Question: Take a history from May Ling 15 years, examine her face,outline the most likely diagnosis...
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Transcript of Question: Take a history from May Ling 15 years, examine her face,outline the most likely diagnosis...
Acne
Question: Take a history from May Ling 15
years, examine her face ,outline the most likely
diagnosis and a management plan
History
(1) Duration: months/years(2) Location : hormone or post adolescent acne(3) Previous treatments: how long and what
works best?(4) Triggers: What does she think causes the
acne?(5) Family history : scarring or isotretinoin (6) Impact: how do you feel about your skin ?
Does it stop you from doing anything?(7) Periods –regular?(8) Seek permission to examine
Examination
(1) Site: face chest , back(2) Severity of the acne: mild moderate and
severe(3) Inflammatory? Pink or red(4) Scarring evidence(5) Psychological impact
Differential diagnosis
(1) Rosacea(2) Perioral dermatitis(3) Acneiform drug eruptions(4) Folliculitis of the trunk
Classification of acne
Mild Moderate Severe
Open comedones ( blackheads)
++ + +
Closed comedones( white heads)
++ + +
Inflammatory Papules
occasional ++ ++
Pustules occasional ++ ++
Inflammatory Nodules + deeper lesions (cysts) + scarring
_ occasional ++
Hormonal or post-adolescent acne in women
(1) Mild, moderate or severe clinical form . (2) Postadolescent women + may continue into the
40s age group. (3) Often history of an acne flare premenstrually,
typically one week b4 the menses or during ovulation.
(4) Usually inflammatory and + deep; describe as ‘blind’ pimples lasting weeks.
(5) Characteristic distribution : lower third face, along the jawline + neck.
(6) Possible associations: hirsutism, menstrual irregularity and signs of polycystic ovary syndrome.
Infantile acne
(1) 6 months to 3 years of age
(2) Comedones and inflammatory lesions
(3) Cheeks, forehead and chin
(4) Usually settle after a few months
(5) Scarring can occur with inflammatoryand deeper lesions
Acne scarring
(1) Resulting from moderate or severe inflammatory acne lesions that heal with the formation of fibrous tissue
(2) As inflammatory lesions heal there are colour changes of purple, red and pink which gradually fade with time + hypo- + hyperpigmentation.
(3) Scars may be depressed + pit-like (termed ‘ice pick’) or flat, thin atrophic scars.
(4) Other scars are thick and lumpy + are hypertrophic or keloid in nature
Management
Explain medical understanding of cause of acne
Acne can be treated Diet is not proven to change acne Advise against picking or squeezing Regular washing soap: twice a day Avoid oily or greasy skin preparations Follow up
Evidence based practice
Strength of recommendation:(1) A: consistent + good quality patient
oriented evidence: topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics + oral contraceptives
(2) B: inconsistent or limited quality patient oriented evidence: herbal treatments + effect of diet
Mechanisms of action
Benzoyl peroxide
Topical retinoids
Antibiotics Oral isotretinoin
Decreased sebum
+ + ++ +++
Decreased abnormal kearatinisation
+ ++ ++ +++
Decreased P. acnes
+ + +++ +++
Decreased inflammation
+ ++ +++ ++++
Treatment
Acne Grading
Topical therapy
Oral antibiotics
Androgen blocker
Oral contraceptives(females)
Mild (1) Topical retinoids: nightly(2) Topical antibiotics( more inflammatory papules + pustules)
_ Indicated if failure topical therapy or inflammatory lesions increase or deeper
_ _
Moderate (1)Combination with topical antibiotic
(2)Pulse therapy:5-7 days
(1)Doxycycline 50-100 mg daily
(2)Bactrim
(1)Spironolactone 50 – 100 mg
(2)Cyproterone acetate 50 mg days 5-15 menstrual cycle
Oral contraceptive
Topical retinoids
(1) Preparations: adapalene ( differin gel or cream), adapalene + benzoyl peroxide ( epiduo gel) , isotretinoin ( isotex cream) , tretinoin ( retin – A, Retrieve cream, Stieva A) , tazarotene ( Zorac cream)
(2) Applied nightly to all areas of the face(3) Thin layer to a cool dry face(4) If sensitive face use every second night(5) Results 6-8 weeks(6) Maintenance therapy months
Oral contraceptives
Composition Brand names
Ethinyloestradiol + cyproterone acetate
Brenda -35 ED, Dianne -35 ED, Estelle -35 ED, Juliet -35 ED
Ethinyloestradiol + desogestrel Marvelon
Ethinyloestradiol + dienogest Valette
Ethinyloestradiol + drospirenone Yasmin, Yaz
Antibiotics therapy in acne
(1) Doxycycline : 50-100 mg daily ( some use 200 mg 1st 2 weeks + 100 mg thereafter)
(2) Bactrim(3) Do not use topical + oral antibiotics
at same time(4) Oral antibiotics for 6-12 weeks course(5) If longer course use benzoyl peroxide
for a week between courses(6) Side effects: photosensitivity with
doxycycline
Oral isotretinoin
(1) Severe acne, unresponsive conventional therapy + psychological therapy
(2) Common side effects: dry gritty eyes, dry skin, dry, chapped skin, headaches, muscle aches + secondary bacterial infections
(3) Contraindicated in pregnancy: start 2nd or 3rd day menstrual cycle + relatively contraindicated depression
(4) Starting dose 0.5 mg /kg/day (5) Stop when acne free 2-3 months(6) Stop all topical treatments + antibiotics