Acne VulgarisWhat’s new?

Acne VulgarisAcne is a common chronic skin condition which has a

significantly negative psychological impact that can be directly improved with treatment

It is a disease common but not limited to adolescence. It can often persist into adulthood

It is estimated that acne accounts for 3.5 million GP visits a year

Severe acne has been associated with suicidal ideation

Acne VulgarisInfection/ blockage of pilosebaceous units

Multifactorial pathogenesis including genetics

Four main processes include altered keratinization, androgen induced sebum production, follicular colonisation by P acnes and inflammation

Diagnostic features - comedones, greasy skin, P acnes and inflammatory papular pustular lesions, nodules and cysts.

MildMild acne: Presence of comedones and a few papulopustules

<20 comedones <15 inflammatory

lesions Or total lesion count

<30

ModerateModerate acne: Presence of comedones, inflammatory papules, and pustules A greater number of lesions are present than in milder inflammatory acne

SevereNodulocystic acne: Presence of comedones, inflammatory lesions, and large nodules

Scars: Raised (hypertrophic or keloid) or atrophic

Acne conglobata: Severe and uncommon form of acne - interconnecting nodules, abscesses, sinuses and scars as well as haemorrhagic and purulent discharge

TreatmentCan be targeted to severity

Mild acne - topical treatments including topical retinoids (1st line), benzoyl peroxide, topical antibiotics. Topical azelaic acid can cause hypopigmentation.

Moderate acne - oral antibiotics at least 2 different antibiotics for prolonged time >6months for their anti-inflammatory properties, COCP, AND topical treatment

Severe acne - Isotretinoin- warn about side effects - dryness, pregnancy tests, mood

TreatmentNew treatments such as radiofrequency, light, and laser devices are all

active areas of research and development. Blue-light photodynamic therapy is the only US FDA-approved treatment.

Systemic reviews show they may improve inflammatory acne in the short term but are ineffective when for severe acne

Other treatment options particularly for scarring include resurfacing techniques, laser therapy and dermal fillers

Warn patients looking for treatments such as dermabrasion / lasers to wait at least 1 year after completing a course of isotretinoin

Techniques Radiofrequency Devices – Use radio waves to heat the dermis and

SC tissue. High temperatures kill bacteria and shrink sebaceous glands. Promising results in studies but small sample sizes.

Light treatment- Cause membrane damage to P acnes. Some penetrate deeper than others. Confliciting efficacy in studies.

Blue light treatment is FDA approved in US. Initial studies have shown after 8 weeks of treatment the number of inflammatory lesions are reduced( 30-70%). But not comedonal lesions.

Laser- Photothermolysis of dilated blood vessels in acne lesions. (TGF-β) a wound healing cytokine.

Acne and diet Eating chocolate and sugary foods have previously been linked with

acne but studies show there is little evidence for these beliefs.

Recent data – mainly from 2013 onwards show preliminary evidence of a low glycaemic load diet and improvement in acne.

Recent data suggests that dairy products may increase the risk of acne, particulalry from pregnant cows. Skimmed is worse due to higher concentration of hormones

Need to be cautious- Some studies show milk has a positive effect on reducing obesity

Antibiotic resistanceThe Global Alliance to improve outcome in acne recommends:

1. Benzoyl peroxide may reduce the development of resistant P. acnes strains and further emergence.

2. Bacterial resistance may be reduced by using topical benzoyl peroxide with topical antibiotics, topical retinoids or oral antibiotics.

3. The combination of benzoyl peroxide and a topical antibiotic (eg. clindamycin, erythromycin) is more effective than either agent alone

4. Topical antibiotic monotherapy is not recommended

5. Use benzoyl peroxide in between abx therapies to prevent future resistance

Conclusion Common Treatment has a big impact on QOL Beware of new evidence on diet Beware of new treatments- not all on NHS Prescribe benzoyl peroxide with oral

antibiotics Prescribe benzoyl peroxide between

antibiotics

References

British association of Dermatologists www.bad.org.uk

Shinjita Das; Rachel V. Reynolds. Recent Advances in Acne Pathogenesis Implications for Therapy. American Journal of Clinical Dermatology. 2014;15(6):479-488.

Dermnet New Zealand Facts on Acne: http://www.dermnetnz.org/acne/index.html

National Institute for Health and Care Excellence Clinical Knowledge Summaries on Acne: http://cks.nice.org.uk/acne-vulgaris#top

Medscape The Global Alliance to improve outcome in acne

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