Managing acne in primary care
Acne is a common skin problem, and is especially prevalent among adolescents.
A community-based study in Singapore revealed that 88 percent of adolescents aged 13–19 years old were affected by acne to varying extent (51 percent mild, 40 percent moderate, 9 percent severe). [Br J Dermatol 2007;157:547-551] While acne is more common in males (61.3 percent) during adolescence, females tend to predominate in post-adolescent period.
As such, how often a GP will encounter an acne case depends on the location of their practice: one that is located in old matured housing estate would expect to see fewer acne cases compared to practices located in newer housing estate, mall, or central business district area.
Diagnosis of acne is easy and is based on picking up comedonal lesions (white and black heads) and inflammatory papules, pustules, and nodules.
There are many causes for acne but the main cause is hormonal. The initiation of acne is largely influenced by the interplay between hormonal, genetic factors, and Propionibacterium acnes. Other risk factors include physical, chemical, environmental, and dietary factors.
In addition, acne can also be a sign indicative of another underlying disease, including polycystic ovarian syndrome (PCOS), Cushing syndrome, or acne medicamentosa (ie, acne caused by or aggravated by medication such as lithium or anti-neoplastic EGFR inhibitors).
Diagnosis of acne is almost always clinical. Laboratory test is only required when there are suspicions of underlying disease driving the acne, such as PCOS.
Common differential diagnosis that need to be considered include pityrosporum folliculitis (on chest and back), rosacea , steroid acne, perioral dermatitis, beard ringworm (tinea barbae), and folliculitis.
A common challenge that a GP often face during acne diagnosis is in differentiating the common acne from rosacea or pityrosporum folliculitis. Both acne and rosacea are chronic inflammatory skin conditions that are commonly seen. To differentiate rosacea from the rest, the absence of comedones and the presence of telangiectasia and dilated blood vessels are often indicative of a diagnosis of rosacea.
Pityrosporum folliculitis is another challenging condition that mimics acne. It resembles acne except that the papular lesions are more monomorphic while the acne outbreaks are more polymorphic with comedones, papules, and nodules. It is important to keep Pityrosporum folliculitis in mind during diagnosis because antibiotics used for acne can actually make Pityrosporum folliculitis worse.
The key aims for treating and managing acne is to prevent scarring and to enable the patient to have a clear face free from acneiform lesions.
The principle of treatment is usually very straight forward. The main approach for treatment often involves suppression of pilosebaceous gland using oral contraceptive pills, anti-androgen, or isotretinoin.
In addition, anti-comedolytic exfoliation using medications containing benzoyl peroxide, alpha (AHA) or beta hydroxy acid (BHA) and anti-bacterial or anti-inflammatory agents such as antibiotics and topical retinoids are also common approaches in the armamentarium for managing acne.
The treatment principles for adolescents are generally similar to that for adults.
Despite the wide range of products available for treating acne, not all patients respond the same way. The variability of response from one individual to the other can therefore pose a challenge to effective treatment.
Often, the challenges a GP faces in treating acne are twofold: those that are clinically related or those attributed to patient’s expectation. Clinically related issues may involve treatment-related skin irritation, using the wrong treatment approach, or even a wrong diagnosis.
On the other hand, cost and impatience with the speed of recovery constitute some of the challenges that may arise from a patient’s mismatched expectation. As such, adequate patient education and counselling play important role in managing the patient’s expectation.
When a patient is not responsive to treatment, referral to a skin specialist is recommended.
The treatment algorithm for acne is very well established and straightforward. The key to a successful treatment is to build a good relationship and rapport with the patient. It takes time to see improvements and patience is warranted. Educating the patients is important so that they have a good understanding as to why, how, and what clinicians are doing and will go a long way in partnering with them on the road to recovery.