Dermatological Society of MalaysiaMinistry of Health Malaysia Academy of Medicine Malaysia

1

MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS

KEY MESSAGES

• Acneisamedicaldiseasewhichrequirestreatment.

• Ifleftuntreated,acnemayhaveaprofoundpsychologicalandemotionalimpact.

• Pathogenesis of acne is multifactorial which includes increased sebum production,Propionibacterium acnesproliferation,alteredfollicularkeratinisation&inflammation.

• Alowglycaemicloaddietandhighfibredietshouldbeencouragedforacnepatients.

• Aimsofacnemanagementaretoinduceclearanceoflesions,maintainremissionandpreventrelapse,physicalandpsychologicalcomplications.

• ComprehensiveAcneSeverityScale(CASS)maybeusedforgradingofacneseverityinclinicalpractice.

• Topicaltherapyisthemainstayoftreatmentformildandmoderateacne.

• Oralantibioticsmaybeusedastreatmentformoderatetosevereacne,butshouldnotbeusedformorethansixmonths.

• Maintenance treatment should be commenced after an initial successful inductiontherapytosustainremission.

• Oralisotretinoinshouldonlybeprescribedbydermatologist.

This Quick Reference provides key messages and a summary of the main

recommendations in the Clinical Practice Guidelines (CPG) Management

of Acne (January 2011).

Details of the evidence supporting these recommendations can be found

in the above CPG, available on the following websites:

Ministry of Health Malaysia : h t t p : / / w w w . m o h . g o v . m y

Academy of Medicine Malaysia : h t tp : / /www.acadmed.org.my

2

MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS

COMPREHENSIVE ACNE SEVERITY SCALE (CASS)

A new grading system named Comprehensive Acne Severity Scale – CASS (modification

of an Investigator Global Assessment [IGA] of Acne Severity) was validated and simple

to use in clinical practice (refer to the following table).

GRADE* DESCRIPTION

CLEAR 0Nolesionstobarelynoticeableones.Veryfewscatteredcomedonesandpapules.

ALMOST CLEAR 1Hardly visible from 2.5 metre away. A few scatteredcomedones,fewsmallpapulesandveryfewpustules.

MILD 2Easilyrecognisable;lessthanhalfoftheaffectedareaisinvolved.Manycomedones,papulesandpustules.

MODERATE 3Morethanhalfoftheaffectedareaisinvolved.Numerouscomedones,papulesandpustules.

SEVERE 4Entire area is involved. Covered with comedones,numerouspustulesandpapules,afewnodulesandcyst.

VERY SEVERE 5Highlyinflammatoryacnecoveringtheaffectedarea,withnodulesandcystpresent.

*Appliedtoeachoftheface,chestandbackindependently.

Inspectionisdoneatadistanceof2.5metersawayforacneonface,chestandback.

Chest area defined as: Anterior torso superiorly defined by suprasternal notch extending laterally to shoulders

and inferiorly by a horizontal line defined by the xiphoid process.

The back area defined as:(Is demarcated by the) superior aspects of the shoulders extending to the neck and

inferiorly by the costal margins

3

MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS

FOOD LIST ACCORDING TO GLYCAEMIC INDEX (GI) CLASSIFICATIONThe GI is a numerical system used to classify carbohydrate food based on the impact they produce on the postprandial blood glucose level. The higher the GI values of the food, the greater the blood glucose response. In general, most refined carbohydrate with devoid of fibre is high in GI while intact carbohydrate (whole grains products), legumes, milk (and milk products), fruits and vegetables are low GI foods.

Foods/DrinksLow GI Medium GI High GI

Example GI Example GI Example GI

Rice Rice,parboiled 48 Brownrice,boiledBasmati,white,boiled

6858

Whiterice,boiledGlutinousrice,white

7398

Bread WholegrainbreadChapatti

5152

Pitabread 57 WholemealbreadWhitebreadSardinesandwich

747573

Breakfast cereals

Oatbran,raw 50 Instantporridge,oats

66 CornflakesCocoa-flavouredpuffedrice

8177

Pasta and noodles

Spaghetti,wholemeal,boiled

37 Ricenoodles,dried,boiled

61 FriedmeehoonFriedmacaroni

9974

Fruits Apple,rawOrange,rawBanana,raw

384351

Pineapple,raw 59 Watermelon,raw 76

Dairy products and alternatives

Milk,fullfatMilk,skimIcecream,lowfatYogurtLow-fatyogurt,fruit,sugar.Soymilk

2732503633

32

Icecream 61

Sugars Fructose 19 SucroseHoney

6861

GlucoseTehtarik

9978

Categories of GI (based on glucose as the reference)

