Number 6 ACNE JULY Inspect the skin to establish the extent of submarine comedones

Transcription

1 Number 6 CORE TUTORIALS IN DERMATOLOGY for primary care PDP Self-test questionnaire Picture showing submarine extent of ICEBERG ACNE UPDATED PDP SELF-TEST QUESTIONNAIRE JULY 2014 Inspect the skin to establish the extent of submarine comedones

2 Duct blocked with sebum and cells Normally harmless bacteria (P. acnes) Increased oil secretion Sebaceous gland P. acnes proliferates Increased oil secretion Inflammatory trigger release Duct ruptures releasing contents Leading to an excessive inflammatory reaction eating too much greasy food there is no proven link between diet and acne, however, eating a sensible diet is beneficial to overall health. the colour of a blackhead is due to pigment in the cells blocking the pore. however, in acne patients, the skin is oversensitive to normal levels of male sex hormones (androgens) which are present in both males and females. their period, probably due to hormonal changes eg; contact with chemicals and oils. eg; humid climate on holiday or a hot kitchen. eg; anti-epilepsy treatments and corticosteroids. however you can try cosmetics specially designed for sensitive skin (which may be labelled as noncomedogenic'). your skin or use harsh abrasives, as this may worsen your acne. Shampoo hair regularly. inflammation into deeper tissue and cause scarring. inflammatory medication at an early stage to help prevent residual skin damage. advice, and has access to a range of licensed treatments that are only available behind the pharmacy counter they carry the letter P on their packaging. treatment this will give your skin the best chance of improving. and not just to individual spots. If your skin is not significantly better within two months, visit your GP for alternative treatment. already tried and give these to your doctor. in the morning and a moisturiser at night. creams and foundations can block the pores. Treatment choice will depend on previous experience, patient acceptability and the type of spots present (whether comedonal or red, inflammatory acne). Over-the-counter treatments can include ingredients such as benzoyl peroxide. Treatments available from your GP include: Topical anti-acne preparations Anti-inflammatory treatments such as nicotinamide Oral antibiotics And for women only, short term oral hormone treatment For very severe acne, specific treatments are available with specialist (usually hospital) supervision. Usually only need treatments you apply to the skin (topical). Needs a topical treatment, possibly with a tablet (oral) treatment. Same as for moderate but with closer supervision and more frequent visits to the GP. May need referral to a specialist. CORE TUTORIALS IN DERMATOLOGY FOR PRIMARY CARE author: Dr Brian Malcolm, BSc, MBChB, MA, DRCOG, DPD, DCH, Dip Derm (Glasg.), FRCGP. General Practitioner AND GPwSI, Litchdon Medical Centre, Barnstaple. associate specialist, north devon healthcare trust. PDP Self-test questionnaire introduction CORE TUTORIALS IN DERMATOLOGY for p RIMARY CARE picture S h O w ING SUb MARINE E x TENT O f ICEb ERG U p DATED Ch A p TER MAY 2014 ACNE Number 6 in a series of 7 Inspect the skin to establish the extent of submarine comedones This self-test questionnaire has been written by Dr Brian Malcolm, based on the recently updated (2014) Chapter 6 Acne of the Core Tutorials in Dermatology for Primary Care. This revised Chapter has been sent out to healthcare professionals with the compliments of Dermal Laboratories. If you have not received a copy of this updated chapter, you can order a copy from Dermal at the address below. Alternatively, the Chapter is available to download from the Dermal website within the Healthcare Professionals Resources section. RESOURCES FOR MANAGING ACNE AVAILABLE FROM DERMAL We have available a Medicine Matters paper, which outlines the management of acne in primary care and different treatment options. There is also a useful algorithm included for the management of acne which suggests pathways for treating the condition. To request a copy please contact Dermal at the address below. PATIENT EDUCATION To encourage better understanding of acne and to provide tips, patient advice leaflets are available. These are available to download from the Patient Resources section of the Dermal website Patient Guidelines for Acne Fact and Fiction How can you help? Treatment outlook Treating acne successfully can take a long time, so don t give up! Failing to take treatment regularly as prescribed is very common! If a particular treatment is not successful there are others you can try! Acne is a common skin disorder, which can affect 80% of adolescents. Fortunately acne usually improves with age, although in some cases it may persist well beyond the teenage years. Hormones called androgens stimulate the sebaceous glands (small oil glands adjacent to the fine hairs on the face, back and chest), to produce oil (sebum), sometimes in excess quantities which blocks the duct resulting in blackheads and/or whiteheads. Doctors refer to these as comedones. When red spots are present (papules and pustules) this is due to inflammation. Comedonal Acne Inflammatory Acne Nodular or Cystic Acne below the surface excess sebum which triggers an inflammatory surrounding skin, leading to more severe inflammation, at the surface extend deep into the area blackhead Papules inflamed that contains the skin s Pustules spots severe cases, the resulting tissue damage can lead to It is important to treat acne at an early stage. This should prevent it getting worse and reduce the risk of residual skin damage. Acne severity can be broken down into three types to help identify the best treatment options. Acne is not infectious or contagious Acne is not caused by Acne is not caused by dirt Sexual activity does not influence acne Acne can become worse for women 2-7 days before The following can also make acne worse: Certain types of employment Sweating and a humid atmosphere Some medicines Some cosmetics Wash affected area twice a day do not scrub Try not to squeeze or pick spots which may force the Red inflamed spots can be treated with an anti- Your pharmacist can offer helpful Follow all instructions supplied with your Apply treatment to the whole of the affected area Follow the two month rule: Write down names of treatments that you have If your skin becomes dry, try applying the treatment Use a water based moisturiser greasy or oily Mild Acne Moderate Acne Severe Acne Useful contacts: The Acne Academy, NHS Choices, Presented with the compliments of Dermal Laboratories See overleaf for helpful hints and advice. MAY 2014 SPONSORED BY DERMAL LABORATORIES, TATMORE PLACE, GOSMORE, HITCHIN, HERTS, SG4 7QR, UK. TEL: (01462)

