Acne: managing patients in primary care

1. A 23 year old man comes to see you with a facial rash. This is a
photograph of his face.

What is the most likely diagnosis?

a.

Seborrhoeic dermatitis

b.

Acne vulgaris

Pre-test

Your

Correct

answer

answer

answer

c.

Rosacea

d.

Acne excorie

e.

Perioral dermatitis

That's not right. The correct answer is b.

The distribution of the rash, age of the patient, and clinical
picture of greasy skin with non-inammatory papules, open
and closed comedones (whiteheads and blackheads), and
inammatory papules, pustules, and nodules makes acne
vulgaris the most likely diagnosis.
2. You consider the diagnosis of acne vulgaris. Which of the
following treatments usually improves acne?

a.

Dietary advice

b.

Topical benzoyl peroxide

c.

Progesterone-only
contraceptives

d.

Skin cleansing

e.

Flucloxacillin

Pre-test

Your

Correct

answer

answer

answer

That's not right. The correct answer is b.

There is no evidence to support specic dietary advice in

patients with acne. Topical benzoyl peroxide usually improves
acne and is a rst line treatment option. Antibiotic resistance
is an increasing and serious problem, so non-antibiotic
treatments should be given preference to antibiotics.
Progesterone-only contraceptives can worsen acne in female
patients. There is no evidence to support skin cleansing, and
intensive cleansing can worsen acne. Flucloxacillin is not used
in the treatment of acne.
3. A 45 year old man comes to see you with an eruption on his
chest and trunk. It is not itchy. He is afebrile and doesnt have
any joint pains. He has not taken any medications recently.

Which statement is correct?

Pre-test

Your

Correct

answer
a.

He is too old for acne

vulgaris

b.

He may have acne

fulminans

c.

He has acne vulgaris

d.

He has Gram negative

folliculitis

answer

answer

That's not right. The correct answer is c.

The most likely diagnosis is acne vulgaris due to the clinical
picture of non-inammatory papules, open and closed
comedones (whiteheads and blackheads), and inammatory
papules, pustules, and nodules.
He is not too old for the diagnosis. While the peak incidence is
age 14-17 in females and 16-19 in males, [ 7 ] adults can
develop acne at any age. The history and clinical picture is not
of acne fulminans as he is afebrile and does not have joint
pains. Gram negative folliculitis is a complication of long term
antibiotic therapy and patients typically present with
supercial follicular pustules or nodules.
4. A 15 year old girl wants some information on acne. Which one
of the following statements is correct?
Pre-test

Your

Correct

answer
a.

The peak incidence of acne

is around 15 in girls

b.

Acne is caused by greasy

skin

c.

The girl will grow out of

acne after puberty

d.

A skin exfoliating regimen

should be established

answer

answer

That's not right. The correct answer is a.

The peak incidence of acne is between ages 14 and 17 in
females and slightly later in males. [ 7 ] Children and mature
adults can also develop acne. In acne, there is altered sebum
composition; clinical evidence of seborrhoea may or may not
be present although severity of acne does correlate with
sebum production. Although acne is self limiting in most
patients, this does not necessarily coincide with the end of
puberty. Acne slowly resolves after the early- to mid-20s,
although it can persist.
Exfoliation may only be helpful in supercial non-inamed
lesions. Often, however, harsh cleansing regimens result in
skin irritation, which limit the tolerability of topical
treatments.

5. A 25 year old man comes to see you as he is worried about an

itchy skin rash in his hair. He is of Afro-Caribbean origin. On
examination there are rm skin-coloured papules on his
occiput. What is the most likely diagnosis?

a.

Impetigo

b.

Gram negative folliculitis

c.

Pseudofolliculitis barbae

d.

Acne vulgaris

e.

Acne keloidalis nuchae

Pre-test

Your

Correct

answer

answer

answer

That's not right. The correct answer is e.

Acne keloidalis nuchae occurs in patients with tightly curled
hair. When it affects the beard area it is called
pseudofolliculitis barbae. Treatment of the condition and
established keloids is very dicult. Longer hairstyles should
be encouraged.
6. A 25 year old man comes to see you as he has a facial rash.
There are just pustules on his face and no comedones. Which
of the following statements is correct?
Pre-test

Your

Correct

answer

answer

answer

a.

Acne vulgaris usually shows

only one lesion type

b.

Drug induced acne is often

monomorphic

c.

Drug induced acne is often

polymorphic

d.

The lesion type is of minor

importance when choosing
a therapy

That's not right. The correct answer is b.

Drug induced acne is often monomorphic, showing one type
of acne lesion only (for example, comedones in chloracne or
pustules in steroid acne). Acne vulgaris is polymorphic with a
variety of different acne lesions at different stages of
evolution. The type of lesion is important when choosing a
therapy.
7. Which one of the following statements about acne scarring is
correct?

a.

Expressing acne lesions

does not result in scarring

b.

Allow the acne to resolve

Pre-test

Your

Correct

answer

answer

answer

before addressing the

scarring
c.

Infantile acne does not

tend to scar

d.

Treatment of acne scarring

is often disappointing

e.

Acne scarring readily

responds to resurfacing
techniques

That's not right. The correct answer is d.

Patients often have several different types of scarring. There
may be atrophic scars due to loss of tissue such as ice pick,
rolling, or boxcar scars. Hypertrophic or keloid scars result
from increased tissue. Even with a combination of treatments
(such as resurfacing by laser, dermabrasion, or chemical peels
with lling treatments for the atrophic areas) the results are
often disappointing. Manipulation of acne lesions is usually
harmful. It introduces infection and ruptures the follicle
resulting in an inammatory reaction and possibly scarring.
However, careful extraction of open comedones by a trained
person can be benecial. Infantile acne requires a similar
treatment approach to adult acne to avoid scarring. As it is so
dicult to treat scarring, early effective management is
required. Patients with nodulocystic acne should be referred
to a dermatologist. [ 23 ]

8. A 35 year old woman comes to see you with a rash. She often
gets facial ushing after she drinks alcohol.

Credit: Dr P Marazzi/SPL
What is the most likely diagnosis?

a.

Secondary Staphylococcus
epidermidis folliculitis

b.

Acne vulgaris

c.

Lupus erythematosus

d.

Acne keloidalis nuchae

e.

Rosacea

Pre-test

Your

Correct

answer

answer

answer

That's not right. The correct answer is e.

This woman has a red skin rash and pustules (yellow) on her
cheek and nose. This is most likely due to rosacea. Rosacea is
a chronic skin disease of unknown cause but similar features
can be seen from overuse of corticosteroid creams. Rosacea
usually begins with temporary ushing, often after drinking
alcohol or eating spicy food. Then it may develop into a
permanent redness of the skin, often accompanied by
pustules resembling acne. Unlike acne, comedones are not
seen in rosacea.
9. Which of the following is the most common side effect of oral
isotretinoin?

a.

Depression

b.

Dry skin

c.

Diarrhoea

d.

Arthralgia

e.

Photosensitivity

Pre-test

Your

Correct

answer

answer

answer

That's not right. The correct answer is b.

Dry skin is an almost universal side effect of isotretinoin. The
other symptoms occur less frequently. Patients need to
adjust their activities because of photosensitivity and also skin

fragility (for example, waxing should be avoided). Laser

treatment to the skin should be delayed until six months after
completion of the course of isotretinoin.

2015 BMJ Publishing Group Ltd