Acne Grading and Management

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Best management of acne should include taking a history of any previous treatment, exploring perception of the condition, discussing acne as a chronic disease and setting realistic goals in its management . This is crucial as it helps to build both confidence and trust between the patient and physician. Inspect and palpate the lesions to determine the grade
3,4 1,2

GENERAL ADVICE FOR ALL GRADES: NO PICKING, GENTLE CLEANSING, NON-GREASY MOISTURISING/MAKEUP, NORMAL DIET

of the acne:

mild Seborrheoa comedones (both closed and open) inflammatory lesions (few papules and pustules).

moderate Comedones, papules, superficial pustules, inflammatory macules and some deep pustules and some post inflammatory hyperpigmentation. +/- truncal lesions

severe Face +/- trunk Comedones, papules, pustules, small ,large nodules, exudative sinus tracts, tissue destruction, post inflammatory hyperpigmentation and severe scarring.

The management of acne of any grade requires a clear understanding about cleansing, application, side effects profile and management of complications such as protection of skin integrity. Always consider psychiatric assessment e.g. by CADI, APSEA or DLQI assessment . Mild Acne
7

2,5,6

1st line: Topical retinoids are the mainstay of the treatment e.g. Adapalene Topical anti-microbials are very effective in preventing any further
progression of acne i.e. consider adding benzoyl peroxide or topical antibiotic alone or in combination

2nd line: Options include azelaic acid, Dapsone, and nicotinamide Physical methods: physical extraction of comedones, salicylic acid peels

Acne Grading and Management

Moderate Acne The treatment comprises of topical, to topical plus oral

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Topical: A topical retinoid either alone or in combination with benzoyl peroxide or

topical antibiotics such as clindamycin or erythromycin are recommended

Systemic: added for patients with moderate acne with scarring who are not
responding to the topical therapy, moderate acne with truncal involvement, or patients with adverse psychological impact. Oral antibiotics include : Oxytetracycline 500 mg PO BD Doxycycline 100-200 mg PO daily Lymecycline 300-600mg PO daily Trimethoprim 200- 300 mg PO BD Erythromycin 500 mg PO BD (recommended only for pregnant and breast feeding patients due to reduced response and P acnes resistance).

Physical methods: comedone extraction, acid peels, PDT

Severe Acne

Consideration for oral isotretinoin:

Prior to starting therapy, educate the patient on side effects including possibility of initial acne flare up, avoiding pregnancy due to risk of fetal toxicity (two methods of contraception) and obtain a signed consent form with the base line blood work (inc liver function, lipid profile, plus bHCG for females) The starting dose is usually 0.5 mg /kg/day for 1 month; the dose can be increased to 1mg/kg/day for at least 4- 6 months depending upon the response

Physical methods: aspiration of pus, +/- intralesional steroids

Other therapies include: Oral contraceptive pills such as Dianette, Alesse for female patients if acne flare-ups are related with menstrual periods. Consider investigation for hormonal imbalance, PCOS, hyperandrogenism. Spironolactone in doses of 25- 100 mg daily. It is mostly indicated in patients with acne and hirsutism. It is not widely used because of its side effect profile.

Acne Grading and Management

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Appendix 1: References

1.Department of Dermatology Acne module. Cardiff University. 2011. 2. Tan J, Wolfe B, Weiss J. Acne severity grading: determining essential clinical components and features using a Delphi consensus. J Am Acad Dermatol. 2012 67:2; 187-93 3.Humphrey S. Adjunctive Skin Care for Acne. Skin therapy Letter. 2013; 9(1) 6-9 4.European Dermatology Forum. Guideline on the treatment of acne. Galderma UK Ltd; 2012. 5.Gollnick H, Cunliffe W, Berson D, et al. Management of acne-a report from a global alliance to improve outcomes in acne. J Am Acad Dermatol 2003 49:S1-37 6.Thiboutot D, Gollnick H, Bettoli V, et al. New insights into the management of acne: An update from the global alliance to improve outcomes in the acne group. J Am Acad Dermatol 2009 60:S1-50 7.Graber E. Treatment of Acne Vulgaris. UptoDate. August 12, 2013 [cited 2013 Nov 6]. Available from: http://www.uptodate.com/contents/treatment-of-acnevulgaris?topicKe...searchTerm=acne&selectedTitle=1%7E50&view=print&displayedV iew=full.