3 QUESTIONS 1. The presence of which type of lesions are a prerequisite for a diagnosis of acne? 2. What type of drugs are most directed against comedonal acne? 3. What levels of resistance are shown by P. acnes to erythromycin? 4. What percentage of patients demonstrate improvement of their acne after 3 months treatment with Dianette? 5. Name two types of scarring seen in acne.

4 QUESTIONS 6. What are the most common side-effects of systemic isotretinoin? 7. What are the potential side-effects of minocycline? 8. What is the peak age of severity of acne for males? 9. What is the principle mode of action of benzoyl peroxide? 10. From what natural resource is nicotinamide used in the treatment of inflammatory acne derived from?

5 REFLECTIVE LEARNING 11. What did I find useful about the learning module on Acne? 12. Having reflected on this module, how might my practice change in managing acne?

6 ANSWERS (PLEASE TURN UPSIDE DOWN) QUESTION 5. Answer: Any of atrophic, hypertrophic, keloid or ice-pick Ref page 1 HYPERTROPHIC/KELOID SCARS Keloid Scars Elevated, surface smooth and pink with irregular shape. ATROPHIC MACULAR SCARS Atrophic Macular Scars Depressed 5-20mm diameter, typically red or violaceous. ICE-PICK SCARS Ice Pick Scars Small, superficial to deep with well defined edge. QUESTION 6. Answer: Dry skin Cheilitis Myalgia Conjunctivitis Ref page 11 Common side effects are cheilitis, which is almost invariable, dry skin, mild conjunctivitis and myalgia. More rarely, paronychia, hyperhidrosis, headaches and disordered liver function and lipid profile can occur. QUESTION 7. Answer: Lupus like syndrome Hepatitis Skin pigmentary disturbances Benign intracranial hypertension Ref page 9 Although all the antibiotics used in the long term treatment of acne are generally very well tolerated, minocycline does have the risk of significant but rare side effects including hepatitis, a lupus like syndrome, benign intracranial hypertension and a blue-grey pigmentary disturbance of the skin which can be quite persistent. Some authorities recommend regular blood monitoring with liver function, ANF (antinuclear factor) and ANCA (antineutrophil cytoplasmic antibody). QUESTION 8. Answer: Age Ref page 1 Acne, unarguably, is core clinical material in dermatology for primary care physician and specialist alike. It affects to some degree 85% of adolescent females and 95% of males 1, although it is only considered clinically significant in approximately 15%. The age of onset is approximately 12 years with peak severity at in females and in males. QUESTION 9. Answer: It works as an antimicrobial active against P. acnes Ref page 5 Works predominately as an antimicrobial by virtue of oxidisation of anaerobic P. acnes, therefore most useful for inflammatory acne with the presence of papules/pustules; can produce a profound reduction in surface bacteria counts (x 100 fold). QUESTION 10. Answer: Vitamin B3 Ref page 6 Nicotinamide Vitamin B3 derivative Active against inflammatory acne Similar in efficacy to topical antibiotics but with no risk of resistance 6