Low : <55Medium : 55 - 70High : >70

4

MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS

DIAG

NOSI

S &

SEVE

RITY

ASS

ESSM

ENT

OF A

CNE

(BAS

ED O

N CA

SS)*

SEVE

REM

ODER

ATE

MIL

D

Pred

omin

antly

com

edon

esPr

edom

inan

tly p

apul

es/p

ustu

les

Pred

omin

antly

com

edon

esPr

edom

inan

tly p

apul

es/p

ustu

les

Topi

cal b

enzo

yl pe

roxid

e OR

Top

ical r

etin

oid*

* OR

Topi

cal a

zela

ic ac

id O

R To

pica

l sal

icylic

acid

Co

mbin

ation

of 2

topic

al ag

ents

Topic

al ag

ent(s

) + O

ral a

ntibi

otic

Com

bina

tion

of

2 to

pica

l ag

ents

Com

bina

tion

of

2 to

pica

l age

nts

OR

Firs

t lin

e to

pica

l age

nt +

topi

cal a

ntib

iotic

Topi

cal a

gent

(s) +

Or

al a

ntib

iotic

Com

binati

on of

2 to

pical

agen

ts +

Oral

ant

ibio

tic O

RHo

rmon

al th

erap

y (fe

mal

es o

nly)

± to

pica

l age

nt

Refe

r der

mat

olog

ist fo

r phy

sical

ther

apy

Refe

r der

mat

olog

ist fo

r ora

l iso

tretin

oin

± P

hysic

al th

erap

y

Mai

nten

ance

ther

apy

with

topi

cal r

etin

oid

or to

pica

l ben

zoyl

pero

xide

* Sev

erity

ass

essm

ent i

s ba

sed

on C

ASS

(mild

1 -

2, m

oder

ate

3, s

ever

e 4

- 5).

Qual

ity o

f life

sho

uld

be ta

ken

into

con

sider

atio

n.

** T

opica

l ret

inoi

ds a

re to

be

avoid

ed in

pre

gnan

cy.

†If t

here

is n

o im

prov

emen

t in

3 m

onth

s, c

onsid

er th

e ne

xt li

ne o

f tre

atm

ent.

‡

Oral

ant

ibio

tic is

reco

mm

ende

d to

be

used

for 4

- 6

mon

ths.

Nodu

les

and

cyst

s

FIRS

T LI

NE

TR

EATM

ENT

THIR

D LI

NE

TREA

TMEN

T

SECO

ND L

INE

TR

EATM

ENT

MAN

AGEM

ENT

OF A

CNE

5

MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERSSU

GGES

TED

MED

ICAT

ION

DOSA

GES

AND

SIDE

EFF

ECTS

Drug

Reco

mm

ende

d Do

sage

Com

mon

Adv

erse

Effe

cts

Cont

rain

dica

tions

Spec

ial P

reca

utio

ns

Topi

cal b

enzo

yl

pero

xide

Appl

yon

ceto

twic

eda

ilyCo

ntac

tder

mat

itis,

dry

ness

,sk

ind

isco

lour

atio

n,s

kin

rash

,pe

elin

g,tr

ansi

entl

ocal

oed

ema

Hype

rsen

sitiv

ityto

be

nzoy

lper

oxid

eAv

oid

cont

actw

ithe

yes,

eye

lids,

lips

and

muc

ous

mem

bran

es.

May

ble

ach

fabr

ics

orh

air.

Topi

cal t

retin

oin

Appl

yon

cein

the

even

ing

befo

rere

tirin

gIn

itial

exa

cerb

atio

nof

sy

mpt

oms,

ski

nirr

itatio

n,

stin

ging

,oed

ema,

blis

terin

g,

crus

ting

ofs

kin,

ery

them

a,

scal

ing,

pho

tose

nsiti

vity,

tem

pora

ryh

ypo/

hype

rpig

men

tatio

n

Hype

rsen

sitiv

ityto

tre

tinoi

n,

preg

nanc

y,la

ctat

ion,

ec

zem

a,s

unbu

rn

cond

ition

s

Avoi

dco

ncom

itant

use

oft

opic

alk

erat

olyt

ica

gent

s.

