There are two fundamental principles necessary for the optimum treatment of acne. Firstly the need to prescribe treatment based on an understanding of the disease and secondly to prescribe according to the patients type of acne and their perception of the disease.
There are four major aetiological factors involved in the development of acne. These are:
The seborrhoea and comedone formation alter the microenvironment of the duct resulting in:Handouts
There is increasing evidence to suggest that comedone formation may precede the seborrhoea. It certainly occurs before inflammation. In the prepubertal years comedones are seen before inflammatory lesions and 85 percent of early inflammatory lesion are associated histologically with a comedone or microcomedone.
Acne severity depends not only upon the physical appearance of the patients acne, but also upon the duration of disease, failure of previous therapy the presence of, or risk from scarring and the psychosocial effects of the disease. We recommend the use of some form of physical objective assessment and some assessment of the psychosocial effects of the disease.
First line treatments can be summarised as follow:
1. Mild comedonal acne: topical retinoid.
2. Mild papular acne: topical retinoid and topical antimicrobial, such as benzoyl peroxide or topical antibiotic.
3. Moderate papular/pustular acne: topical retinoid and topical antimicrobial, especially benzoyl peroxide plus oral antibiotic (especially of the tetracycline group). In cases of females requiring the pill, then topical therapy as indicated plus Dianette.
4. Severe disease: high dose antibiotics, such as minocycline 200 mg per day, or trimethoprim (300 mg twice daily) oral isotretinoin.
Most patients with mild or moderate disease should show 20% improvement in two months , 40% improvement in four months and 80% improvement in 8 months.
Reasons for a poor response to therapy are:
1. Poor compliance. Poor compliance can be found, surprisingly, in up to 60% of patients.
2. Wrong diagnosis. An event which I am sure never occurs in Finland!
3. P. acnes resistance. This occurs particularly with erythromycin , clindamycin and occasionally with tetracycline. Be suspicious in patients who have received many and varied oral and topical antibiotics. Treatment of P. acnes resistance consists of the use of non-antibiotic therapy such as retinoids, hormones, and benzoyl peroxide
4. Side-effects of therapy. Both common , but in particular uncommon side effects, will be described in the presentation
5. Unusual acne cases-such as patients with sandpaper acne , macrocomedones and submarine comedones.
It is also important not to forget the use of physical modalities of treatment, such as blackhead removal, gentle cautery of the larger whiteheads, light therapy, cryotherapy and intralesional steroids.
There are a large group of patients with difficult disease. Such patients represent but a small percentage of our clinical practice but such diseases can be very challenging to the dermatologist and these will be discussed in the nexhttp://www.medicalmasterclass.comt two presentations.
W. J. Cunliffe, Leeds