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Acne Vulgaris Acne Vulgaris Acne Vulgaris Acne Vulgaris Acne Vulgaris
Acne Vulgaris Acne Vulgaris Acne Vulgaris Acne Vulgaris Acne Vulgaris
Acne Vulgaris Acne Vulgaris Acne Vulgaris Acne Vulgaris Acne Vulgaris
Evidence
ACNE VULGARIS
Ilse Truter
Drug Utilization Research Unit (DURU), Department of Pharmacy, Nelson Mandela Metropolitan University
Acne is a disorder of the pilosebaceous follicles causing comedones, papules and pustules on the face, chest and
upper back.1 It affects virtually all adolescents, to varying degrees of severity, and usually appears at the time of
puberty.1 Although it may sometimes be unsightly and can persist for several years, it is not usually serious and
resolves in most patients by the age of 25 years.2 However, it can have a significant psychological impact as it affects
young people at a stage in their lives when they are especially sensitive about their appearance.2
Diagnosis is usually straightforward and most patients presenting in a community pharmacy will generally be seeking
appropriate advice on correct product selection rather than wanting someone to put a name on their rash. The
majority of cases seen in the pharmacy setting will be mild and can be managed appropriately without referral.
More persistent and severe cases need referral for more potent topical or systemic treatment. It is important to
note that all forms of acne can cause scarring.3
Aetiology/pathophysiology
The pathogenesis of acne vulgaris is multifactorial.6 The various
pathogenic factors represent specific targets for treatment and it
has been proven that treatment directed at different pathogenic
factors achieves better results than treatment methods aimed at
the same pathogenic factors.7
A cascade of events takes place at puberty resulting in the
formation of non-inflammatory and inflammatory lesions.
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Definition
Mild
Moderate
Severe
Moderate acne
Similar to mild acne, but more papules and pustules.
Patients with moderate acne typically have a few to several
nodules. Lesions are often painful and there is a real
possibility of scarring.5
Severe acne
Similar to moderate acne but with nodular abscesses,
leading to extensive scarring. Patients with severe acne
have numerous or extensive lesions.
Another classification of acne severity is to grade acne as
follows7:
Grade 1: Comedones only.
Grade 2: Inflammatory papules present in addition to the
comedones.
Grade 3: Pustules present in addition to any of the
above.
Grade 4: Nodules, cysts, conglobate lesions or ulcers
present in addition to any of the above.
Acne can also be classified by the type of lesion comedonal, papulopustular, and nodulocystic (pustules and cysts
are considered inflammatory acne)3:
Comedonal acne
Comedonal acne presents with a tendency to greasiness
and the presence of enlarged pores, comedones and
occasionally papule and pustule formation. There may be
plenty of open or obstructed comedones, but with scant
inflammatory changes. Comedonal acne may cause scarring, requiring systemic therapy.
Inflammatory acne
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Evidence
Conditions to eliminate
14
Less commonly
Azathioprine
Ciclosporin
Disulfiram
Phenobarbital
Quinidine
Tetracycline
Vitamins B1, B6, B12 and D2
When to refer
The following symptoms suggest the need for referral1,2,5,11,12:
Moderate or severe acne.
Development of severe complications (for example, deep
pustules, severe cases of nodular acne and/or pigmentation).
Suspected occupational causes.
Mild acne, if there is no improvement after two months
with over-the-counter (OTC) treatment or if treatment
response is poor.
Acne beginning or persisting outside the normal age
range for the condition or late onset acne.
Severe psychological stress.
Suspected medicine-induced acne.
Suspected rosacea.
Unpleasant side effects from current acne therapy.
Table 3: Specific questions to ask the patient with acne when taking a dermatological history 1,5
Question
Relevance
Age of onset?
Certain skin problems start in one particular location before spreading to other parts of
the body, for example impetigo usually starts on the face before spreading to the limbs.
Acne is typically confined to the face, chest and upper back.
Severity?
Moderate acne is not confined to the face, but also involves the back and chest. Lesions
are often painful and there is a real possibility of scarring.