Avoi

dex

posu

reto

sun

light

oru

ltrav

iole

t(UV

)lig

ht.

Avoi

dco

ntac

twith

eye

s,m

outh

,ang

les

ofn

ose,

muc

ous

mem

bran

esa

ndo

pen

wou

nds.

Avoi

dfa

cial

scr

ub.

Avoi

dus

eof

topi

calp

repa

ratio

nsw

ithh

igh

conc

entra

tion

ofa

lcoh

ol,m

enth

ol,s

pice

sor

lim

e.

Topi

cal a

dapa

lene

Appl

yon

ced

aily

to

affe

cted

are

asa

fter

was

hing

inth

eev

enin

gbe

fore

retir

ing

Mild

ski

nirr

itatio

n,s

calin

g,

eryt

hem

a,d

ryne

ss,s

tingi

ng,

burn

ing,

pru

ritus

Hype

rsen

sitiv

ityto

ad

apal

ene

Avoi

dco

ntac

twith

eye

s,li

ps,a

ngle

sof

nos

ean

dm

ucou

sm

embr

anes

.

Avoi

dcu

ts,a

bras

ions

,ecz

emat

ous

skin

ors

unbu

rned

ski

n.

Min

imis

eex

posu

reto

sun

light

.

Topi

cal c

linda

myc

inAp

ply

twic

eda

ilyIrr

itatio

n,d

ryne

ss,s

tingi

ng,

eryt

hem

a,c

onta

ctd

erm

atiti

sHy

pers

ensi

tivity

to

clin

dam

ycin

or

linco

myc

in,

ulce

rativ

eco

litis

,an

tibio

tic-r

elat

edc

oliti

s

Alco

holb

ase

solu

tion

may

cau

seb

urni

nga

ndir

ritat

ion

of

the

eyes

esp

ecia

llyin

ato

pic

indi

vidua

ls.

Topi

cal e

ryth

rom

ycin

Appl

ytw

ice

daily

Dryn

ess,

ery

them

a,b

urni

ng,

prur

itus

Hype

rsen

sitiv

ityto

er

ythr

omyc

inAv

oid

cont

actw

ithe

yes

and

othe

rmuc

ous

mem

bran

es.

Topi

cal s

alic

ylic

aci

dAp

ply

once

toth

rice

daily

Irrita

tion,

sen

sitiv

ity,e

xces

sive

dr

ynes

sHy

pers

ensi

tivity

to

salic

ylic

acid

Avoi

dpr

olon

ged

use

inh

igh

conc

entra

tions

and

ove

rlar

ge

area

sof

the

body

.

Avoi

dbr

oken

ski

n,m

outh

,eye

san

dm

ucou

sm

embr

anes

.

6

MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS

Drug

Reco

mm

ende

d Do

sage

Com

mon

Adv

erse

Effe

cts

Cont

rain

dica

tions

Spec

ial P

reca

utio

ns

Topi

cal s

ulfu

r and

its

com

bina

tions

Appl

yon

ceto

twic

eda

ily.I

nitia

tew

itho

nce

daily

,the

nin

crea

se

grad

ually

.

Skin

irrit

atio

n,d

erm

atiti

sHy

pers

ensit

ivity

tos

ulfu

r,

child

ren

less

than

2

year

sol

d

Avoi

dco

ntac

twith

eye

s,m

outh

and

oth

erm

ucou

sm

embr

anes

.

May

sta

inth

esk

inb

lack

and

em

itfo

uls

mel

lwhe

nap

plie

dco

ncom

itant

lyw

ithm

ercu

rialc

ompo

unds

.

Topi

cal a

zela

ic a

cid

Appl

ytw

ice

daily

Skin

irrit

atio

n,m

ostly

bur

ning

or

itchi

ng,o

ccas

iona

llye

ryth

ema

and

scal

ing

Hype

rsen

sitiv

ityto

pr

opyle

neg

lycol

Avoi

dbr

oken

ski

n,m

outh

,eye

san

dm

ucou

sm

embr

anes

.

