acne vulgaris in primary care dr olusegun omosini st2 gpvts
Post on 19-Dec-2015
226 views
TRANSCRIPT
![Page 1: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/1.jpg)
Acne Vulgaris in Primary care
Dr Olusegun Omosini
ST2 GPVTS
![Page 2: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/2.jpg)
epidermiology
Almost every teenager can expect to experience acne to some degree during the adolescent years.
They tend to "grow out of it" by the early 20s but it can persist rather longer.
Being mediated by androgens, it tends to affect boys more than girls. Acne tends to occur in adolescence, when hormones are in a state of
flux. In girls it may flare up when they are pre-menstrual. The severity of the problem is probably less related to androgen levels
as to end-organ sensitivity.
‘it remains a conundrum why a condition that so undermines self assurance and self esteem should strike at such a vulnerable time in life.’
![Page 3: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/3.jpg)
pathology
This is a disorder of the pilosebaceous follicles found in the face and upper trunk.
It is characterized by the obstruction of the follicle with keratin plugs.
At puberty, androgens increase the production of sebum from enlarged sebaceous glands that become blocked and infected with Propionibacterium acnes causing an inflammatory reaction.
The primary lesion is the comodone which is a follicle impacted and distended by incompletely desquamated keratinocytes and sebum.
Comedones are seen as small white nodules below the skin surface.
![Page 4: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/4.jpg)
sebum
Mixed with lipids (from the surface skin cells), sweat and environmental material,makes the covering oil of skin surface
Sebum is produced by sebaceous glands,found over most of the body. sebaceous glands consists of lobes connected by ducts, which are
lined with cells similar to those on the skin surface. Most sebaceous glands open out into the hair follicle. Some free
sebaceous glands open directly onto the skin surface. These include Meibomian glands on the eyelids and fordyce spots on the upper lip or genitals.
Sebaceous glands on the mid-back, forehead and chin are larger and more numerous than elsewhere (up to 400-900 glands per square centimetre).
Sebum production is under the control of Androgens i.e increased by Androgens
![Page 5: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/5.jpg)
pathogenesis
Patients with acne often have increased production of sebum,hence oily skin. This may be because of:
High overall levels of sex hormones (mainly the androgen, testosterone).
Hyperandrogenism in females Increased free testosterone because of low levels of circulating
sex-hormone-binding-globulin (SHBG). More active conversion of weaker androgens to stronger
androgens such as dihydroxytestosterone (DHT) by the enzyme 5-reductase within the skin.
Higher sensitivity of the skin to DHT.
![Page 6: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/6.jpg)
Aetiology
Normal physiological reaction in puberty Disease of the ovaries
– Polycystic ovarian syndrome– Benign or malignant ovarian tumors
Disease of the adrenal gland – Partial deficiency of the adrenal enzyme 21 Hydroxylase– Benign or malignant adrenal tumors
Disease of the pituitary gland – Cushing’s syndrome due to excessive adrenocorticotrophic hormone – Acromegaly due to excessive growth hormone production – Adenoma of the adrenal gland especially prolactinoma
Obesity and the metabolic syndrome Medication-phenytoin,steroids,barbiturates,OCPills.
![Page 7: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/7.jpg)
presentation
The primary lesions are comedomes. They present at the time of puberty and continue for a variable
number of years thereafter, usually stopping in late teens or early 20s but uncommonly continuing well into adulthood.
They may extend beyond the face to the shoulders, back and chest (seborrhaeic areas).
They tend to run a variable course with marked fluctuations, often being worse in girls who are pre-menstrual.
The severity of the condition varies enormously between individuals.
It is unsightly but the degree of psychological distress does tend to be disproportionate.
![Page 8: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/8.jpg)
Types of acne lesions
Non-inflammatory/primary lesions: Open comedones (blackheads) Closed comedones (whiteheads)
![Page 9: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/9.jpg)
Closed comedone (whitehead)
![Page 10: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/10.jpg)
Open comedones (blackheads)
![Page 11: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/11.jpg)
Close up of blackhead
![Page 12: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/12.jpg)
Inflammatory lesions
Papules (small red bumps) Pustules (white or yellow ‘squeezable’ spots) Inflamed nodules (large red lumps)
![Page 13: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/13.jpg)
cause of inflammatory acne?
Chemicals produced by P. acnes diffuse into the surrounding skin (dermis) and attract white blood cells (polymorphonucleocytes and monocytes).
The cells lining the sebaceous ducts also produce inflammatory mediators so pimples may occur in the absence of bacteria.
Foreign body reaction White blood cells (macrophages and giant cells) removing the debris may cause a more severe granulomatous inflammatory reaction.
Irritation by lipids Free fatty acids and sebum penetrate the dermis after the duct has ruptured
Hypersensitivity (allergy) to P. acnes
![Page 14: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/14.jpg)
![Page 15: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/15.jpg)
Secondary lesions
Excoriations (picked or scratched spots) Erythematous macules (red marks from
recently healed spots, mostly in fair skin) Pigmented macules (dark marks from old
spots, mostly in dark skin) Scars
![Page 16: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/16.jpg)
Acne scar
![Page 17: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/17.jpg)
Acne conglobata
Unpleasant form of nodulocystic acne Interconnecting abscesses and sinuses,
which result in unsightly hypertrophic (thick) and atrophic (thin) scars.
There are groups of large macrocomedones and cysts that are filled with smelly pus.
It is occasionally associated with hidradenitis suppurativa,
![Page 18: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/18.jpg)
Acne conglobata
![Page 19: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/19.jpg)
Acne fulminans
Allergic reaction to P. acne Abrupt onset Inflammatory and ulcerated nodular acne on chest and
back Severe acne scarring Fluctuating fever Painful joints Malaise (ie. the patient feels unwell) Loss of appetite and weight loss Raised white blood cell count.
