Acne Vulgaris

Contributed by Jean Watkins, a sessional GP in Hampshire.

Acne vulgaris
Acne is common in teenagers. Mild and moderate cases with greasy skin, comedones (blackheads and whiteheads), follicular rashes, moving on to papules and pustules, will often respond well to topical benzoyl peroxide, axelaic or salicylic acid and may also require an antibiotic such as tetracycline 500mg twice daily or erythromycin 508mg daily to control it. Acne may be aggravated in women on a contraceptive pill containing progesterone. An alternative, such as Dianette, containing an oestrogen and antiandrogen should then be considered.

Cystic and severe acne
Some cases of acne will progress to the formation of nodules and cysts. Others, like this boy, will fail to respond to the basic treatments and require further consideration. These cases may respond well to isotretinoin but, in order to obtain this they will require referral to a dermatology specialist, as the drug is available only from hospitals. In 85 per cent of patients with acne, it will clear by the late teens or early twenties.

Isotretinoin
After nine months of treatment with isotretinoin, this boy was delighted with the result. Apart from the expected side- effects of dry lips, nose bleeds and a slight exacerbation of his old eczema, he had no problems. The list of possible side-effects is almost endless. For women, pregnancy must be avoided while taking the drug as it is teratogenic. Pregnancy tests must be done prior to starting the drug, monthly while on it and for a further month after ending the treatment. Depression has been related to the taking of the drug and patients are advised to discontinue it if mood changes are noticed.

Acne scarring
Untreated severe acne may leave the patient with unsightly scars that persist for a lifetime. Distress about appearance may well lead to depression. This should also be taken into account when considering the use of isotretinoin, which would of course improve the acne that could well be the cause of the depression.

One study found that acne, without primary psychiatric illness, was the presenting symptom in patients with dermatological illness in seven out of 16 cases of suicide. In other words, the pros and cons of the use of isotretinoin must be carefully weighed.

Ice-pick scars of acne
This type of scar usually occurs on the cheeks and is seen to have steep sides with a jagged edge. They may be shallow or deep. The decision to do something about the scars depends on the disfigurement they cause and the effect they are having on the patient's life. The most successful approach to ice-pick scars is surgical removal. This may benefit from follow-up with laser treatments around 12 weeks after the operation. Surgical removal does, of course, always carry the risk of a more obvious, problematic scaring afterwards.

Acne excoriee
Some patients find the temptation to pick and scratch their acne impossible to resist. The consequences may lead to raw, weeping areas that leave unsightly scars. It occurs more commonly in women between the ages of 30-45 years and is often associated with other psychological problems such as depression or eating disorders. It is suggested that a prolonged six month course of an antibiotic such as tetracycline may be helpful. If this fails, referral for retinoid treatment may be considered. Sometimes attention to the underlying psychiatric problem may be more productive.

Infantile acne
The cause of this problem is unknown but it is thought that the changes are hormonal in origin. It occurs in young children from one to six years and is more common in boys. Comedones, papules and pustules develop mainly on the cheek but may also occur on the chin. Topical benzoyl peroxide or erythromycin gel may suffice but sometimes antibiotics such as erythromycin, trimethoprim (not tetracycline) or isotretinoin may be required in severe cases. Severe cases may be followed by permanent scars and there is an increased likelihood of the child developing acne at puberty.

Polycystic ovarian syndrome
In this condition the ovaries are enlarged with a number of cysts within them. A history should reveal irregular periods. Sometimes there may be amenorrhoea. Patients are likely to be obese and hirsute with a greater propensity to hypertension and diabetes. This patient was still troubled by acne at the age of 44. The diagnosis can be confirmed by checking the hormone profile, fasting glucose and fasting lipids. The importance of insulin resistance has been realised and treatment with metformin or a glitazone preparation may improve symptoms. This woman was prescribed isotretinoin.

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