ACNE TOP TIPS FOR GPs! Louise Moss GP Moss Valley Medical Practice, Eckington, GPwSI for NDCCG Sept 2013
Acne-an important condition
Aim for today To have a better understanding of how to treat Acne well, when to refer and what to have done first.
Objectives To introduce the NDCCG acne pathway To introduce the NDCCG acne audit
Acne is common Prevalence Up to 50-95% of adolescents in Western countries Most settles by 25 yrs 7% persists longer esp women Acne persisting beyond 25 yrs is likely to persist until age 45
ACNE Accounts for 5% of dermatological referrals 50% will have received sub-optimal therapy
ACNE - The basics Understand what causes acne Target your treatment accordingly Follow up your patient to enhance compliance
Diagnosis
Assess your acne properly Take a good history Type of lesion Where? Grade severity
Types of Acne lesion.. COMEDONES If these appear early they are a poor prognostic indicator Use a blackhead extractor and start effective treatment.
Comedones precede the development of inflammatory lesions. This 9 yr old had blackheads for 2 years before inflammatory papules appeared.
Papulopustular acne
Nodular/conglobulate acne
Scarring
Don t forget the trunk Site
Grade your acne Mild Moderate Severe
Management Use a patient information leaflet and talk patient through why you are using each treatment.
Causes of Acne Vulgaris
What to use for what.. androgen induced excess sebum production 1 st line option COC/ 2 nd line option cocyprindiol 2000/35 comedone formation topical retinoid e.g. adapalene inflammation -benzoyl peroxide e.g. Acnecide gel or Quinoderm cream infection- colonisation with P. acnes antibiotics topical or oral
Comedonal acne
Severe irritant dermatitis
Mild papular-pustular acne
Mild papular-pustular acne use BOTH a topical anti-inflammatory agent eg Quinoderm cream /Acnecide 5% gel and an antibacterial one e.g. clindamycin (Dalacin T) If there are comedones add a topical retinoid as well. Consider using combination products e.g. Duac (clindamycin & BP) or Epiduo gel (adapalene & BP)
Treatment of moderate inflammatory acne
Oral antibiotics in combination with appropriate topical treatments Quinoderm/Acnecide cream in the morning Topical adapalene at night e.g. Differin cream or gel Oral antibiotics First-line Doxycycline 100mg od Second-line Erythromycin 500mg bd Third-line Trimethoprim 300mg bd
Moderately severe acne in women consider adding co-cyprindiol 2000/35 Once sustained improvement (3 months) consider changing to an oestrogenic COC e.g. Gedarel 30/150 to prevent rebound.
Severe Acne refer early
Monitoring Review after two months expect 50% improvement at this point, no more. Assess compliance. Consider doubling the dose of doxycycline or a second-line antibiotic. Reinforce use of BP & Adapalene. Minimise the risk of antibiotic resistance - use BP with abx, stop systemic abx after 3/12 of sustained improvement
Patient info www.bad.org.uk www.pcds.org.uk The acne information leaflet used at CRH FT is in appendix A. If you are considering referring for oral isotretinoin you can give them a copy of the leaflet in appendix B.
Referral Criteria Severe acne- refer early for oral isotretinoin if large nodulocystic lesions, scarring or no rapid response to treatment Moderately severe acne which has not responded to 2 x 4 month courses of different antibiotics PLUS topical treatment, especially if starting to scar.
Refer only.. Those requiring oral isotretinoin. Do FBC, fasting lipid profile and liver function tests first. If they are female make sure they are on contraception ( even if they are not sexually active)
SO TOP TIPS.. Look properly and document type of lesions and grade so you can assess improvement- Use the right treatment for the right sort of lesion If there are comedones use adapalene Antibiotic monotherapy is not adequate treatment! Review every 2 months Limit antibiotic repeats to 2 months
NDCCG ACNE AUDIT % of last 20 patients seen with acne and at least the last 3 acne referrals made in whom 1. a record of severity/ extent of acne/ type of lesions was made 2. a topical retinoid/ adapalene was used 3. topical treatment is used in addition if an oral antibiotic is prescribed
QOF QP 2013/14 update 21/6/13 QP3+6 QOF worksheet 4. If a referral for oral isotretinoin was made the referral criteria were met i.e. Moderately severe acne which has not responded to 2 x 4 month courses of different antibiotics PLUS topical treatment or Patients with severe acne or severe psychological symptoms
Moss valley s Audit Data collection Period from December 2012 to Jun 2013 Word search on System One acne vulgaris, adapalene, benzoyl peroxide, Duac 108 patients on list
RESULTS Out of 108 patients, 21 excluded as: 18 have no consultations, just repeats meds issued 3 have consultations, but prescribing without any documentation on acne One of which has 2 abx on repeat (no review over 6/12) Only 87 patients analysed
CONCLUSION No meds review for 21 patients (19.4%) over 6 months 30% has no assessment recorded Only 2% monotherapy treatment 100% referral for isotretinoin meet criteria
RECOMMENDATIONS Only allow two issues of acne repeat meds Leeds grading chart on wall/computer Increase awareness of guidelines among doctors Re-audit in 6 months