Introduction

This quiz was based on content from "How to treat acne", BPJ 20 (April 2009). Dr Amanda Oakley provides specialist comment.

There are now in excess of 25 interactive quizzes available which provide an ongoing opportunity for accumulating CME points. These are available from www.bpac.org.nz.

GP panel:

For most GPs, the focus of treating acne is to prevent new lesions forming, while addressing individual concerns of the patient. People are affected psychologically to varying degrees by their acne – some have severe acne and seem not to be bothered by it at all and do not even raise it as a concern (especially young males) and some have only a few lesions on their face but are significantly depressed and anxious because of this. The panel said that they would not always ask about depression if the patient was seeking treatment for acne and did not have any obvious signs of distress. Sometimes a patient may present with depression which is their primary reason for seeking treatment and after questioning it appears that a significant cause of the depression is the presence of acne, which pre-dated the depressive illness.

N.B. Regardless of the number or severity of lesions, acne that causes significant psychological distress is classified as “severe acne”.

Should doctors be actively asking patients if they want to treat their acne?

Specialist comment:

It is always useful to ask how much the acne is bothering the patient, to determine its perceived severity and the likely adherence to potentially tedious and longterm treatment regimens. They are usually grateful to be asked how it affects them and will readily admit to low self-esteem. Questions may then reveal in some individuals significant embarrassment, withdrawal from social encounters, family friction and clinical depression.

The Cardiff Acne Disability Index (ADI)* is simple to use, however results do not always correlate with clinical acne severity. Each of five questions scores 0, 1, 2, or 3. The scores are added together to make the ADI. The maximum possible score is 15.

Question 1 asks whether their acne has induced negative feelings such as aggression, frustration or anger.

Question 2 asks whether the acne has interfered with social encounters.

Question 3 asks whether the acne has prevented swimming. This question might be altered to include other sports with communal changing rooms.

Question 4 asks the effect of the acne on their feelings i.e., the degree of concern or depression caused by it.

The last question is the patient’s assessment of severity.

* Motley RJ, Finlay AY. Practical use of a disability index in the routine management of acne. Clin Exp Dermatol. 1992 Jan;17(1):1-3.

GP panel:

In the case scenario, this patient would be classified as having mild acne. However the panel felt that this classification was subjective and that the presence of inflammatory lesions would indicate to them more than mild acne.

The myth about junk food causing acne is still prevalent among young people and their parents. The panel would like to ask the Specialist if there is any evidence of a link between certain foods and cause or exacerbation of acne (e.g. milk). Also, is there any dietary source that is beneficial e.g. vitamin C?

Many GPs may be reluctant to ask about the use of cosmetics and skincare products as they do not know what are good and bad products and how to judge this. Does the Specialist have any general advice about this? What products or ingredients can be recommended? What should be avoided?

Specialist comment:

Inter-observer agreement on acne severity is very poor, even with the aid of photographic grading scales – which tend to evaluate inflammatory lesions rather than comedones. Inflammatory lesions can be very small and superficial hence “mild”, and comedones can be numerous and large, hence “severe”.

Food may influence acne. Acne is absent or much less common in some rural populations than in Westernised urban environments. Some studies have suggested this may be related to dairy products, perhaps because of hormones in milk. Others have evaluated the role of high-glycaemic foods, fat intake or fatty acid composition. Acne is associated with polycystic ovaries and metabolic syndrome; insulin resistance may also play a role.*

However, we do not know how to advise our patients. We should probably at least encourage a low-glycaemic, low-fat diet. The Stone Age “hunter-gatherer” diet has been reported of benefit. But these diets are difficult for New Zealand teenagers to follow.

I share the panel’s difficulty with tackling cosmetic use. The evidence for specific products causing or aggravating acne is mixed. Women are likely to ignore instructions to avoid moisturisers and foundation, so I advise them to use a gentle non-soap cleanser and choose water-based “light” or non-oily face creams.

* Spencer EH, Ferdowsian HR, Barnard ND.  Diet and acne: a review of the evidence. Int J Dermatol. 2009 Apr;48(4):339-47.

GP panel:

Although the panel agrees that topical treatments such as benzoyl peroxide or adapalene would be appropriate in this case, often they may prescribe doxycycline due to cost issues. The topical treatments are not subsidised and can be unaffordable to many people. Doxycycline may also be selected if a rapid resolution to the acne was required. Or alternatively, they may prescribe a short course of flucloxacillin or a cyproterone based contraceptive for female patents.

Specialist comment:

Despite dermatologists’ pleas, topical acne therapy remains unsubsidised. Nevertheless, we must tell our patients that it is recommended and likely to be of benefit. They are often already spending a great deal of money on remedies of dubious benefit. Ask them!

Antibiotics do not take care of comedones, which should be managed initially with topical benzoyl peroxide and/or topical retinoids. New combination topical products will enhance compliance and results (e.g., benzoyl peroxide / clindamycin and benzoyl peroxide / adapalene). Topical antibiotics as sole treatment are deprecated owing to lack of efficacy and bacterial resistance.

