Overview of new guidance for the management of acne vulgaris

Acne is one of the few diseases that almost everyone suffers from at some stage in their lives.

It is far from the trivial condition that some people seem to see it as.1 Over 80% of teenagers suffer from acne and about three in 10 need treatment from a GP2, however the psychological impact can be devastating for many sufferers as evidenced by acne being the second most common cause of suicide in teenage boys. Increasingly, acne persists beyond adolescence, affecting 12% of women and 3% men aged over 25 years.

Such a common disease is bound to have effects beyond its physical signs and symptoms as suggested by the suicide statistic but the psychological effect is often ignored at a time when patients would benefit most from support.4-6 Studies have shown that 70% of patients have a sense of shame and embarrassment, 65% suffer from anxiety and 27% have frank depression. Management therefore, must not only include a thorough physical examination but also a psychological assessment at the initial visit and adequate reassessment at subsequent visits. It is vitally important that patients’ views are taken fully into account as there are many myths and misconceptions around acne, its causes and its treatment. Any mismatch between patient and GP expectations can compromise outcomes.

A multidisciplinary Acne Working Group was convened to address the need for management guidance for primary care that extends beyond pharmacological treatment. The new guidance considers the evidence base for relative treatment efficacies and summarises the outcome of meeting discussions and consultation in order to provide a practical management tool, including when to refer, summarised in a one-page algorithm for easy reference.

The guidance explores the most suitable treatments, using a systematic approach, and recommends prompt referral to a consultant dermatologist when appropriate. The aims of treatment are to:

  • Reduce the duration of the acne
  • Reduce inflammation
  • Prevent scarring
  • Reduce psychological impact

As well as clearing acne lesions and preventing scarring, effective pharmacological treatment reduces the psychological impact of acne and improves self-esteem and QoL. Acne severity has been summarised in the guidance as a continuum and although selection of appropriate treatment is based on whether the acne is mild, moderate or severe, duration of acne, psychosocial impact and patient preference are also extremely important factors.

  • Mild – predominantly comedones (open or closed) and /or a few inflammatory lesions.
  • Moderate – widespread comedones, more numerous inflammatory lesions and some minor pitting/scarring lesions.
  • Severe – extensive inflammatory lesions which may include nodules and more significant scarring.

This physical grading is usually straightforward and many articles have been written matching grades to treatment however, before reviewing this advice, it is worth considering a grading approach to the psychological side of acne that is all too often ignored. Mild, moderate and severe grades will also suggest appropriate levels of psychological support or therapy in addition to regular follow-up. This is where the new guidance scores over previous ones – by emphasising the importance of psychological management at all stages of the treatment cycle.

  • Mild – some evidence of avoidance of normal daily behaviours. Support by use of websites/ patient organisations
  • Moderate – low mood as well as evidence of avoidance of pleasurable or normal daily behaviours. Offer in-house counselling services and enlist parent or partner support
  • Severe – avoidance of all pleasurable or normal daily behaviours with positive indicators of reactive depression and even suicidal ideation. Refer to mental health team/ psychologist and/or dermatologist

Whichever grade is higher should govern the level of treatment offered so even mild physical acne with severe psychological upset should be treated aggressively.

Questions that can be used to measure the psychosocial impact of acne

  1. How does your acne make you feel?
  2. Does your acne affect your quality of life? If so, in what way?
  3. What does your acne stop you from doing?
  4. How does your acne impact on your work, school or relationships?
  5. What things in your life have been made more difficult by your acne?

Treatments for acne are often looked at in terms of activity against comedones or inflammatory lesions. In fact, many of the topical agents used are active against both types of lesions.  In common with other guidelines, the new guidance recommends benzoyl peroxide and topical retinoids as first-line treatments for mild acne.  Topical retinoids inhibit the formation of comedones and microcomedones, the so-called precursors of all acne lesions (ref 22 from guidance), whilst benzoyl peroxide and topical retinoids loosen those comedones that have already formed (ref 23 from guidance).

Benzoyl peroxide9-10 comes in a range of strengths from 2.5% up to 10% but a review of the evidence suggests little added benefit above 5% with a much greater tendency for irritation. Combined with a topical retinoid may also add to the irritant effect.

