QuestionSBA
QuestionChoice
This is correct because this patient has severe acne vulgaris which is evident by the presence of widespread inflammatory lesions and scarring. This would be the best next step in management. Topical adapelene with topical benzoyl peroxide should be prescribed with an oral antibiotic such as lymecycline to prevent antibiotic resistance. Tetracyclines have anti-inflammatory effects, but note that these are contraindicated in pregnancy or breast-feeding which does not apply to this case.
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Topical adapelene with topical benzoyl peroxide and oral lymecycline
QuestionChoice
This is incorrect because oral isotretinoin is prescribed for patients with severe acne vulgaris resistant to traditional topical and systemic antibiotic therapies. This patient has not tried topical medication or antibiotics yet. Although this patient wants stronger medication, isotretinoin is not prescribed within primary care due to its side effect profile. Some of these include deranged liver function, increased risk of suicide and depression, and teratogenicity.
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Oral isotretinoin
QuestionChoice
This is incorrect because this is the treatment for mild acne rosacea. In acne rosacea, patients typically present with papules, pustules and flushing of the nose, cheeks and forehead. It usually affects an older patient demographic and can present with telangiectasia. Topical metronidazole is not used for acne vulgaris.
53123
b
Topical metronidazole
QuestionChoice
This is incorrect because this is the treatment for impetigo which is an infection typically caused by Staphylococcus aureus and usually affects infants. It presents with golden crusted lesions which this patient does not have. Impetigo is usually managed in primary care with oral antibiotics and topical fusidic acid.
53124
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Oral flucloxacillin and topical fusidic acid
QuestionChoice
This is incorrect because spironolactone is rarely used as a first-line treatment for acne vulgaris. It is also important to avoid prescribing this drug in males because it is an anti-androgen medication which works by reducing testosterone levels and can cause feminising side effects.
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Spironolactone
QuestionComment
Is this not severe enough for isotretinoin?????
24668
QuestionComment
innit scarring is usually an indication for isotretinoin????
25374
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HarryDM
QuestionComment
I think the GP has to try the initial management methods, before referring him to derm for isotretinoin.
25824
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Acute Body
QuestionComment
GPs dont prescribe oral isotretinoin
62231
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Sydney Sweeney
QuestionComment
why refer to dermatology for actual treatment when you can just let a 15 year old get extensive scarring first (clowns)
62248
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anon
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Nightshift NICU
QuestionComment
Once scarring has started any GP in their right mind should be turning to accutane, that's what mine said at least. 
27103
QuestionComment
no GP should be prescribing accutane mate
62232
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Sydney Sweeney
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lil' aneurysm
QuestionComment
If there's scarring he should be referred to dermatology for isotretinoin. 
62204
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Pulseless Electrical Activity
Concept
Chapter
# Summary

Acne vulgaris is a common chronic disorder of the pilo-sebaceous unit, resulting in blockage of the follicle, formation of comedones and inflammation. Key signs and symptoms include open/closed comedones, inflammatory papules and pustules, and in severe cases, nodules and cysts. The disorder predominantly affects the face, neck, chest, and back, and has a significant psychological impact due to altered physical appearance. Acne is primarily diagnosed clinically, with further investigations necessary only in uncertain cases or prior to commencing certain treatments like isotretinoin. Treatment is guided by severity and may involve topical or systemic therapy based on the NICE guidelines. Potential complications include post-inflammatory hyperpigmentation, hypopigmentation, erythema, psycho/social/sexual dysfunction, and scarring.


# Definition

- A a chronic disorder of the skin affecting the pilo-sebaceous unit, in which there is blockage of the follicle leading to comedones and inflammation. 
- Vulgaris translates as "common", which is true as this condition affects over 80% of adolescents.

# Epidemiology

* It is one of the most common dermatological conditions globally, affecting individuals of all ethnicities and ages.
* Prevalence is highest in adolescents and young adults, with up to 80% of individuals experiencing some degree of acne during their lifetime.
* While most common in adolescents, adult-onset acne can occur, affecting people well into their 30s and beyond.
* Acne affects both males and females, but the prevalence and severity may vary between genders.
* The psychological impact of acne can be significant, affecting self-esteem and overall quality of life.