Severe acne has all the characteristics of moderate acne plus the development of cysts.
Lesions are often widespread and scarring is frequent.
In some occupations, workers are exposed to irritants and chemicals (for example,
hairdressing) or to excessively hot and humid conditions causing sweating. Car mechanics, for example, are exposed to frequent or prolonged contact with grease and oils,
which can cause acne-like lesions.
Skin disoders may be the first sign of internal disease. For example, diabetes can
manifest with pruritis and thyroid disease with hair loss and pruritis. Acne can be due to
a hormonal imbalance.
Foreign travel
Tropical skin conditions can be contracted when abroad but lesions do not appear until
the person has returned home.
Some skin conditions (such as scabies) can infect those with whom the patient is in close
contact.
Ask for the patients opinion. This may help with the diagnosis or shed light on anxieties.
Temperature
The backs of the fingers can be used to identify generalised warmth or coolness of the
skin. Generalised warmth might indicate fever. Local warmth could indicate inflammation or cellulitis.
Distribution
The pattern of involvement of the skin may assist with diagnosis. Acne typically affects
the face, chest and upper back, whereas psoriasis typically affects elbows, knees, scalp
and the sacral area, adult seborrhoeic dermatitis affects the face and mid-chest.
Lesion shape
Are the lesions arciform (in an arc), linear, annular (in a ring) or clustered? Tinea
corporis (ringworm) usually presents as an annular rash.
Recent trauma
Have the lesions developed on a site of trauma or injury. This is seen in, for example,
psoriasis and warts.
Non-pharmacological management
The following non-pharmacological treatment advice can be
given to patients with acne2:
There is no evidence that poor hygiene causes acne, but
cleansing the affected areas two to three times daily is
recommended. An antibacterial soap or a mild cleanser
to degrease the skin and to remove bacteria can be used,
and can help to reduce the severity of the condition,
although extra washing, the use of antibacterial soaps
and scrubbing have, according to evidence, no added
benefit.4 Sweat should not be allowed to remain on the
skin, but should be washed off as soon as possible.
Patients should be advised to avoid hairstyles in which
the hair is constantly touching the face, and to shampoo
15
Evidence
Pharmacological treatment
The pharmacological treatment of acne can be divided into
topical and systemic treatment. The different medicines used
in the treatment of acne are illustrated in Figure 1.4
Topical treatments
Non-prescription topical treatment is usually the first line of
treatment for mild to moderate acne. Topical OTC acne
treatments typically contain benzoyl peroxide, azelaic acid,
salicylic acid, sulphur or an antibacterial.
The overall aim of topical therapy is to remove follicular
plugs, allowing sebum to flow freely, and to minimise
bacterial colonisation of the skin. Treatment must be used
regularly for up to three months to produce benefits.2 Approximately 60% of patients should see an improvement in
their symptoms after eight to 12 weeks.5 If symptoms fail to
improve after this time period, referral is necessary. Four
types of preparations are available2:
Inflammation
Increased sebum
production
Proliferation of
Propionibacterium acnes
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Hair
Benzoyl peroxide
Benzoyl peroxide is generally accepted as the first-line
topical treatment for mild to moderate acne.2 It exerts its
main effect by having a mild but significant keratolytic effect
(therefore acting in a comedolytic fashion), but it is also a
broad-spectrum antimicrobial, acting in a non-antibiotic
fashion.7 It has potent antimicrobial effects but is sloweracting than systemic antibiotics.7 It reduces the concentration of P acnes., has slight anti-inflammatory and mild
anticomedogenic effects. Many studies have investigated
the efficacy of benzoyl peroxide. No resistance has been
reported to date.7 It is applied once or twice daily to the
entire affected area.7 There is no evidence to suggest that
10% benzoyl peroxide is more effective than 5%.5 Therefore,
because of its potential to cause erythema and irritation,
concentrations of 10% should probably be avoided.5 Lower
strengths should be used in persons with sensitive skin and
in very young or anxious patients.7 Higher concentrations
and washes can be used on the chest, shoulders and back.7