Topical antibiotics are mainly effective against inflammatory papules and pustules11 and, as most cases present with a mixture of lesions, they are best used in combination with benzoyl peroxide to reduce the likelihood of resistance developing during treatment in patients with a mixture of comedones and inflammatory lesions.  Topical treatments, used in combination, are usually suitable for the initial management of moderate localised acne.  Benzoyl peroxide combined with a topical antibiotic is more effective than either treatment used as monotherapy and does not increase adverse effects.12 Using proprietary combination products, for example benzoyl peroxide and clindamycin (Duac®) avoids the patient having to apply two products separately and a once-daily application may help with patient concordance.  This is where the guidance adds further value in considering the impact of treatment regimes on patients’ already disrupted lives with patient concordance being an extremely important factor.  Benzoyl peroxide unplugs pores to increase exposure to clindamycin and is bactericidal even against resistant strains of P.acnes.  Clindamycin’s anti-inflammatory action improves the tolerability of benzoyl peroxide.

Topical retinoids are also an important option for the treatment of moderate acne in combination with benzoyl peroxide or with oral antibiotics. Although these combinations are effective in treating both inflammatory and non-inflammatory lesions, concerns about bacterial resistance to erythromycin remain.11

If moderate acne does not respond to combinations of topical treatments, oral antibiotics should be considered. They are also used for practical purposes where the acne is relatively inaccessible to topical treatment; e.g. on the back.13,14 A once a day treatment like doxycycline or lymecycline along with a retinoid or benzoyl peroxide topically is appropriate to use. Even if a retinoid is chosen, regular use of benzoyl peroxide every few weeks or so for a few days does help overcome antibiotic resistance.13

Even with the optimal treatment approach, some cases will fit into the severe grading category and the guidance mirrors the advice from NICE about when to consider referral with a good emphasis on priority in different situations16.

When to refer17
Priority
Criteria for referral
See urgentlyHave a very severe variant such as fulminating acne with systemic symptoms (acne fulminans). Suicidal ideation.
See soonHave severe acne or painful, deep nodules or cysts (nodulocystic acne) and could benefit from oral isotretinoin
Have severe social or psychological problems, including a morbid fear deformity (dysmorphophobia)
Routine appointment
Are at risk of, or are developing scarring despite primary care therapies
Have moderate acne that has failed to respond to treatment which should generally include at least two courses of both topical and systemic treatment over a period of at least six months. Failure is probably best based upon a subjective assessment by the patient
Are suspected of having an underlying endocrinal cause for the acne (such as polycystic ovary syndrome) that needs assessment

 
Whatever the severity of acne, treatment is usually successful but little has been written before about how to maintain and then stop treatment. Patients are often very anxious about their acne returning and reluctant to give up a treatment that has finally worked, therefore care is also needed at this stage of management. The new guidance makes some very sensible recommendations for stepping up treatment and maintenance. It is essential not to withdraw all treatment simultaneously and to use all agents at full therapeutic doses (except for oral antibiotics where necessary) in terms of maintenance. Whether it is reducing the frequency of visits for psychological support or tailing off oral antibiotics whilst still continuing with topical treatments. The latter can finally be withdrawn by reducing the strength and then the frequency of application whilst stepping down from dual to monotherapy.

Acne is a very common disease that can have a devastating effect on some of its sufferers. A patient centred approach is important in most aspects of medicine but never more so than when dealing with acne. It often affects teenagers at a most vulnerable time in their lives and then persists into early adult life when self-confidence and first impressions are so important for employment prospects and relationships. This new guidance is robust in its approach to drug therapy whilst emphasising the importance of treating each patient in the context of their lifestyle and expectations, taking into account any factors that influence choice of drug and regime to maximise patient concordance and the chance of a successful outcome. GPs and other healthcare professionals are now able to manage the whole patient with acne, not just the skin, but must lobby hard with primary care organisations to ensure that new treatments are accepted onto formularies and that the full range of psychological therapy is available promptly when needed.

To request a copy of the guidance, please contact Sarah Hill at Stiefel Laborotories on sarah.hill@stiefel.com

