Acne Treatment Guide PDF

# Acne - The incidence of acne in teenagers is extremely high. It has been estimated that over half of all adolescents will experience some degree of acne. - Most acne sufferers respond, at least initially, to self-treatment. Mild acne often responds well to correctly used over-the-counter treatmen...

# Acne - The incidence of acne in teenagers is extremely high. It has been estimated that over half of all adolescents will experience some degree of acne. - Most acne sufferers respond, at least initially, to self-treatment. Mild acne often responds well to correctly used over-the-counter treatments. - Pharmacists should remember that self-conscious teenagers regard acne as a major problem, and that a sympathetic response to requests for help, together with an invitation to return and report progress, can be as important as the treatment selected. ## Information to be collected - **Age** - Acne commonly occurs during the teenage years, and its onset is commonest at puberty, although it may start to appear a year or so before puberty. - Acne can persist from a few months to several years; with onset at puberty, acne may continue until the late teens or even early twenties. - The hormonal changes, which occur during puberty, especially the production of androgens, are thought to be involved in the causation of acne. - Increased keratin and sebum production during adolescence are thought to be important contributory factors, the increased amount of keratin leading to blockages of the follicles and the formation of comedones (a comedone is a mass of keratin and sebum). - **Very young** - Acne is extremely rare in young children & babies and any such cases should be referred, since an androgen secreting (hormone producing) tumor may be the cause. - **Older** - For patients in whom acne begins later than the teenage years, other causes should be considered, including drugs (such as combined hormonal contraception), occupational factors and hyperandrogenism in women. - Oils and greases used at work can precipitate acne, and it would be worth asking whether the patient comes into contact with such agents. - Acne worsens just before/during menstruation; this is due to changes in progesterone. - **Duration** - The information gained here should be considered in conjunction with facts about medication (prescribed or OTC) tried already, and about other medicines being taken. - Acne of long duration where several over-the-counter preparations had been correctly used without success would indicate referral. - **Severity** - OTC treatment may be recommended for mild acne. - Comedones may be 'open' (blackhead) or 'closed' (white head); the sebum in closed comedones can't reach the skin surface. - The plug of keratin, which is at the entrance to the follicle in a comedone, is initially white (whitehead), later becoming darker coloured because of the accumulation of melanin (blackhead). - However, sebum is still produced, so that swelling occurs, and the comedone ruptures, discharging its contents under the skin. - The released sebum causes an inflammatory response; if the response is not severe, small red papules appear. - In more severe acne angry-looking red pustules are seen and referral to the GP for alternative forms of treatment, such as topical or systemic antibiotics, is needed. - **Affected areas** - Acne principally affects the face (99% of people with acne), the upper back and shoulders (50%) and the chest (15%). (all areas with large numbers of sebaceous glands). - Rosacea is a chronic inflammatory skin condition, which is sometimes confused with acne. - Occurring in young (20-39) and middle-aged (40-59) adults and sometimes in older people, the characteristic features of rosacea are reddening, papules and pustules. Only the face is affected. ## Medication - The pharmacist should establish the identity of any tried treatment, & its method of use. - Inappropriate medication use, e.g., infrequent application or short duration of use, could affect the success chances. - Information about current therapy is important, since acne can be drug-induced. - Lithium, phenytoin & progestogens, levonorgestrel & norethisterone (e.g., in the oral contraceptive pill) may be culprits. - If acne is suspected as a result of drug therapy, the patients should be advised to discuss this with their doctor. ## Treatment time scale - A patient with mild to moderate acne, which has not responded to treatment within 8 weeks should be referred. ## Management - OTC treatment may be recommended for mild- to- moderate acne - The general aims of therapy are to remove follicular plugs so that sebum is able to flow freely, and to reduce the numbers of bacteria on the skin. - Treatment should therefore reduce comedone formation. - The most useful formulations are lotions, creams & gels. - Gels with an alcoholic base dry quickly but can be irritating. - Gels with aqueous base dry slower but are less likely to irritate the skin. - A non-comedogenic moisturiser can help if