ACNE VULGARIS

28 May

Acne Vulgaris is a chronic and common skin condition that most often affects adolescents. This condition forms different types of presentations on the skin including, spots, redness and inflammation.

- Acne is one of the most common skin conditions in the UK leading to 3.5 million visits to primary care every year.
- Acne is the most common skin disease in the US and affects 80% of the population at some point in life [1]
- Acne is more common in males during adolescence but in adulthood, higher in women [2]
- The Global Burden of Disease Study 2010 found that acne vulgaris is the eighth most common skin disease, with an estimated global prevalence of 38% [3]
- Approximately 85% of people between the ages of 12 and 24 experience at least minor acne [4]
- Blocked hair follicles
- Testosterone
- Acne in families
- Periods
- Pregnancy
- Polycystic Ovary Syndrome
- Certain medications- steroids, lithium, anti-epileptics
- Smoking
- High glycaemic index
- Cosmetics [10]
Medical Students
Acne Classification
- Non-inflammatory acne:
  - Comedones (open = blackheads, closed = whiteheads)
- Inflammatory acne:
  - Papules (inflammation from comedone contents)
  - Pustules (result from further inflammation)
Sebum & Follicular Plugging
- Sebum has antibacterial, antioxidant, and protective roles
- Increased sebum production (due to puberty, pregnancy, etc.) contributes to acne
- Disrupted keratinisation in the pilosebaceous unit → follicular blockage
Cutibacterium acnes (C. acnes)
- Considered a low-virulence, opportunistic pathogen
- Associated with inflammatory acne, soft tissue infections, and skin damage
- Triggers immune response leading to inflammation
Inflammatory Mediators
- Acne lesions are associated with increased levels of:
  - E-selectin (leukocyte recruitment via IL-1 and TNF-α)
  - Vascular adhesion molecules, interleukins, integrins
  - CD3+ and CD4+ T cells, macrophages
Patients
- Acne happens when too much oil (sebum) is made and pores get blocked
- Hormones (like during puberty or pregnancy) can increase oil production
- Blocked pores lead to whiteheads, blackheads, or pimples
- A natural skin germ called C. acnes can make the skin red and swollen
- The body reacts with inflammation, causing spots or painful bumps [5,6,7,8,9]
- Skin trauma (eg. usage of soaps, detergent, or other agents)
- Food habits (high glycemic index)
- Stress
- Insulin resistance
- Increased BMI
- Endocrine disorders
- Greasy skin
- Genetics
- Age (12-24) [11,12]
- Involves the neck, chest, back and other parts of the body
- Blackheads (open comedones) and whiteheads (closed comedones)
- Small, tender red bumps
- Yellow or white spots
- Swelling
- Redness
- Dark/red marks
- Scarring [5]
- Clinical diagnosis (risk factors and presentation of acne)
- Hormonal evaluation
- Bacterial cultures [12]
- Rosacea
- Peri-oral (around the mouth) dermatitis
- Folliculitis (inflammation of the follicles) and boils
- Drug-induced acne
- Keratosis pilaris (a dry skin condition caused by keratin build-up) [1]
Medical Students
- Personalise discussion based on:
  - Acne severity and possible causes
  - Pros and cons of treatments
  - Reproductive health considerations (e.g. contraception)
- Discuss contraindicated treatments in pregnancy (e.g. topical retinoids, oral tetracyclines)
Lifestyle Advice
- Avoid over-cleansing the skin
- Use pH-neutral or slightly acidic cleansers
- Avoid oil-based products (e.g. make-up, sunscreen)
- Reduce skin irritation by:
  - Starting treatment gradually or on alternate days
  - Minimising skin contact to reduce scarring
Mild to Moderate Acne
Offer a 12-week course of one of:
- Topical adapalene + benzoyl peroxide
- Topical tretinoin + clindamycin
- Topical benzoyl peroxide + clindamycin
- Monotherapy: topical benzoyl peroxide if others are contraindicated or not tolerated
Formulation Tips:
- Use creams/lotions for dry/sensitive skin
- Use gels for oily skin
Moderate to Severe Acne
Offer a 12-week course of one of:
- Topical adapalene + benzoyl peroxide
- Topical tretinoin + clindamycin
- Topical adapalene + benzoyl peroxide
  + oral lymecycline or doxycycline