Oral

tetr

acyc

line

500

mg

-1

gda

ilyin

2

divid

edd

oses

Ga

stro

inte

stin

ald

istu

rban

ces,

di

scol

oura

tion

ofte

eth

and

nails

,pho

tose

nsiti

vity,

visua

ldi

stur

banc

es

Hype

rsen

sitiv

ityto

te

tracy

clin

es,

child

ren≤8

yea

rso

ld,

preg

nanc

y,la

ctat

ion

Shou

ldb

ead

min

iste

red

with

ple

nty

ofw

ater

,whi

les

ittin

gor

sta

ndin

g,1

hou

rbef

ore

or2

hou

rsa

fterm

eals

toa

void

oe

soph

agea

lulc

erat

ion.

Abs

orpt

ion

isim

paire

dby

food

,m

ilk,d

airy

pro

duct

s,ir

ons

alts

and

ant

acid

s.

Oral

dox

ycyc

line

50-

100

mg

once

to

twic

eda

ilyGa

stro

inte

stin

ald

istu

rban

ces,

ph

otos

ensi

tivity

,hyp

erse

nsiti

vity,

perm

anen

tsta

inin

gof

teet

h,

rash

Hype

rsen

sitiv

ityto

te

tracy

clin

es,

child

ren≤8

yea

rso

ld,

preg

nanc

y,la

ctat

ion

Shou

ldb

ead

min

ister

edw

ithp

lent

yof

wat

er,w

hile

sitt

ing

ors

tand

ing,

1h

ourb

efor

eor

2h

ours

afte

rmea

lsto

avo

id

oeso

phag

ealu

lcera

tion.

Oral

ery

thro

myc

in

Eryt

hrom

ycin

Eth

ylSu

ccin

ate

(EES

):

400

-800

mg

twice

dai

ly

Eryt

hrom

ycin

Ste

arat

e:

25

0-5

00m

gtw

iced

aily

Gast

roin

test

inal

dis

turb

ance

s,

rash

,urti

caria

,hea

dach

e,

dizz

ines

s

Hype

rsen

sitiv

ityto

er

ythr

omyc

inHe

patic

and

rena

lim

pairm

ent,

pr

olon

ged

QTin

terv

al,

conc

omita

ntth

erap

yw

ithc

olch

icin

e(to

xicity

)and

lo

vast

atin

(rha

bdom

yolys

is)

Disc

laim

er:

•Th

eou

tline

ofd

rug

dosa

gea

nda

dmin

istra

tion

isin

tend

eda

sa

gene

ralg

uide

toth

erap

y.

•Th

ead

vers

eef

fect

slis

ted

are

note

xhau

stive

.

•Ca

utio

nis

adv

ised

whe

npr

escr

ibin

gfo

rpat

ient

sw

itho

ther

med

ical

pro

blem

sor

on

mul

tiple

dru

gs.

7

MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS

REFERRAL

Theurgencyforreferralisdividedintothefollowingcategories:

Urgent : Within24hours

SeenEarly : Withinoneweektofourweeks

Non-urgent : Basedonavailableappointmentdate

i. Urgent referral (to a psychiatrist)

Majordepressionoranysuicidalbehaviour

ii. Seen Early

a. Severeacneornodulocysticacnethatmayneedisotretinoin

b. Severesocialorpsychologicalproblemsincludingamorbidfearofdeformity(dysmorphophobia)anddepression

iii. Non-urgent

a.Fordiagnosis

r Suspectedrosacea

r Suspecteddrug-inducedacne

r Acnebeginningorpersistingoutsidethenormalagerangefortheconditionorlateonsetacne

r Suspectedoccupationalcauses

r Suspectedunderlyingendocrinologicalcause(suchasPolycysticOvarianSyndrome)requiringfurtherassessment

r Rarevariantsofacnesuchasacneexcoriae,chloracneandacnefulminans

r SuspectedDemodexfolliculitis

r Pityrosporumfolliculitis

r Gramnegativefolliculitis

b. Specialistservices

r Resistanceorintolerancetocurrenttreatment

r Moderateorsevereacne

r Possiblescarringorfailuretoachieveadequateresponse

r Failedoralantibiotictherapy

r Pregnancywithmoderateandsevereacne

r Acnerequiringsurgery(suchasincisionanddrainageofcysts)

r Forspecialisedphysicaltreatment