Benzoyl peroxide can be used alone in mild acne or in
combination with topical retinoids in severe comedonal and
early inflammatory acne. It may be used in combination with
systemic antibiotics when prolonged or repeated courses of
the latter are necessary. A variety of other agents (for
example, miconazole and hydrocortisone) have been used
in combination with benzoyl peroxide but none has proved to
be significantly better than benzoyl peroxide alone.5
Benzoyl peroxide can cause drying, burning and peeling
on initial application.1,5 If patients experience these side
effects, they should stop using the product for a day or two
before starting again. Patients should start on the lowest
strength available, especially if they have a sensitive or fair
skin.1,5
Prescription treatment
Azelaic acid
Azelaic acid is a suitable topical agent for mild to moderate
acne due to its antimicrobial effect on P acnes and its
influence on follicular hyperkeratosis.3 It is usually applied
twice daily. Its safety and efficacy have not been proven for
use for more than six months.3
Retinoids
Topical retinoids target the microcomedo, which forms the
earliest precursor of visible acne lesions.7 They have
multiple anti-acne actions, namely to inhibit/reduce the
number of microcomedones, reduce mature comedones,
reduce inflammatory lesions, promote normal desquamation
of follicular epithelium, have an anti-inflammatory effect,
enhance the penetration of other medicines and maintain
remission by inhibiting microcomedones.7 Different topical
retinoids are available, namely tretinoin, adapalene,
isotretinoin and tazarotene.3,7 They have similar efficacy but
share a common side effect namely initial irritation on
application.7 The topical retinoids should be applied to the
whole affected area and not only on visible lesions.
According to the Global Alliance recommendations,7 the
topical retinoids should be the primary form of treatment for
Oral antibiotics
Oral antibiotics are indicated for moderate to severe acne
(Grades 2 to 4).7 Examples are tetracyclines (especially
doxycycline, lymecycline, minocycline, and the older firstgeneration tetracyclines such as oxytetracycline), erythromycin, clindamycin and co-trimoxazole.7 Penicillins are not
considered to be effective in the management of acne.
Minocycline, doxycycline and lymecycline have similar
efficacy and pharmacoeconomically there is very little
difference between them.7 The Standard Treatment Guidelines and Essential Drugs List for South Africa: Primary
Health Care12 recommends benzoyl peroxide 5% gel applied
at night, as well as oral doxycycline 100 mg daily for three
months, if there are many pustules.
Oral antibiotics induce improvement within the first three
or four months of treatment, with little improvement thereafter,
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Evidence
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Treatment of scars
Small scars can be treated with chemabrasion (which uses
chemicals to peel away top layers of skin), laser resurfacing
(which uses a carefully controlled laser to burn away scar
tissue) or dermabrasion (which uses a whirling wire brush to
skim off scar tissue) under the supervision of a trained
professional.4,15 Deeper, discrete scars can be excised.4
Wide, shallow depressions can be treated with subcision or
collagen injection.4 Collagen implants are temporary and
must be repeated every few years.4
Conclusion
The management of acne vulgaris by non-dermatologists is
increasing.8 Pharmacists have a definite role to play in the less
severe forms of acne and especially with respect to the counselling of patients with any form or severity of acne. Acne can be
extremely distressing and can impact severely on the quality of
life of a person. Initially mild acne should be treated with topical
agents. The choice of treatment depends on whether
comedonal or inflammatory lesions predominate. In more
severe disease, addition of systemic drugs to topical therapy is
required. Oral antibiotics are the mainstay of treatment for
moderate to severe acne. Early referral of those with severe
acne may prevent scarring. Acne responses to treatment vary
considerably. Frequently more than one treatment modality is
used concomitantly. Best results are seen when treatments are
individualised on the basis of clinical presentation.
The reader is strongly encouraged to consult the following sources for more detailed evidence-based information on
acne:
References:
1.