# Risk Factors

Several factors contribute to the development and exacerbation of acne, including:

* Hormonal changes (e.g. during puberty, menstrual cycle, polycystic ovary syndrome)
* Increased sebum (oil) production
* Blockage of hair follicles and sebaceous glands by keratin and sebum
* Bacterial colonization (Propionibacterium acnes)
* Family history of acne
* Certain medications (e.g. corticosteroids, hormonal treatments)

# Pathophysiology

- In normal skin, skin cells in the stratum corneum of the epidermis (corneocytes) desquamate successfully without blocking pilo-sebaceous units.
- In acne, the corneocytes are excessively cohesive. They do not detach successfully.
- Because of this, the keratin rich corneocytes accumulate and block off hair follicles causing follicular hyperkeratinisation.
- Sebum is trapped in the hair follicle since it cannot be drained away. Androgens may also contribute to this causing sebaceous gland hyperplasia and increased sebum production. 
- This combination of sebum and keratin forms micro-comedones - the earliest feature of acne vulgaris. This is only visible under a microscope.
- Gradually, the follicle becomes more distended with keratin and sebum, and the micro-comedone enlarges to become a comedone. 
- Initially, these are closed comedones, referred to as whiteheads. The contents are not exposed to the skin surface or oxygen, and therefore appear as fleshy/white papules.  
- Eventually, closed comedones become open comedones. As their contents become exposed to oxygen, they oxidise which causes black discolouration. Open comedones are therefore  referred to as blackheads.
- Comedones are then colonised with a gram positive bacillus called Propionibacterium (Cutibacterium) acnes. This is a commensal organism (part of the normal skin flora) but leads to an inflammatory response in the right conditions of the comedone, in a predisposed patient. 
- The comedone is subsequently transformed into an inflammatory papule, which is now associated with erythema. A papule is a solid, raised lesion less than 0.5cm in diameter. 
- As things progress and more neutrophils accumulate, the inflammatory papule becomes a pustule; this is a lesion less than 0.5cm in diameter that contains pus. 
- Eventually, the inflammatory papule or pustule becomes so distended that it ruptures into the dermis, triggering a marked and deep seated inflammatory response. 
- This leads to the formation of nodules/cysts, which are painful and red. A nodule is a solid lesion larger than 0.5cm, and cysts are walled off fluid containing structures. 

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# Classification

- Non-inflammatory: blackheads and whiteheads.
- Inflammatory: inflammatory papules, pustules, and nodules (cysts.)
- Mild acne: predominantly non-inflammatory lesions. 
- Moderate acne: predominantly inflammatory papules and pustules. 
- Severe acne: nodules (cysts), scarring, acne fulminans, and acne conglobata. 

# Clinical Features

- Open/closed Comedones, inflammatory papules and pustules, nodules, and cysts may be present.
- The face is most often affected. The neck, chest and back may also be affected.
- Psychological dysfunction due to changes physical appearance
- Scarring: associated with inflammatory acne. Hypertrophic and keloid scars are more common in darker skin tones. 
	- Atrophic: flat or indented, such as ice-pick, box-car, or rolling scars.
	- Hypertrophic: raised scars.
	- Keloid: raised scars that extend beyond the initial boundaries of the injury. 
- Post-inflammatory hyperpigmentation and hypopigmentation: associated with inflammatory acne. 
- Post inflammatory erythema: associated with inflammatory acne.
- Acne fulminans: an uncommon but severe, serious acne presentation. 
	- Inflammatory nodules/cysts that are painful, ulcerating, and haemorrhagic appear, with associated systemic upset (raised white cell count, joint pain, fever, fatigue.) 
	- These patients should be reviewed urgently within 24 hours. It usually affects teenage male patients.
- Acne conglobata: another uncommon presentation of severe nodular/cystic acne with interconnecting sinus tracts and extensive scaring. 

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# Investigations

- Acne is a clinical diagnosis and investigations are not usually needed. 
- Swabs may be indicated if the diagnosis is uncertain (e.g. if ruling out infectious pustules.)
- Investigations will be required prior to commencing isotretinoin if indicated.
- In some particular presentations where an endocrine cause is suspected, there may be endocrinological investigations (hyperandrogenic states such as PCOS or androgen secreting tumours.)

# Treatment

Management of acne is multifaceted including education, topical/oral treatments and lifestyle modifications. 

