraction can provide symptomatic relief ; however , the procedure carries risks of PIH , scar formation , and skin atrophy . This case particularly highlights the importance of blood test monitoring in addition to verbally screening for adverse events during appointments . Although the risk is low , oral isotretinoin does have side effects , and early identification will prompt further investigation , as well as dose adjustment or discontinuation if necessary . In line with recent
ACNE VULGARIS
8 . Which ONE of the following antibiotics is a first-line treatment for acne ? a Azithromycin . b Doxycycline . c Cefalexin . d Amoxicillin .
9 . Which TWO medications are safe to use in pregnancy ? a Topical benzoyl peroxide . b Oral isotretinoin . c Spironolactone . d Topical azaleic acid .
10 . Which THREE situations warrant consideration for referral to a dermatologist ? a The presence of scarring . b Significant psychological distress . c No treatment response after two weeks . d Acne in prepubertal children .
MHRA guidelines , screening for mental health disorders and sexual dysfunction may become important in isotretinoin monitoring .
CONCLUSION
ACNE vulgaris is a common presentation that occurs predominantly in adolescents and young adults . The clinical course ranges from mild comedonal acne requiring lifestyle and / or topical management alone , to severe nodular acne that is resistant to multiple courses of therapies and results in permanent disfigurement .
Although a range of topical agents is available for mild to moderate disease , oral isotretinoin remains the gold standard of treatment in severe or persistent cases . In the first instance , GPs should initiate topical therapies and / or oral antibiotics in an escalating manner . Referral to a dermatologist is warranted if therapy fails after three months , or if scarring , hyperpigmentation , or significant psychological distress is present . Lasers and light therapies may be useful adjuncts , although these are costly and require stronger evidence . Certain patient subgroups , such as those who are pregnant and darker skinned individuals , have reduced treatment options . Further studies looking at the impact of diet , gut microbiome and other lifestyle factors on acne severity may provide key treatment targets in the future .
RESOURCES
• Oratane ( oral isotretinoin ) Consumer medicine information leaflet bit . ly / 3Yyi86U
• The Australasian College of Dermatologists A-Z of Skin : Acne Vulgaris dermcoll . edu . au / atoz / acnevulgaris
References Available on request from howtotreat @ adg . com . au
Figure 11 . Postinflammatory erythema and icepick scarring post-treated nodulocystic acne .