Acne

The main reason for referring a patient with acne is for Roaccutane treatment.

Indications for Roaccutane

1. Severe nodulo-cystic acne – any age and either sex.

Roaccutane is such an effective treatment for severe nodulo-cystic acne that we suggest referral without trying other treatments first. We will see several nodulo-cystic acne patients as soon as possible in order to lessen the risk of scarring.

2. Moderate acne that has failed to respond to prolonged courses of systemic antibiotic treatment (>6 months) in addition to topical treatment, and including hormone therapy for women.

3. Mild to moderate acne in patients who have an extreme psychological reaction to their acne and have failed to respond to prolonged courses of systemic antibiotic treatment, and including hormonal therapy in women.

If you can manage most patients with acne, we can see more quickly those who require Roaccutane.

If you do consider the patient will require Roaccutane, please do the following just prior to the appointment.

1. Fasting lipids

2. LFTs and FBC.

3. Pregnancy test for females. In females, consider starting on the oral contraceptive pill prior to referrals.

4. Please enclose the blood results with the letter – we are often told that the results will follow later but invariably they don’t!

How to Manage Mild to Moderate Acne in General Practice

TOPICAL

Benzoyl Peroxides

Panoxyl Aqua Gel 2.5%, 5%, 10%
Brevoxyl.
Acnezide gel 5%
P.acnes is an anaerobe and Benzoyl Peroxide kills it as it provides oxygen. It often irritates at first, but less so if in an aqueous base. It is a bleach so wash hands after use.
Benzoyl Peroxide with Erythromycin, eg: Benzomycin Gel ( twice a day)
Benzoyl peroxide with clindamycin, eg: Duac gel ( once a day).

Antibiotics:

Erythromycin, eg: Stiemycin
Clindamycin, eg: Dalacin T Lotion (or Solution for greasy skin)
Erythomycin with Zinc -Zineryt
Clindamycin with zinc - Zindaclin

Topical Retinoids

Retin A Cream 0.025%
Retin A Gel 0.01% and 0.025%
Isotrex Gel (a topical form of Roaccutane)
Differin Gel/cream (Adapalene)

Remember that retinoids can irritate when used topically, but this usually settles. Use 2-3 times weekly at first and build up the strength of the product and ultimately use BD if possible. Use Differin cream only at night. Sometimes combine retinoid with Erythromycin, eg, Isotrexin Gel.

Preference for Topical Treatment

With resistance of P.acnes to antibiotics developing rapidly, we would favour the use of topical retinoids. However, avoid using them in pregnancy. Benzoyl Peroxide is effective but can be irritant and is a bleach and both these factors limit its use.

SYSTEMIC AGENTS

Systemic Antibiotics

In general, use topical treatment at the same time as oral antibiotics. Benzoyl Peroxide products or topical retinoids are especially useful.

The problem of systemic antibiotics is increasing resistance of P.acnes.

Oxytetracycline Start at 500 mg BD, one hour before meals, or four hours after meals. Continue for at least six months on this dose. Avoid in children and avoid in pregnancy.

Doxycycline (Vibramycin 100mg) Daily
Lymecycline (Tetralysal 300) Daily
Minocin MR 100 mg daily
Erythromycin 500 mg BD
Trimethoprim 100 mg BD

Tetracyclines are usually well tolerated although the bowels may be upset with either diarrhoea or constipation early on in treatment. Vaginal candidiasis is fairly common. A rare side effect with Tetracyclines is benign intracranial hypertension and so beware of headaches and examine the optic fundi if symptoms are persistent. Photosensitivity may also be a problem.

The evidence for one Tetracycline over another is not strong but the once daily treatments are certainly easier for the patients.

Minocin MR is usually well tolerated but the occasional patient can develop bluish pigmentation of the skin after prolonged use. It is, however, a rare side effect at the dose of 100 mg per day. This Minocin pigmentation tends to fade with time but it can be permanent.

A very rare side effect of Minocin is a hypersensitivity reaction that includes hepatic failure, fever, and a rash with a lupus-like arthritis. The patient should be warned that if they do develop fever, rash, arthritis or jaundice that they should stop Minocin and consult with their GP.

Hormonal

The combination of Ethinyl Oestradiol 35 mcg with the anti-androgen Cyproterone Acetate 2 mg (Dianette) can be very effective in the treatment of acne, with or without topical treatment and/or systemic antibiotics. There have been reports of cyproterone acetate causing hepatic carcinoma but for the small dose used in Dianette, the evidence is tenuous and thus long term use is not thought to be a problem. This is at odds with the family planning guidelines.

Antibiotics and “The Pill”

The evidence that a long-term low dose antibiotic reduces the efficacy of the OCP is more theoretical than real.

Advice:

1. Ask women taking the OCP to use additional contraception for the first two weeks of long term antibiotic treatment.

2. Women on OCP with 20 mcg oestrogen in whom periods are irregular, suggest a higher dose pill.

3. If diarrhoea develops, some additional contraception should be used for the rest of that month.