- Each treatment combination is given as a 12 week course. 
- Combination therapies help reduce antimicrobial resistance. 
- Antibiotics are used predominantly since they have anti-inflammatory effects, rather than for their antimicrobial effects.
- **Mild-moderate acne** is treated with any 2 of the following in combination:
	- Topical benzoyl peroxide.
	- Topical antibiotics (clindamycin)
	- Topical retinoids (tretinoin/adapalene)
- **Moderate-severe acne** is treated with a 12-week coures of the following first line options:
	- Topical retinoids (tretinoin/adapelene) + topical benzoyl peroxide.
	- Topical retinoids + topical antibiotics (clindamycin)
	- Topical benzoyl peroxide + topical retinoid (tretinoin/adapelene) + oral antibiotic (lymecycline/doxycycline.)  
	- Topical azelaic acid + oral antibiotic (lymecycline/doxycycline) 
	- Second line oral antibiotics: trimethoprim and erythromycin e.g. in pregnant/breast-feeding women where tetracyclines are contra-indicated. 
	- Combined oral contraceptives (COCPs) (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women

NB: topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy, and so women of childbearing potential will need to use effective contraception, or choose an alternative treatment to these options.
	
- As per NICE guidelines, referral to specialist Dermatology is indicated in the case of:
	- Acne fulminans.
	- Mild-moderate acne not responding to two 12 week courses of treatment as above.
	- Moderate-severe acne not responding to one 12 week course of treatment as above, including an oral antibiotic.
	- Psychological distress/mental health disorder contributed to by acne.
	- Acne with persistent pigmentary changes.
	- Acne with scarring.
- Other available agents:
	- Co-cyprindiol: anti-androgenic contraceptive agent - may be trialled in primary care on female patients, but usually second line COCP due to increased risk of venous thromboembolism, and can only be given for 3 months. 
	- Spironolactone: anti-androgenic - not often used. Not for male patients. 
	- **Isotretinoin (oral retinoid):** the usual next step if the standard treatment fails and is prescribed by a dermatologist. 
		* Notable adverse effects: dry skin/mouth/eyes/lips (most common), teratogenecity, photosensitivity, low mood, nose bleeds, hair thinning, raised triglycerides, intracranial hypertension 
		* Isotretinoin is a well established teratogen that results in miscarriages and severe birth defects. As a result, the manufacturer recommends that all female patients taking isotretinoin are also using two forms of contraception from one month before until one month after use. For this reason a pregnancy test should also be done before initiating treatment
		* There is a controversial association between isotretinoin and depression/suicide. Recent research has shown that concerns about links between isotretinoin and depression or suicide are not established. This has now been included into the NICE guidelines. However it is still important to screen for depression/suicidal ideation before prescribing and during treatment.
	
	
# Complications

- Post-inflammatory erythema
- Post-inflammatory hyper- and hypo- pigmentation
- Psycho/social/sexual dysfunction 
- Scars (atrophic, hypertrophic, keloid)
	- Keloid scars: over-proliferating scar tissue/collagen extending beyond the boundaries of the lesion. Takes 3-4 weeks typically to develop after injury. They can cause itch and pain. It is fleshy, smooth, firm, and does not regress with time. The original injury may be minor, for example piercing or insect bite. Treatment is usually with intralesional steroids (triamcinolone). Cryotherapy and laser may also be used. Surgical resection is unlikely to be successful due to further scarring. Risk factors include:
		- Darker skin/Chinese/Hispanic origin 
		- Less than 30 years of age
		- Previous keloid scarring 
	- These are distinct from hypetrophic scars, which are thick and raised but remain within the injured boundary and tend to improve over time.  

# NICE Guidelines

[NICE CKS for Acne Vulgaris](https://cks.nice.org.uk/topics/acne-vulgaris/)
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*A mixture of papules, pustules and comedones seen on the anterior aspect of the chest.*
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*Ice pick scarring seen on the cheeks following severe acne.*
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*An example of moderate acne vulgaris seen on the face.*
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Acne can be effectively managed with a combination of topical adapalene, which is a retinoid that helps to clear blocked pores and reduce inflammation, topical benzoyl peroxide, which has antimicrobial and anti-inflammatory properties, and oral lymecycline, an antibiotic that reduces bacteria and inflammation.
A 15-year-old male presents to the GP with concerns regarding changes to his skin. He says this has occurred over the past year and he has used several over-the-counter facial washes which have not helped. On examination, there are widespread inflammatory papules and pustules, nodules, and scars on his face, neck, and shoulders. He is adamant that he wants to try a stronger medication.

Which of the following is the best next step in the management of this patient?
a