the skin becomes dry as a result of treatment ## Benzoyl peroxide - Benzoyl peroxide can be considered the first-line over-the-counter treatment for inflammatory and non- inflammatory acne. - Benzoyl peroxide is available in a variety of vehicles (eg, cleansers, gels, lotions, creams, pads, masks, washes) and concentrations, generally ranging from 2.5 to 10%. Benzoyl peroxide is usually applied once daily - It has a keratolytic action, helping peeling of the skin, and also has antibacterial properties, which should help to reduce the skin flora. Anti-inflammatory action occurs at all strengths. - Concentrations higher than 2.5% may not contribute to increased benefit and may be more likely to cause skin irritation. - Regular application can result in improvement for most people with acne of all severities ## Advice on using benzoyle peroxide - At first, benzoyl peroxide is very likely to produce reddening and soreness of the skin, and patients should be warned of this. - Gels can be helpful for people with oily skin and creams for those with dry skin. - Washing the skin with mild soap/cleansing rinsed off with water and allowed to dry fully before applying benzoyl peroxide can help reducing the amount of sebum on the skin. - Benzoyl peroxide prevents new lesions forming rather than shrinking existing ones. Therefore, it needs to be applied to the whole of the affected are, not just to individual comedones. - Facial washes containing benzoyl peroxide should not be used while the patient is using another topical benzoyl peroxide preparation. - Benzoyl peroxide increases the risk of sunburn. Avoidance of sunlight is not always possible, so the patient should use an appropriate sunscreen or protect treated skin on the chest and back by wearing a t- shirt. - During the first few days of use, the skin is likely to redden and may feel slightly sore. Stinging, drying and peeling are likely. ### To reduce irritation - Start with the lowest possible strength. - Apply sparingly & infrequently during the 1st week. - Wash off the application of benzoyl peroxide after 15 min initially, and increase exposure in increments of 15 min until the drug can be tolerated for 2 h or more. - If after that irritation doesn't improve discontinue the product. ## Sensitisation - Occasionally, sensitization to benzoyl peroxide may occur after a period of use. - The skin becomes reddened, inflamed & sore, and treatment should be discontinued. ## Bleaching - Warning should be given that benzoyl peroxide can bleach clothing and bedding. - If used at night, white sheets and pillowcases are best used, and patients can be advised to wear an old T-shirt or shirt to minimize damage to good clothes. - Contact between benzoyl peroxide and the eyes, mouth and other mucous membranes should be avoided. ## Other keratolytics - Include potassium hydroxyquinoline sulphate and salicylic acid. They are second-line treatments. - Salicylic acid has comedolytic effect and mild anti-inflammatory properties - Salicylic acid is usually applied once daily and subsequently increased to two or three times per day if needed - The frequency of application can be reduced to once daily or every other day if the patient develops skin dryness or peeling - Available in a number of nonprescription gels, lotions, solutions, cleansers, pads, and masks - Salicylic acid can also be used in combination with benzoyl peroxide, as the mechanisms of action of these drugs complement each other in the treatment of acne - Topical sulfur has been used for the treatment of acne for many years, although there are few data supporting its efficacy. Sulfur is often combined with salicylic acid or benzoyle peroxide in nonprescription products ## Nicotinamide - Topical nicotinamide gel has mild anti-inflammatory action & is applied twice daily. There is limited evidence of effectiveness - Side effects may include skin dryness &/or irritation. - Several weeks' treatment maybe needed to see the full effects. ## Tea Tree Oil - Tea tree oil (TTO) is an essential oil derived from the leaves of the Melaleuca alternifolia plant. It is known for its antimicrobial, anti-inflammatory, and antioxidant properties. - Tea tree oil has demonstrated efficacy in reducing mild-to-moderate acne and offers a natural alternative to conventional treatments like benzoyl peroxide. - While it may take longer to show results. - The reduced incidence of side effects makes it appealing for individuals with sensitive skin ## Antiseptic agents - Skin washes and soaps are available containing antiseptic agents such as chlorhexidine. - They can be useful in acne by degreasing the skin, and by reducing the skin flora. - There is limited evidence of effectiveness. ## Topical Retinoids - Adapalene, tretinoin and isotretinoin are topical retinoids that are commonly prescribed by the doctor. - They can cause skin irritation, particularly in people with eczema, but most importantly they are contraindicated in pregnancy. Retinoids are teratogenic and can damage the developing