Acne

Introduction

Acne can be defined as an inflammatory disease of the pilosebaceous follicles, causing comedones, papules and pustules on the face (99% of cases), chest (60%) and upper back (15%).

It affects approximately 80-95% of adolescents (onset typically occur at puberty).

It usually resolves in males during their early twenties.
Females are more likely to have ongoing acne persisting into their thirties and forties.

NOTE: Although acne is closely associated with adolescence, up to 12% of women and 3% of men aged 25 to 40 years continue to get facial acne or develop acne (late-onset acne) after adolescence.

Clinical Features

Acne lesions are classified as

Non-inflammatory - Open (blackheads) and close (whiteheads) comedones
Inflammatory - Pustules, red papules, nodules and cysts
Resolving - Macules or scars

Indicative of Referral

Most cases seen in the pharmacy setting will be mild and can be managed appropriately without referral to the doctor. However, more persistent and severe cases (e.g. those causing significant psychological impact) need referral for more potent topical or systemic treatment.

A clinical manifestation of polycystic ovary syndrome can be acne vulgaris.

Any woman who has menstrual irregularity (infrequent or no periods) and also exhibits hirsutism and/or is overweigh must be referred for further investigation.

General Measures

Minimise exposure to any aggravating factors.

Drugs - e.g. anabolic steroids, some contraceptives, corticosteroids, phenytoin and fluconazole.
In some patients, high glycaemic index foods (e.g. refined carbohydrates, sugar) and dairy products (including whey protein) can exacerbate acne severity.
Hot, humid environments in which the face is exposed to steam, at work (e.g. chefs, baristas) or during leisure (saunas, spas) could aggravate acne.

Ensure all skincare products, cosmetics and sunscreens are noncomedogenic and nonacnegenic.

Most "oil-free" products are noncomedogenic and less likely to aggravate acne.

Try not to pick and squeeze the spots, because this causes scabs that make the skin look worse.

Treatment

For initial treatment of mild acne, suggest over-the-counter topical products (e.g. benzoyl peroxide, salicylic acid, azelaic acid and niacinamide).

Nicotinamide is a more recent addition to the OTC market. Data suggests that it is as effective as clindamycin 1% gel; however, no randomized controlled trial seems to have been conducted to support this finding.
One or more OTC topical products can be used for an additive effect; however this may increase irritation.

If OTC topical products are not sufficiently effective, subsequent treatment depends on the dominant type of acne present.

When treating acne, antibiotics, including topical antibiotics (e.g. clindamycin) and oral antibiotics (e.g. tetracyclines, erythromycin) are used for their anti-inflammatory action rather than their antibacterial effect.

Avoid using antibiotics long term. Stop once papular inflammation has resolved or inflammatory acne activity is controlled.

Antiandrogens, such as combined oral contraceptive pill and spironolactone can be used to treat acne in female patients.

Spironolactone is contraindicated in pregnancy.

NOTE: More information on benzoyl peroxide and topical tretinoin is discussed separately.

Adjunctive Therapies

Evidence of efficacy for salicylic acid and sulphur is poor. Both agents have been used for many years on the basis of their keratolytic action, but according to current evidence, they are best avoided.

Tea tree oil is a product derived from the Australian Melaleuca alternifolia tree that possesses antimicrobial and anti-inflammatory properties.

Clinician-administered light sources are used for the treatment of acne, though well-designed clinical trials supporting the benefit of these treatments are limited, and there is uncertainty about the efficacy of these interventions.

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