- Topical azelaic acid + oral lymecycline or doxycycline
- Use topical benzoyl peroxide alone if others are unsuitable
Alternatives:
- Replace lymecycline/doxycycline with trimethoprim or oral macrolide if contraindicated
- Use combined oral contraceptives with topicals in women (if suitable)
- Co-cyprindiol for moderate-severe acne after other treatments fail
When to Refer
- Refer to dermatology team if:
  - Severe acne scarring persists ≥12 months after clearance
Do Not Use
- Topical or oral antibiotics as monotherapy
- Combination of topical + oral antibiotics
Patients
- Discuss what may be causing your acne
- Talk through treatment options, pros and cons
- If you're considering pregnancy or using contraception, mention this as some acne treatments may not be safe
Everyday Care
- Don’t over-wash your skin – gentle is best
- Use pH-balanced or slightly acidic cleansers
- Avoid oil-based products like some make-up or sunscreen
- Try not to touch your face too much – it can increase the chance of scarring
- Start treatments slowly to avoid skin irritation
Mild to Moderate Acne
Your doctor may offer a 12-week course of one of these:
- A skin treatment combining adapalene + benzoyl peroxide
- Tretinoin + clindamycin
- Benzoyl peroxide + clindamycin
- If you can't use some medicines, benzoyl peroxide alone may be suggested
Choose:
- Creams/lotions for dry skin
- Gels for oily skin
Moderate to Severe Acne
Doctors may offer a 12-week course of:
- Topical adapalene + benzoyl peroxide
- Tretinoin + clindamycin
- Adapalene + benzoyl peroxide, with oral antibiotics like lymecycline or doxycycline
- Azelaic acid + an oral antibiotic
If oral antibiotics cause side effects or aren’t safe, other antibiotics like trimethoprim or macrolides may be used
Women may be offered the contraceptive pill with creams instead of antibiotics
In some cases, stronger pills like Dianette® may be used if nothing else works
Specialist Referral
- If acne scars remain after a year of clear skin, you might be referred to a specialist dermatology team
Not Recommended
- Antibiotics alone (topical or oral)
- Using both oral and topical antibiotics together [1]
- Self-image and depression
- Ice pick scars- small, deep holes in the skin
- Rolling scars- rolling or uneven appearance found in the skin
- Boxcar scars- round or oval pits in the skin
- Can be treated as a type of cosmetic surgery but is not usually funded under the NHS (exceptions have included cases which can cause significant psychological distress) [10]
- Acne will clear more quickly if you scrub your skin clean
- Wearing makeup causes acne breakouts
- Acne will clear once the teenage year has finished
- Tanning helps clear up acne
- Squeezing/popping pimples will be rid of acne quicker
- Chocolate is bad for your skin
- Eating greasy foods can cause acne
- Cutting out gluten will help clear the skin
- Dairy can cause acne [13,14]
- What are the possible reasons for my acne flares?
- Is there a long-term treatment to manage my acne and prevent exacerbations?
- Are there any changes I need to make to my skincare routines?
- Should I avoid certain foods to help manage acne?
- The British Association of Dermatologists
- Talkhealth
- Acne Support
[1] https://cks.nice.org.uk/topics/acne-vulgaris/background-information/prevalence/#:~:text=An
[2] https://pubmed.ncbi.nlm.nih.gov/23657180/
[3] https://www.nature.com/articles/s41598-020-62715-3
[4] https://pubmed.ncbi.nlm.nih.gov/23210645/
[5] https://www.msdmanuals.com/en-gb/professional/dermatologic-disorders/acne-and-related-disorders/acne-vulgaris?query=acne
[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051853/
[7] https://www.nature.com/articles/s41598-022-25436-3#:~:text=Cutibacterium
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780801/
[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051853/
[10] https://www.nhs.uk/conditions/atopic-eczema/causes/
[11] https://www.almirall.com/your-health/your-skin/skin-conditions/acne/risk-factors
[12] https://bestpractice.bmj.com/topics/en-gb/101
[13] https://www.aad.org/public/diseases/acne/acne-myths
[14] https://www.healthline.com/health/beauty-skin-care/acne-and-diet-myths#acne-and-dairy