baby. - Adapalene 0.1% gel is the only topical retinoid available without a prescription. - Topical tretinoin should not be applied at the same time as benzoyl peroxide. If both agents are prescribed, benzoyl peroxide should be applied in the morning and tretinoin in the evening. - Tretinoin is less stable when exposed to benzoyl peroxide due to oxidation, an effect magnified during light exposure - Some newer formulations of tretinoin (eg, tretinoin gel microsphere, micronized tretinoin gel, tretinoin 0.05% lotion in polymeric emulsion) are stable in the presence of benzoyl peroxide. - Adapalene, also remains more stable than tretinoin in the presence of benzoyl peroxide. ## Antibiotics - Oral antibiotic therapy, available on prescription (i.e. prescription- only medicine [POM]), usually consists of tetracyclines. Doxycycline and lymecycline are most often used, as a once- daily dose is more convenient, and they can be taken with food - Doxycycline causes increased sensitivity to sunlight and patients should be advised to use sunscreen. - Minocycline should no longer be prescribed for acne as it is associated with severe adverse reactions and skin pigmentation - If taking oxytetracycline or tetracycline, patients should be reminded not to eat or drink dairy products up to an hour before or after taking the antibiotic. The same rule applies to antacid or iron preparations. - Evidence suggests that failure of antibiotic therapy in acne in the past may have been due to sub-clinical levels of antibiotic due to chelation by metal ions in dairy products or antacids. - Tetracyclines are contraindicated in pregnancy, breastfeeding, and in children less than 12 years. - Erythromycin is also used in acne but tends to be used as second- line treatment. - Bacterial resistance to erythromycin is now high, so it may not be effective. - Topical antibiotics (such as clindamycin 1%) are used as a treatment for mild to moderate acne, but they should always be prescribed in combination with benzoyl peroxide to prevent development of bacterial resistance ## Practical points - **A) Diet** - There is absolutely no evidence to link diet with acne, despite emerging data suggest that high glycaemic index (GI) diets (which may include sweets or chocolate) may exacerbate acne. - **B) Sunlight** - It is commonly believed that there are beneficial effects of sunlight on acne. due to its peeling effect, which helps unblock follicles, & the drying or degreasing effect of the sun on the skin. - A systematic review found that ‘convincing direct evidence for a positive effect of sunlight exposure on acne is lacking - Benzoyl peroxide causes photosensetisation → Care must be given that patients using benzoyl peroxide should avoid exposure to sun or use a sunscreen product. - **C) Keratolytics** - All keratolytics make the skin peel, and can therefore be useful in acne. - They should be applied to the whole of the affected area, not just to individual comedones, and are best applied to skin following washing. - During the first few days of use, the skin is likely to become reddened and feel sore. - Warning should be given that such an irritant effect is likely to occur, otherwise treatment may be abandoned inappropriately. - **E) Continuous treatment** - Acne is notoriously slow to respond to treatment and a period of up to 6 months may be required for maximum benefit. - It is generally agreed that keratolytics such as benzoyl peroxide require a minimum of 6-8 weeks' treatment for benefit to be shown. Patients should therefore be encouraged to persevere with treatment, whether with over-the-counter or prescription products, and told not to feel discouraged if results are not immediate. - The patient also needs to understand that acne is a chronic condition and continuous treatment is needed to keep the problem under control. - **F) Skin hygiene** - Acne is not caused by poor hygiene, or by failure to wash the skin sufficiently often. - Regular washing of the skin with soap & warm water, or preferably with antibacterial soap or skin wash can be helpful by degreasing the skin and reducing the numbers of bacteria present. - Avoid over- cleaning the skin (which may cause dryness and irritation) - **G) Topical Corticosteroids** - The use of topical hydrocortisone, clobetasone or any other corticosteroid is contra-indicated in acne because steroids can potentiate the effects of androgenic hormones on the sebaceous glands, hence making acne worse. - **H) Make-up and skin care products** - Heavy, oily foundations and moisturizers are likely to exacerbate acne because they are comdeogenic. - If make up is to be worn, water-based rather than oily foundations are best, and they should be removed thoroughly at the end of the day. - skincare preparations with a pH close to that of the skin (5.5) may be helpful. - If dry skin is a problem, use a fragrance- free water- based moisturiser. - **I) Removal of comedones** - Avoid picking and squeezing spots and blackheads, as this may increase the risk of scarring.