Rutter P. 2004. Community Pharmacy: Symptoms, Diagnosis and
Treatment. Edinburgh: Churchill Livingstone.
2.
Nathan A. 2008. FASTtrack: Managing Symptoms in the Pharmacy.
London: Pharmaceutical Press.
3.
South African Medicines Formulary (SAMF). 2008. 8th Edition. Edited by
CJ Gibbon. Claremont: Health and Medical Publishing Group of the
South African Medical Association.
4.
The Merck Manual of Diagnosis and Therapy. 2006. 18th Edition. Edited
by MH Beers. Whitehouse Station: Merck Research Laboratories.
5.
Rutter P. 2005. Symptoms, Diagnosis and Treatment: A Guide for
Pharmacists and Nurses. Edinburgh: Elsevier Churchill Livingstone.
6.
Harper JC & Fulton J. 2008. Acne Vulgaris. eMedicine, 15 July.
Available on the web: http://emedicine.medscape.com/article/1069804print (date accessed: 15 December 2008).
7.
Acne Guideline 2005 Update. 2005. Compiled by W Sinclair & HF
Jordaan. South African Medical Journal, 95 (11): 883-892.
8.
Haider A & Shaw JC. 2004. Treatment of Acne. Journal of the American
Medical Association, 292: 726-735.
9.
Feldman S, Careccia RE, Barham KL & Hancox J. 2004. Diagnosis and
Treatment of Acne. American Family Physician, 69: 2123-2130, 2135-2136.
10. Lauharanta J. 2007. Guidelines Advisory Committee (GAC). Summary
of Recommended Guideline: Acne Management. (EBM guidelines.) April.
Available on the web: www.gacguidelines.ca (date accessed: 15
December 2008).
11. MeReC Bulletin. 1999. The Treatment of Acne Vulgaris: An Update. 10
(8). Liverpool: National Prescribing Centre.
12. Standard Treatment Guidelines and Essential Drugs List for South Africa:
Primary Health Care. 2003. Pretoria: The National Department of Health.
13. Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, Siegfried EC,
Thiboutot DM, Van Voorhees AS, Beutner KA, Sieck CK & Bhushan R.
2007. Guidelines of Care for Acne Vulgaris Management. National Guideline
Clearinghouse. Available on the web: http://www.guideline.gov/summary/
summary.aspx?doc_id=10797 (date accessed: 12 December 2008).
14. Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, Siegfried
EC, Thiboutot DM, Van Voorhees AS, Beutner KA, Sieck CK & Bhushan
R. 2007. Guidelines of Care for Acne Vulgaris Management. Journal of
the American Academy of Dermatology, 56 (4): 651-663.
15. Acne Vulgaris Treatment Overview. 2007. Acne Health Centre. WebMD.
Available on the web: http://www.webmd.com/skin-problems-and-treatments/
acne/acne-vulgaris-treatment-overview (date accessed: 15 December 2008).
Recommended treatment
Grade 1
This degree of acne should be managed topically. A topical retinoid will suffice in most cases, but the addition of benzoyl
peroxide or azelaic acid may be necessary in resistant cases.
Grade 2
In milder cases with superficial inflammatory papules, the same treatment as above can be followed. However, where the
papules are more deeply situated, a systemic antibiotic is indicated.
Grade 3
In these cases there is always a severe, deep inflammatory process present with a marked influx of neutrophils, necessitating systemic antibiotics. These should always be used in combination with a topical retinoid and, if the systemic treatment
needs to go on for longer than three months, topical benzoyl peroxide should be added. Hormonal treatment can be used with
good success at this stage in female patients who desire contraception or who have other gynaecological indications for this
treatment.
Grade 4
Systemic isotretinoin represents the treatment of choice in these patients. In females, an oral contraceptive combined with
anti-androgens can sometimes be effective. Systemic antibiotics can bring about excellent improvement in these cases, but
the improvement is of short duration and these medicines do not represent a long-term solution for this type of acne.
Unacceptably long courses of antibiotics are usually necessary.
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