Systemic antibiotics are warranted if there are many or deep inflamed lesions, but they do not work any faster than topicals. Combined oral contraceptive agents, especially those with antiandrogens such as cyproterone or drospirenone, are effective for women with seborrhoea and mild to moderate acne.

GP panel:

The panel agreed that this person was suffering from moderate acne and that a three-month course of doxycycline, along with the topical treatments was required. The decision not to prescribe minocycline is usually based on cost. The potential severity of the adverse effects related to this medication are perhaps not fully realised. The panel would be interested on the Specialists comment on the place of minocycline in the treatment of acne.

Specialist comment:

The most common oral antibiotics for treating acne vulgaris are the tetracycline derivatives, although erythromycin, trimethoprim, co-trimoxazole and clindamycin have also been used extensively. The rationale is the effect on Propionibacterium acnes as well as the intrinsic anti-inflammatory properties of these antibiotics.  Sensitivity of Propionibacterium acnes to erythromycin is lower than to doxycycline or minocycline.

Doxycycline is fully subsidised and effective if taken regularly in doses ranging from 50 mg to 200 mg daily. Side effects from doxycycline are common but rarely serious (nausea, oesophagiitis, photosensitivity).

Minocycline is considered second-line. It is partially subsidised. Dermatologists think it may be more effective than doxycycline in patients that forget to take their pills, as it is supposed to stay in the sebaceous glands for several days. It has some serious potential adverse effects (dizziness, hypersensitivity reactions, hepatitis, lupus erythematosus, long-lasting bluish pigmentation), but these are very rare.

GP panel:

Despite much debate and industry media coverage, it appears that many GPs are unaware that they are now able to prescribe subsidised isotretinoin and the ones that do know are not “actively signing people up”.

Prescribing with the aid of a decision support tool made the GPs feel confident that they were covering all required aspects and were prescribing safely. The best resources were bestpractice decision support and BMJ learning tool. However the GPs are unclear at this stage how to fulfil the medico legal requirements of prescribing isotretinoin. Does a training course need to be completed?

Some issues that the panel discussed included the fact that a double appointment was needed for an initial prescription of isotretinoin, due to the amount of work involved. Also, it is important to determine that the patient wishes to receive isotretinoin and is not influenced by a “pushy parent”.

The panel will be interested to see if there is an overall increase in the number of people using isotretinoin or simply a shift of the same patients that were previously receiving prescriptions from a dermatologist.

Bpac comment: On the Special Authority application form for isotretinoin, the prescriber has to indicate that they: “have an up to date knowledge of the treatment options for acne and are aware of the safety issues around isotretinoin and are competent to prescribe isotretinoin”. No specific training course currently exists. In order to fulfil this Special Authority requirement, the GP must be competent to undertake the treatment in the same way as for any other clinical situation. It is the responsibility of the individual to familiarise themselves with isotretinoin and the treatment of acne. It is strongly recommended that a decision support prescribing tool is used.

Specialist comment:

It takes a long time to become expert and comfortable prescribing isotretinoin. Dermatologists in training are closely supervised for four years and may treat hundreds of patients with this drug. The route to acne-clearance is rarely straightforward, requiring dose adjustment and interruption, and careful management of side effects. The patient should be prepared for this. Prolonged consultations and careful follow-up are necessary.  It is best to have a working relationship with a local dermatologist; but many dermatologists are struggling to accept the changed prescribing environment and prefer to see the patient themselves.

Myths and legends abound. Many patients with acne and /or their parents are misinformed and may demand or refuse appropriate treatment. Procede with care!

GP panel:

Although isotretinoin is a major teratogen, it does not affect sperm, only the embryo. However male partners of females using isotretinoin are recommended to use condoms (as well as their partner using oral contraception) until one month after treatment has ceased. Any patient using isotretinoin also should not donate blood during and for one month after treatment has finished, due to the risk of a pregnant woman receiving this blood.

In the special authority criteria for isotretinoin, it states that the patient must agree not to become pregnant during the course of treatment. Can a patient be trusted if they say they are not sexually active or is it simply not good practice to prescribe isotretinoin if a patient refuses oral contraceptives? The doctors on the panel disagreed on this. Some felt that if a patient would not use oral contraceptives or if they had doubts that they would take it, they would not prescribe isotretinoin. One GP said that they would prescribe to a non-sexually active female refusing oral contraceptives, if they were well informed of the risks and capable of taking responsibility for their own contraception if they did become sexually active (which the GP can provide if requested).

The panel also noted that due to the risk of sharing pills, it is important that male patients are also told about the teratogenicity of isotretinoin and understand that contraception is required if females use this medication. They wonder if the Specialist can comment on any research into patient compliance with contraception whilst using isotretinoin and the level of sharing of medication. How are patients accepting the risks?