7 ANSWERS QUESTION 1. Answer: Comedones (can be both open and closed) Ref page 1 The diagnosis of acne rarely poses problems to the physician. However, one should be able to demonstrate the presence of both comedones and papules/pustules. The earliest expression of the disease process is the microcomedone; mid-facial comedones may pre-date inflammatory acne by several years. Subsequent lesions which must be confidently differentiated by the physician are both closed and open comedones (white and blackheads), papules, pustules, nodules and a variety of scars, atrophic, ice-pick and hypertrophic/keloid. It is the recognition of the lesion mix that determines both the potential severity of the acne and the rationale for individually tailored treatment regimes. QUESTION 2. Answer: Retinoids (synthetic Vitamin A derivatives) Ref page 6 Indicated for treatment of comedonal acne. Most effective against open comedones, but regular treatment may prevent progression of the microcomedone and consequently decrease subsequent acne severity. QUESTION 3. Answer: 60-70% Ref page 8 In vitro studies demonstrate alarming rates of resistance of P. acnes to antibiotics in common usage. Resistance to erythromycin has been recorded as high as 60%-70% and a study in 1996 demonstrated 25% of all community P. acnes was resistant to one or more of the commonly used drugs. Increasing incidence of resistance in acne patients 7 QUESTION 4. Answer: 80% Ref page 9 It works primarily as an anti-androgen as a consequence of the cyproterone, and its primary action is to reduce sebum production. The average reduction is 30% and 80% of patients show improvement after 3 months continuous treatment.

8 STOP...inflammatory acne and its associated redness GET READY... to help patients with inflammatory acne GO...R x AHEAD Nicam Gel nicotinamide An effective treatment without antibiotics 4% nicotinamide gel is of comparable efficacy to 1% clindamycin gel in the treatment of acne vulgaris. Because topical clindamycin, like other antimicrobials, is associated with emergence of resistant microorganisms, nicotinamide 1 gel is a desirable alternative treatment for acne vulgaris. After eight weeks treatment nicotinamide gel showed 1 : Nicam Gel Prescribing Information Nicam 4% w/w Gel Nicotinamide 4% w/w Use: For the topical treatment of mild to moderate inflammatory acne vulgaris. Directions: Apply to the affected area twice daily after the skin has been thoroughly washed. Enough gel should be used to cover the affected area. Contra-indications, warnings, side-effects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. In the unlikely event of a reaction stop treatment. Keep away from the eyes and mucous membranes, including those of the nose and mouth. May cause dryness of the skin. Other less frequent side effects include pruritus, erythema, burning sensation and irritation. If excessive dryness, irritation or peeling occurs reduce the dosage to one application per day or every other day. Package quantity, NHS price and MA number: 60g tube 7.10, PL00173/0166. Legal category: P MA holder: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: November Nicam is a trademark. Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Dermal. Reference: 1. Shalita A.R., Smith J.G.Topical nicotinamide compared with clindamycin gel in the treatment of inflammatory acne vulgaris. International Journal of Dermatology, Vol 34, No 6, June DEM447/JUN14