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Acne vulgaris
General Practice ST3 Warwick
E-mail: becca.alsop{at}doctors.org.uk
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Abstract |
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 TOP Abstract Acne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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Acne vulgaris is a common inflammatory condition affecting the pilosebaceous unit. It affects most adolescents at some point and is most prevalent between the ages 13–18. It tends to improve for most sufferers by their mid-twenties. In a minority of people (3% of men and 12% of women), acne may persist well into adulthood.
The effects of acne may be both physical (with disfigurement and scarring) and psychological. The emotional effects are often unrelated to the clinician's perception of the severity of the lesions and may lead to poor self-esteem, confidence issues, interference with forming relationships and depression.
A range of treatments are available, both over the counter and on prescription, which should be effective in improving almost all acne presentations. Commencing appropriate therapies promptly together with timely referral should aim to avoid scar formation and address psychological impact.
There are a number of areas in which the general practitioner may improve the patient's disease experience. As well as recognising acne as a treatable medical condition, there are a number of widely held health beliefs which may need eliciting and addressing. As one of the skin complaints commonly encountered in general practice (and noted as such in the curriculum document, topic 15.10), the GP should be able to:
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Causative factors |
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TOPAbstractAcne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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Acne has a multifactorial aetiology. Four contributory processes which have been identified are as follows:
- increased sebum secretion
- abnormal follicular differentiation causing blockage of the pilosebaceous duct (producing comedones)
- colonization of the pilosebaceous duct with Propionibacterium acnes
- release of inflammatory mediators
Androgen secretion is the major trigger for adolescent acne. However, acne varies in severity from individual to individual, so occasionally there may be additional points to consider. These may include:
- Genetic factors (family members have bad acne)
- Endocrine factors (higher levels of androgenic hormones) due to:
- Polycystic ovaries
- Excessive corticosteroids (e.g. high-dose steroid treatment or, rarely, Cushing's disease)
- Polycystic ovaries
- Psychological stress and depression
- Environmental factors such as:
- Cosmetics including certain moisturizers, foundations and pomades (watch out for lanolin, petrolatum, vegetable oils, butyl stearate, lauryl alcohol and oleic acid)
- Petroleum oils (causing chloracne)
- Physical occlusion from headbands and chin straps (e.g. under a violinist's chin)
- Cosmetics including certain moisturizers, foundations and pomades (watch out for lanolin, petrolatum, vegetable oils, butyl stearate, lauryl alcohol and oleic acid)
- Medication (may be causative or aggravating factors):
- Hormonal—systemic steroids, contraceptives (including Progestrone-only pill (POP), Depo-Provera, etc.), anabolic steroids (may cause severe acne, including acne conglobata)
- Antiepileptics (carbamazepine, phenytoin and phenobarbital)
- Antituberculous therapies (ethionamide, isoniazid and rifampicin)
- Antidepressants (lithium and amoxapine)
- Ciclosporin
- B vitamins
- Hormonal—systemic steroids, contraceptives (including Progestrone-only pill (POP), Depo-Provera, etc.), anabolic steroids (may cause severe acne, including acne conglobata)
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Presentation |
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TOPAbstractAcne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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Acne may present with a range of lesions depending on its severity. Most commonly, it affects the face but it may extend to the neck, back and upper chest. It is important to assess the lesions on all affected areas to determine classification and appropriate treatment. Lesions include:
- ‘Blackheads’ (open comedones)—consisting of dilated pores with a keratin plug
- ‘Whiteheads’ (closed comedones)—small cream-coloured dome-shaped papules without inflammation
- Inflammatory papules (red) and pustules (host response to P. acnes)
- Cystic areas
- Nodules and scars from old lesions ± keloid formation
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Classification |
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TOPAbstractAcne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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A number of complex classification systems exist to try to assess acne quantitatively. It is more practicable to focus on the most severe lesions present and direct treatment accordingly as this will also cover all lesser lesions (Table 1). It is important to remember that the patient is likely to overestimate the severity of their acne, while the doctor is at risk of underestimating it.
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Management tips |
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TOPAbstractAcne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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An important task for the GP may be to dispel popular myths about acne. Teenagers may often believe they are to blame in some way. They may be relieved to be told that acne is not caused by poor hygiene, bad behaviour or diet.
Regarding treatment, patients (and parents) need to realize that acne has nothing to do with lack of cleanliness. As the black tip of a comedo is oxidized sebum, not dirt, it will not be removed by scrubbing (which may actually make things worse). The best advice is to wash the skin with gentle soap and water twice daily.
If prescribing a topical treatment, patients should be aware that the majority work by preventing new lesions rather than reducing existing ones. Therefore, the medication should be applied to all skin in the affected area. If it is a once daily preparation, the majority are best applied to clean skin in a thin layer at night.
As previously mentioned, acne can have a significant psychological impact on an individual. Part of a patient's assessment should include some screening questions to look for underlying depression. In particular, the link between depression and suicide of patients on oral retinoids is now thought more likely to be due to the emotional effects of suffering with acne rather than due the drugs themselves.
After choosing an appropriate starting treatment (topical, oral or both), the effect should be assessed every 6–8 weeks. Lack of response should prompt a change in regime rather than the continual addition of new therapies. Multi-therapy regimes are associated with more compliance issues as well as problems with excess skin irritation.
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Other management options |
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TOPAbstractAcne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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There are a variety of physical therapies available for acne. These include:
- Cryotherapy to control new nodules
- Intralesional steroid injections to shrink older nodules
- Comedone expression or removal by cautery or diathermy
- Microdermabrasion (for mild acne)
- Blue light phototherapy (with or without use of a photosensitizing agent)
The majority of these would be performed under a dermatologist's supervision, however, microdermabrasion is increasingly being offered in private beauty clinics. While this may be useful for mild non-inflammatory acne, it is likely to make inflammatory acne worse and should be avoided in this case.
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When to refer (NICE guidance) |
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TOPAbstractAcne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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Most patients with acne can be managed in primary care. However, referral to a specialist service is advised if they:
- have a very severe variant such as fulminating acne with systemic symptoms (acne fulminans)
- have severe acne or painful, deep nodules or cysts (nodulocystic acne) and could benefit from oral isotretinoin
- have severe social or psychological problems, including a morbid fear of deformity (dysmorphophobia)
- are at risk of, or are developing, scarring despite primary care therapies
- have moderate acne that has failed to respond to treatment which should generally include several courses of both topical and systemic treatment over a period of at least 6 months. Failure is probably best based upon a subjective assessment by the patient.
- are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs assessment
Key points
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References |
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TOPAbstractAcne and the GP...Causative factorsPresentationClassificationManagement tipsOther management optionsWhen to refer (NICE...References |
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AcneNet. A comprehensive online acne information resource. Accessed via www.skincarephysicians.com/acnenet/.
Purdy S, DeBerker D. Acne vulgaris. BMJ Clinical Evidence (2007) Accessed via clinicalevidence.bmj.com.
DermNet NZ, Oakley A. Acne vulgaris. Accessed via dermnetnz.org/acne/acne-vulgaris.html [last accessed 21.05.2008].
NICE Guidance. Referral advice: a guide to appropriate referral from general to specialist services. (2001) Accessed via www.nice.org.uk/nicemedia/pdf/Referraladvice.pdf [last accessed 21.05.2008].
Simon C. OGPL: Dermatology. Oxford: Oxford University Press. (in press).
TalkAcne.com. Accessed via www.talkacne.com/.
Webster GF. Commentary: a UK primary care perspective on treating acne. British Medical Journal (Aug 2002) 325:475–479.
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