References
1. Simpson NB, Cunliffe WJ. Disorders or the sebaceous glands. In Burns T, Breatnach S, Cox N, et al, editors. Rook’s textbook of Dermatology. Sevemth edition. Oxford:Blackwell Science;2004:p43.15-43.75
2. Garner SE. Acne Vulgaris. In: Williams H, Bigby M, Diepgen T, et al. (Eds) Evidence-based dermatology. London: BMJ Publishing group:87-114.
3. Goulden V, Stables G, Cunliffe W. Prevalence of facial acne in adults. J Am Acad Dermatol 1999;578:577–580.
4. Cunliffe WJ. Minocycline for acne. Doctors should not change the way they prescribe for acne. BMJ 1996;312(7038):1101.
5. Institute for Clinical Systems Improvement (ICSI). Acne Management. Bloomington (MN):Institute for Clinical Systems Improvement (ICSI): 2006.
6. Tan JK. Psychosocial impact of acne vulgaris: evaluating the evidence. Skin Therapy Lett 2004; 9: 1-3
7. Brown SK, Shalita AR. Acne vulgaris. Lancet 1998;351(9119), 1871-76.
8. Waller JM et al. ‘Keratolytic’ properties of benzoyl peroxide and retinoic acid resemble salicylic acid in man.  Skin Pharmcol Physiol 2006;19(5):283-9.

9. Waller JM et al. ‘Keratolytic’ properties of benzoyl peroxide and retinoic acid resemble salicylic acid in man.  Skin Pharmcol Physiol 2006;19(5):283-9.
10.    Tucker R and Walton S.  The role of benzoyl peroxide in the management of acne vulgaris.  Pharmaceutical J 2007;279: 48-53.
11. Simonart T and Dramaix M. Treatment of acne with topical antibiotics: lessons from clinical studies. Brit J Dermatol 2005;153(2), 395-403.
12. Wolf, J.E. (2002) Acne and rosacea: differential diagnosis and treatment in the primary care setting. Medscape. www.medscape.com [Accessed: 25/07/2007].
13. Thiboutot, D. New treatments and therapeutic strategies for acne. Arch Fam Med 2000;9(2):179-187.
14.Brown SK and Shalita AR. Acne vulgaris. Lancet 1998;351(9119), 1871-1876
15. Taylor GA and Shalita AR. Bezoyl peroxide-based combination therapies for acne vulgaris. Am J Clin Dermatol 2004:5(4):261-5.
16. NICE.Referral advice – a guide to appropriate referral from general to specialist services.London:NICE;2001
17. Eady EA, Cove JH, Holland KT, Cunliffe WJ. Erythromycin resistant propionibacteria in antibiotic treated acne patients: association with therapeutic failure. Br J Dermatol 1989;121(1):51-7.

Abbreviated Prescribing Information

Duac® Once Daily Gel

Duac® Once Daily Gel  Prescribing Information
Active Ingredients: clindamycin 1% w/w and benzoyl peroxide 5% w/w.  Uses: Mild to moderate acne vulgaris.  Dosage and administration: Adults: Apply once daily in the evening, to affected areas after the skin has been thoroughly washed, rinsed with warm water and gently patted dry. Children:  Safety and efficacy has not been established in children under 12 years of age.  Contra-indications: Hypersensitivity to clindamycin, benzoyl peroxide or any of the excipients. Should not be used in patients with a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis.  Precautions and warnings: Avoid contact with the mouth, eyes and mucous membranes and with abraded or eczematous skin.  Apply with caution to sensitive areas of skin. The product may bleach hair or coloured fabrics. Patients should be advised that, in some cases, 4-6 weeks of treatment may be required before the full therapeutic effect is observed.  Interactions: Concomitant topical antibiotics, medicated or abrasive soaps and cleansers, soaps and cosmetics that have a strong drying effect, and products with high concentrations of alcohol and/or astringents, should be used with caution as a cumulative irritant effect may occur.  Pregnancy and lactation: The safety of Duac® Once Daily Gel in human pregnancy has not been established, therefore caution should be exercised when prescribing to pregnant women or women of childbearing age who are not practising adequate contraception.  Treatment of nursing mothers with Duac® Once Daily Gel should be restricted to essential cases.  Side effects: Duac® Once Daily Gel may rarely cause pruritus, paraesthesia, erythema and skin dryness at the site of application.  Local skin reactions are infrequent, modest and usually resolve with continued use. Very rarely, allergic reactions have been reported.  For further information on side effects, please refer to the summary of product characteristics.  Legal category: POM.  Package quantities & NHS price: 25g £9.95, 50g £19.90.  Product Licence number: PL 0174/0217.  Marketing Authorisation Holder: Stiefel Laboratories (UK) Ltd. Holtspur Lane, Wooburn Green, High Wycombe, Bucks, HP10 0AU, UK.  Date of preparation: June 2008.

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Stiefel Laboratories (UK) Ltd at adverse.reaction@stiefel.com.

Preparation Date: Jun 2008

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