Specialist comment:

I am nervous every time I prescribe isotretinoin to a female. It is essential to ensure she understands the implication of pregnancy. I obtain signed consent. I talk about sexual activity, improved self esteem leading to new relationships, pregnancy testing, contraception, emergency contraception, rape and termination of pregnancy. I make sure she knows who to call or email for further advice.  I do not prescribe if I am not convinced she can be relied on. But mistakes happen and you have to be prepared for that.

The overall risk of birth defects is estimated as up to 30% after exposure during embryogenesis. The burdensome iPLEDGE system in the USA may not have reduced the numbers of pregnancies.* Pregnancy testing does not prevent pregnancy. Studies have shown that some exposed pregnant women did not received counselling. Some women did not use contraceptives due to motivational, cultural and religious barriers.

“Yet because acne is so horrific and so common, even the most conservative risk/benefit analysis finds that, overall, isotretinoin provides far more benefit than risk.”*

* Abroms L, Maibach E, Lyon-Daniel K, Feldman SR. What Is the best approach to reducing birth defects associated with isotretinoin? PLoS Med 2006;3(11): e483.

GP panel:

The panel had no specific comment for this question. Benzoyl peroxide should be applied to the entire affected area. It appears that question interpretation may have been a factor here in the almost one-third of respondents that selected wrong answers.

The panel would like to know what the role of salicyclic acid is in acne treatment. It once was popular but seems to have gone out of favour now. Is it effective? Also what advice can a GP give to a patient for selecting an OTC medicated product, which one should they choose?

Specialist comment:

Over-the-counter acne medications may be effective, well tolerated and cosmetically elegant for some patients. Salicylic acid (beta hydroxy acid) remains popular and can be found in cleansers and leave-on treatments. It has mild comedolytic and anti-inflammatory effects, but may cause irritant dermatitis (like benzoyl peroxide and topical retinoids). Other useful components include glycolic acid (alpha hydroxy acid), azelaic acid, resorcinol, sulphur, sodium sulfacetamide. Antiseptics such as triclosan are popular as cleansers. Zinc, retinoic acid, niacinamide, tea tree oil, green tea, and ayurvedic therapies also are frequently used.

But good information about these ingredients is hard to find. I advise basing your recommendations on benzoyl peroxide. This has comedolytic, keratolytic and antiinflammatory action. It is available as wash-off or leave-on lotions, gels and creams in various concentrations and priced from $20 to $30 for 40 g (about one month’s supply). The low concentrations (2.4 – 4%) are just as effective as higher strength products, and less irritating.

GP panel:

The panel felt unsure of the correct answer to this question. They also wondered if a “significant improvement” from the patient’s perspective is different from that of the doctor. The GPs on the panel would tell patients to expect to see an improvement within six weeks. If no improvement was seen within three months, they may consider an alternative treatment. Often when patients do see an improvement, they are very reluctant to cease treatment. Dose tapering is encouraged but there is often resistance to this.

Specialist comment:

Whatever drug is being studied, improvement occurs steadily but slowly, plateauing at about six months. There is probably little benefit to reviewing before three months treatment has been completed, except to encourage compliance and to manage adverse effects. But many patients achieving 60% reduction in the number of spots report “no benefit” from the treatment as nothing less than complete clearance is good enough for them.

Dose tapering has not been well studied in acne. It is useful in rosacea, but rosacea responds much more quickly and completely to doxycycline in most cases.

I favour using doxycycline 100 mg daily rather than small doses for six months, then stopping. If acne clears, it can be stopped earlier – we need to balance efficacy in an individual with increasing bacterial resistance in the community. But topical therapy must be continued as maintenance therapy. If significant acne recurs, it’s probably time to consider oral isotretinoin.

GP panel:

The GPs noted that although it is important to recommend adequate contraception with doxycycline, their threshold with accepting “not sexually active” is lower than with isotretinoin. They wonder if there are any statistics on doxycycline affected pregnancies.

GPs are more familiar with the adverse effects of doxycycline and how to deal with them. It is not uncommon that adverse effects are experienced, and they sometimes can be quite severe. It is important that advice is given to the patient and reinforced by the pharmacist e.g. using sun protection, taking medicine with a glass of water.

Specialist comment:

Doxycycline and other tetracyclines are not teratogens. The data sheet reports:

1. The use of tetracyclines during tooth development (last half of pregnancy, infancy and in childhood to the age of 12 years) may cause permanent teeth discolouration. Enamel hypoplasia has also been reported.
2. Results of animal studies indicate that tetracyclines cross the placenta, are found in foetal tissues and have toxic effects on the developing foetus manifested by retardation of skeletal development. The importance of this in humans is not known, however, doxycycline should not be used in pregnant women unless the benefit outweighs the risk.

So if a woman prescribed doxycycline becomes pregnant, she should stop it. The data sheet does not report any interaction with oral contraceptive agents. I advise the use of additional contraception for the first four weeks of the combination. The physiological basis for this advice is loss of gut bacteria, and decreased enteric recycling of estrogen metabolites.