The patient’s unmet needs (PUNs)
An 18-year-old woman attends the surgery with severe acne, much of which she conceals with her hairstyle. She is obviously distressed by her condition, tossing the empty packets of antibiotics on the table with the comment: ‘These are useless.’ On further discussion she becomes quite tearful and seems significantly depressed. ‘Nobody’s helping me,’ she says. ‘No one has even told me what diet I should follow.’ She has looked up her condition online and is keen to be referred to a dermatologist with a view to starting isotretinoin.
The doctor’s educational needs (DENs)
Which antibiotics are recommended in acne as first or second line, and what are the reasons for treatment failure?
Acne may present with a mixture of comedones, papules, pustules, nodules, cysts or scarring. The type of acne and the severity should guide treatment. Topical retinoids, rather than oral antibiotics, are the mainstay of treatment for comedonal acne. But antibiotics are indicated in patients with extensive disease – as in this case – including truncal acne and moderate to severe papulopustular acne.
Oral antibiotics should never be used as monotherapy because of the risk of antimicrobial resistance. Non-antibiotic antimicrobials, including benzoyl peroxide and azelaic acid, should be used alongside. Topical antibiotics would be used in those not on oral antibiotics.
Oral doxycycline (100-200mg daily) and lymecycline (300-600mg daily) are recommended as first-line treatment in preference to minocycline (100-200mg daily) and oxytetracycline (500mg twice daily), because doxycycline and lymecycline have a superior side-effect profile and better patient adherence.1 Erythromycin (500mg twice daily) is effective and should be used in patients who cannot tolerate tetracyclines.2 Trimethoprim (300mg twice daily) is effective in cases where other antibiotics cannot be used.2 If a topical retinoid is used, adapalene should be selected in preference to tretinoin and isotretinoin.1
Poor treatment response may be due to:
- the wrong diagnosis
- poor adherence to therapy
- inappropriate assessment of the overall acne severity
- side-effects of, or intolerance to, therapy
- bacterial resistance or underlying conditions such as congenital adrenal hyperplasia or polycystic ovary syndrome.
Non-comedogenic oil- and fragrance-free moisturisers, cleansers and creams may alleviate the side-effects of treatment and so improve adherence.
Is there any role for special diets in acne?
There have only been a few published studies evaluating the role of special diets in acne, but there is no significant evidence either for or against a specific diet. In particular, no significant link has been found between the consumption of chocolate or sugar and acne.3
Do hairstyles – particularly floppy, concealing fringes – have a role to play in causing or aggravating the condition?
Evidence about whether fringes can have an impact on acne is limited, but case reports and patient experience would suggest that having a fringe does aggravate acne.4 Whether this is through increased sebum production, lack of sunlight, use of hair products or contact and friction is not entirely clear.
How common is comorbid depression in acne?
Comorbid depression is common with acne, although published estimates vary greatly and evidence is complex because the severity of psychological impact is wide ranging. Around 10% of patients with acne may have depression and the prevalence seems to be higher in females and those with more severe acne.
How should GPs manage patients with depression and acne – which is the priority?
Cases of acne are best managed on an individual basis. Often, acne may be one of the causative factors for the depression. It is well known that acne can limit an individual’s social and work activities and negatively affect personal relationships and self-esteem.
Unless the depression is extremely severe or the acne is viewed as insignificant, it would seem reasonable to treat the acne early to prevent worsening of disease, as this would reduce the risk of scarring and any longer-term psychological impact.
How effective is co-cyprindiol? If this treatment is used, how long would it take for any improvement to be noticed?
All oestrogen-containing oral contraceptives have the potential to improve acne in some women. And cyproterone acetate combined with ethinylestradiol has been found to be effective – in the UK, it is not licensed as a contraceptive but as a treatment for severe acne in women.
The risk of venous thromboembolism is highest for first-time users and during the first year of use.5 Careful selection and counselling is required when prescribing the combined pill for acne. Acne treatment often takes several weeks to work, but some benefit should be seen after six weeks.
