Clinical
· Open [blackheads], closed [whiteheads], papules [inflamed], pustules, nodules or cysts [deeper]
· Scars from deep nodules [keloid, ice pick scars…]
· If before puberty, need to exclude adrenal pathology.
Treatment [review all in 6 weeks]
· Blackhead or whitehead with few papules or papulopustular
· Topical retinoid with benzoyl peroxide – Epiduo – apply thinly once daily in the evening. DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY. Can cause skin irritation, use thinly.
· Azelaic acid 15% [alternative to above, less irritating] – apply twice daily, stop after 1 month if not better.
· Papules and some pustules
· Benzoyl peroxide & clindamycin 1% – Duac – apply once daily in the evening. CAN STAIN CLOTHING. Can cause initial skin irritation – this will likely improve within 1-2 weeks.
· Zinc acetate & erythromycin [if above fails] – Zineryt – apply twice daily.
· Marked pustular [combination therapy]
· Topical retinoid ON – Isotrex – apply thinly once daily in the evening. DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY. Can cause skin irritation, use thinly.
· Benzoyl peroxide OM – benzoyl peroxide 4% – apply once daily in the morning. CAN STAIN CLOTHING. Can cause initial skin irritation – this will likely improve within 1-2 weeks.
· Oral antibiotics
· Marked pustular @ risk of scarring or widespread – Oral antibiotic
· 1st – tetracycline 500mg BDfor 3m, then reduced to 250mg twice daily for 3m. DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY. [alternative Oxytetracyline 500mg BD, Lymecycline 408mg OD]
· 2nd – Doxycycline 100mg OD – DO NOT USE IF YOU ARE PREGNANT OR PLANNING ON PREGNANCY.
Erythromycin 500mg BD for 3 months then 250 mg bd for 3 months – Only one licensed for use in pregnancy. Less effective as high degree of resistance against P. acnes.
· Continue for at least 4-6m [maintain on topical] – should reduce by 30-50% @ 3m.
Dianette
· Not indicated for use solely as an oral contraceptive – higher risk of VTE
· Indication – Severe acne that has not responded to oral antibiotic or moderately severe hirsutism
· Withdraw 3-4 cycles after condition treated
Referral criteria – for trimethoprim, dapsone, oral isotretinoin [LFT, fasting Lipid, FBC]
· Moderate acne or nodular lesions fails responding with >=2 3m courses antibiotic
· Psychological distress
· Severe or severe nodulocystic acne
· Are at risk of, or are developing, scarring despite primary care therapies
Information sheet: http://www.patient.co.uk/health/acne