![Page 20: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/20.jpg)
Acne fulminans
![Page 21: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/21.jpg)
Infantile acne
Infantile acne Generally affects the cheeks, and sometimes the
forehead and chin, of children aged six months to three years.
More common in boys and is usually mild to moderate in severity. In most children it settles down within a few months.
The acne may include comedones inflamed papules and pustules, nodules and cysts. It may result in scarring.
![Page 22: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/22.jpg)
Infantile acne
![Page 23: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/23.jpg)
What is the cause of infantile acne?
The cause of infantile acne is unknown. It is thought to be genetic in origin. Hormone abnormalities in older children with acne may be
associated with the following conditions: Congenital adrenal hyperplasia Cushing's Disease 21-Hydroxylase deficiency Precocious puberty Androgen-secreting tumors
![Page 24: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/24.jpg)
Should any tests be done?
In most babies with acne, no investigations are necessary.
In older children, or if there are other signs of virilisation, the following screening tests may be useful.
Blood tests: DHEAS, testosterone, 17-hydroxyprogesterone, LH, FSH, prolactin
![Page 25: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/25.jpg)
Solar comedones
![Page 26: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/26.jpg)
What tests should be done?
About 50% of females with acne have an imbalance of hormones although this is usually only mild.
Any symptoms suggestive of primary cause should be investigated in full.
Otherwise, not necessary
![Page 27: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/27.jpg)
General principles of treatment
Acne can be effectively treated, but response is usually slow Face washing bed-rock of management Where possible, avoid excessively humid conditions Ultraviolet light helps. Try not to apply irritant oils or cosmetics to the affected skin. Abrasive skin treatments can aggravate acne Try not to scratch or pick the spots No relationship between particular foods and acne has been
proven
![Page 28: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/28.jpg)
Treatment mild acne
Wash affected areas twice daily with a mild cleanser and water or an antiseptic wash.
Acne products should be applied to all areas affected by acne, rather than just put on individual spots.
A thin smear should only be applied to dry clean skin at nighttime.
Acne products may work better if applied in the morning as well.
They often cause dryness particularly in the first 2-4 weeks of use. This is partly how they work. The skin usually adjusts to this.
Apply an oil-free moisturizer only if the affected skin is obviously peeling.
![Page 29: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/29.jpg)
Topical medication
retinoid preparations eg tretinoin 0.1-0.25%, isotretinoin 0.05%, adapalene 0.1%.
treatment of choice for comedonal acne anti-inflammatory effect prevents comedone formation application at bedtime (retinoids inactivated by light) azelaic acid is an allternative anticomedonal preparation benzoyl peroxide 2.5-10% eg benzamycin gel salicyclic acid Tea tree oil products
![Page 30: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/30.jpg)
Topical antibiotics
clindamycin 1% Erythromycin 2% and 4% with zinc acetate
1.2% - most useful when inflammatory lesions predominate
topical antibiotics should be used in combination with retinoids to prevent antibiotic resistance
![Page 31: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/31.jpg)
Treatment of moderate acne
Step 1 plus oral antibiotics
an adequate dose of antibiotic should be given for at least three months before deciding that a patient has failed to respond
after three months therapy then a reduction of acne lesions by 30-50 per cent should have occurred(pt assessment)
Good response? continued for a further three months and then the patient maintained on an appropriate topical regimen
Poor response to oral antibiotic therapy then an alternative antibiotic may be substituted
![Page 32: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/32.jpg)
Oral antibiotics
First line - Tetracycline, 2nd line-Erythromycin, doxycycline,
minocycline(causes SLE), Trimethoprim is increasingly used by
dermatologists
![Page 33: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/33.jpg)
Oral antiandrogen:
cyproterone acetate 2mg with ethinyloestradiol 35 mug (Diannette) dly
Similar efficacy as oral antibiotics but also contraceptive and controls hirsutism
risk of venous thromboembolism is high conventional low-dose second- or third-
generation COCs are more appropriate
![Page 34: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/34.jpg)
NSAIDS
Some patients are helped by nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen
![Page 35: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/35.jpg)
Treatment severe acne
Many patients will be treated with oral isotretinoin. If this is not suitable, the following may be used: High dose oral antibiotics for six months or longer In females, especially those with polycystic ovary
syndrome, oral antiandrogens such as Diannette or spironolactone may be suitable long term. Systemic corticosteroids are sometimes used for their antiandrogenic effect.
Flutamide and finasteride also been reported to be of benefit in hyperandrogenic women, though not liscenced
![Page 36: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/36.jpg)
Physical treatments for acne
Sunlight is anti-inflammatory and can help briefly.o skin cancer.
Cryotherapy Intralesional steroid injections Comedones can be expressed by cautery or
diathermy. Microdermabrasion can help mild acne. Lasers and light systems (blue light) X-ray treatment-no longer recommended for acne as
it may cause skin cancer.
![Page 37: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/37.jpg)
Who to refer
Immediate referral indicated (within a day): have a severe variant of acne such as acne fulminans or
gram-negative folliculitis
Urgent referral have severe or nodulocystic acne and could benefit from
oral isotretinoin have severe social or psychological problems, including
a morbid fear of deformity
![Page 38: Acne Vulgaris in Primary care Dr Olusegun Omosini ST2 GPVTS](https://reader035.vdocument.in/reader035/viewer/2022062216/56649d405503460f94a1a421/html5/thumbnails/38.jpg)
Routine referral At risk of or are developing scarring despite
management have moderate acne that has failed to respond to
treatment which has included two courses of oral antibiotics, each lasting three months.
are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs assessment