How strong is the link between depression and isotretinoin, and would pre-existing depression be a contraindication to treatment?
Although there are reports of patients who have suffered from severe depression, serious mood change or committed suicide while taking isotretinoin, no causal relationship has been established. And mood changes are common in adolescents and young adults.
There is evidence that the risk of depression is no greater during isotretinoin therapy than during conservative acne therapy.6 In fact, treatment of severe acne with isotretinoin may often be associated with mood improvement. So depression is not a contraindication to treatment.
But as evidence is lacking, current UK guidelines on the prescription of isotretinoin7 recommend enquiry about previous psychiatric health for all patients considered for isotretinoin, that all patients and their families are made aware of the potential for mood change and a direct enquiry about psychological symptoms at each clinic visit. If symptoms of depression or mood change do occur, ideally isotretinoin should be discontinued. But some patients may wish to continue because of the benefit to their skin. In these cases, specialist psychiatric support should be obtained.
What other issues should be discussed with the patient prior to referral for isotretinoin?
Isotretinoin is a potent teratogen, so women normally need to participate in the Pregnancy Prevention Program to receive repeated monthly prescriptions of the drug.7 The course of treatment is typically for four to six months, and pregnancy should be avoided for the month after finishing the course.
Women are required to use two forms of contraception (one hormonal and one barrier form) while taking isotretinoin. Starting female patients on an oral contraceptive at time of referral is helpful, as patients need to be established on a hormonal contraceptive before isotretinoin is commenced.
Other side-effects of isotretinoin include altered liver function, raised blood lipids, skin and mucosal dryness, muscle aches, headaches and vision problems – particularly night vision – so isotretinoin is contraindicated in airline pilots.
Baseline bloods with fasting lipids may be helpful so that treatment can be started promptly when the patient is reviewed in secondary care.
Acne is a disease of the pilosebaceous unit and pathophysiology includes:
- androgen-dependent increase in sebum production
- abnormal follicular differentiation with hyperkeratinisation
- colonisation with gram-positive anaerobic Propionibacterium acnes
- early peri-follicular inflammation prior to microbial colonisation
- later inflammation due to P. acnes colonisation
- Lifetime risk is estimated to be 80%
- Peak incidence is at 13-16 years in both sexes
- During adolescence it is more common in males; the opposite is true in adulthood
- Open and closed comedones, papules, pustules, nodules, cysts and scarring
- Depends on type and severity
- May include antiseptics, antibiotics, retinoids and hormonal therapy
Dr Shernaz Walton is a consultant dermatologist at Hull Royal Infirmary and honorary clinical reader at Hull York Medical School
Dr Vanessa Smith is a dermatology SpR at Leeds Teaching Hospitals
1 Nast A, Dréno B, Bettoli V et al. European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol 2012;26:S1:1-29
2 Strauss J, Krowchuk D, Leyden J et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007;56:651-63
3 Fulton J Jr, Plewig G and Kligman A. Effect of chocolate on acne vulgaris. JAMA 1969;210:2071-4
4 Bowyer A. Fringe or pop acne. BMJ 1965;25:1548-9
5 Mayor S. European evaluation concludes third-generation pills are associated with a small increase in risk of venous thromboembolism. BMJ 2001;323:828.4
6 Marqueling A and Zane L. Depression and suicidal behaviour in acne patients treated with isotretinoin: a systematic review. Semin Cutan Med Surg 2007;26:210-20
7 Goodfield M, Cox N, Bowser A et al. Advice on the safe introduction and continued use of isotretinoin in acne in the UK. Br J Dermatol 2010;162:1172-9
The British Association of Dermatologists is the central association of UK dermatologists. Its aim is to improve the treatment and understanding of skin disease. Visit bad.org.uk for patient information leaflets, as well as up-to-date guidelines for clinicians, conferences in dermatology and information on training.