Acne Vulgaris
Diagnosis/Definition
- A follicular eruption with comedones (“blackheads and whiteheads”), red papules, pustules and nodules, generally found on the face and upper trunk. Disease peaks at adolescence but can be seen in children as young as 8 and is not uncommon in adulthood.
- Mild Acne – Superficial lesions, mostly comedones, and some inflamed papules and pustules, no evidence of scarring and no nodules.
- Moderate Acne – Lesions may involve the face and trunk, mild superficial scarring may be seen, with papules, pustules, comedones, and a few nodules. Nodules are not the dominant lesion.
- Severe Acne – Acne is causing persistent painful nodules, comedones, papules, and may have deep scars. In addition, acne has not responded to conservative optimal treatment.
Initial Diagnosis and Management - Document education regarding known causes of acne and emphasize chronic course of disease. There is no cure though it improves with time in most cases and there are many methods of care available which can control it well. Instruct in the importance of non-comedogenic skin care products. Eliminate the use of other acne treatments and recommend only twice daily (best) facial washing with a mild soap.
- Mild Acne – Topical Tretinoin cream (Retin-A) nightly (or at less frequent intervals if too much irritation). Most patients will not tolerate a potent strength and should begin with 0.025% or 0.05% cream. Explain that Retin-A frequently causes some redness and scaling which improves with time and can be minimized by closely following prescribing advice. Tretinoin may cause an initial worsening of acne at 3-4 weeks and has maximum benefit after 4-5 months. Increase strength as tolerated. In addition, topical antibiotics such as erythromycin or clindamycin solution applied twice daily (best) are used to help reduce the P. Acnis population in the follicles. Follow up at 8 -12 weeks to encourage compliance.
- Moderate Acne – Topical Retin-A and antibiotic as above. Oral antibiotics – Tetracycline (taken with water, no food) 250-500mg PO, doxycycline 100 mg PO, erythromycin 250 – 500mg PO or Septra DS 1 PO, all twice daily can be used. These meds address the inflammatory acne and should be used for a minimum of 2-3 months before declaring a treatment failure. Follow up at 8-12 weeks to encourage compliance.
- Severe Acne – Referral to dermatology if there is not a marked improvement at 12-week follow-up to full regimen for moderate acne.
- Low progestin – type of oral contraceptives: For women who have acne that waxes and wanes cyclically with their menstrual cycle, BCPs can help reduce the flares. If the woman has hirsutism and/ or irregular menses and/or acne that does not respond to conservative treatment, further evaluation for polycystic ovarian syndrome or a mild form of congenital adrenal hyperplasia should be considered. Two BCPs are labeled for acne: Ortho-Tricyclen, and Estra Step. Yasmin, while not labeled to treat acne is, nevertheless, commonly recommended by dermatologists for acne treatment.
Ongoing Management and Objectives
- Reduction/Prevention of scarring and good resolution of lesions are the primary objectives.
- Gentle skin cleansing is encouraged: Mild soaps (ie Dove, Oil of Olay for Sensitive Skin, Cetaphil, Phisoderm, Purpose, Neutragena) may be used to cleanse the skin. Discourage scrubbing with washcloths, Buff-Puffs, and any cleanser that contains abrasives of any type as these can worsen acne, and contribute to scarring. Avoid soaps such as Dial, Zest, Coast, Irish Spring, Safeguard, Noxzema, Ivory – these seem to contribute to worsening of acne.
- Mild Acne – If there is minimal improvement at 8 weeks, review medication use and compliance. Encourage patient to continue regimen even if only mild improvement is seen. Topical benzoyl peroxide (BP) gel (over-the-counter, OTC) can be added if there is no irritation from Retin-A or substituted for Retin-A if patient cannot tolerate side effects of Retin-A. BP should be used at a separate time of day from Retin-A as it may inactivate the Retin-A if they are mixed directly. BP wash or soap (available in 4-10% strengths OTC) may be gently used as a cleanser in the shower every other day. Add an oral antibiotic if patient is compliant with medications and is still dissatisfied with results.
- Moderate Acne – Manage as above at 12 weeks continuing initial antibiotic. Follow up at 3-4 months and consider changing antibiotic to doxycycline 100 mg PO bid or minocycline 50-100 mg PO bid if not responding well.
Indications for Specialty Care Referral - Refer patients with mild or moderate acne that has not cleared with 6 months of conventional, conservative treatment (prescription meds).
- Refer patients with acne that is refractory to treatment especially if likely to cause severe and disfiguring scars.
- Make a referral if the medication Accutane is being considered because of prior treatment failure, or acne is severe enough to consider it as a treatment option. Female patients may be referred for consideration for Accutane as well, but will eventually need to be on two reliable forms of contraception for a minimum of one month prior to start of Accutane. We will send patient back to referring provider to initiate this if the patient is a candidate for Accutane.
Criteria for Return to Primary Care
Acne stabilized, improvement on regimen of therapy, or completion of Accutane course.
