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July 28, 2021 01:06pm
By Jill Murphy, Associate Editor
Acne is a common, chronic skin disorder involving inflammation and/or blockage of the sebaceous follicles.
Acne is a common, chronic skin disorder involving inflammation and/or blockage of the sebaceous follicles. The major pathogenic factors involved include follicular hyperproliferation and keratinization with abnormal desquamation, increased sebum production due to androgenic stimulation, and microbial colonization of pilosebaceous units by
, which results in inflammation. Clinical features include a range of lesions, such as open and closed comedones, inflammatory papules, pustules, nodules, and cysts
. Presentations of acne can range from a mild comedonal form to severe inflammatory cystic acne of the face, chest, and back.
An estimated 50 million individuals in the United States are affected by acne, and the cost of treating acne is more than $3 billion per year.
The disorder has an 85% prevalence rate among those 12 to 24 years old, with peak prevalence occurring during adolescence. Recent studies also cite the increasing prevalence of adult acne, particularly in women.
The physical effects of acne include the potential for disfigurement, scarring, and permanent discoloration. Psychological effects can be significant and include the potential for psychological scarring due to emotional trauma, poor self-esteem, depression, and anxiety.
Acne Risk Factors
Evidence supports the presence of several risk factors in the development of acne. Common risk factors include the following:
Some evidence exists for high glycemic foods and possibly dairy intake as risk factors for acne.
Opinion to no evidence exists for chocolate intake as a risk factor.
Subjective assessment of the patient with acne should include the following:
Objective assessment should include clinical assessment of acne severity. Categorization of acne severity, based on clinical presentation, is presented in
TABLE 1:ASSESSMENT OF ACNE SEVERITY10
Acne Treatment Goals
Principles of acne treatment include the control of noninflammatory and inflammatory processes, prevention or minimizing of scarring and permanent pigmentation changes, and elimination or reduction of modifiable acne-causing factors. Long-term treatment is often necessary. It is essential that interventions to support therapeutic adherence be included in each patient’s treatment plan, such as engaging the patient in shared decision making. Lastly, treatment of patients with acne should support optimal psychosocial health and well-being.
Treatment options include OTC medications, prescription creams and ointments, and antibiotics. Common pharmacologic therapies for the treatment of acne are highlighted in
TABLE 2:ACNE PHARMACOLOGIC THERAPIES2,3,9,10,12-14
Single Topical Antibiotics
Fixed-Dose Combination Products
Treatment of Acne
The treatment of acne depends on the severity of acne as determined by clinical presentation.
presents an evidence-based approach to the treatment of acne according to classification of acne severity.
TABLE 3:TREATMENT OF ACNE10,14,15
Mild to Moderate
Moderate to Severe
Mild to moderate papulopustular acne
Moderate to severe papulopustular/moderate nodular acne (no pitting)
Severe nodular or conglobate acne
benzoyl peroxide (or benzoyl peroxide + topical clindamycin combination product)
Oral antimicrobial + topical retinoid
oral antimicrobial + azelaic acid
oral antimicrobial + topical retinoid + benzoyl peroxide
Referral to PCP or dermatologist
Alternative topical retinoid or azelaic acid
Alternate topical retinoid + alternate benzoyl peroxide or azelaic acid or oral antimicrobial
Consider endocrine evaluation and hormonal therapy if positive for signs of androgen excess
Referral to PCP or dermatologist
Topical retinoid +/- benzoyl peroxide
PCP= primary care provider
Acne Referral Guidelines
Health care providers in the retail clinic setting can greatly improve access to effective care and support optimal management in patients with acne
. However, certain clinical presentations involving severe cases of acne require referral to a primary care provider or dermatologist. In the following instances, it is most appropriate to refer patients presenting with acne to a higher level of care:
Acne Patient Education
Comprehensive education in support of therapeutic adherence should be provided to all patients to help them manage their condition. Patient education should include setting realistic goals and expectations, how to use treatment therapies, awareness of potential adverse effects of medications, likely time scale for improvement, and duration of treatment.
Patients should be encouraged to use medications as directed and allow sufficient time for acne products to take effect. Washing the skin with a gentle cleanser twice daily is recommended. Patients should also be advised to avoid picking at acne lesions as this may cause permanent damage and scarring. Encourage the use of cosmetics and toiletries that do not clog pores and recommend the use of sunscreen with all acne medications.
Lastly, plan for follow-up assessment and care at 4- to 8-week time intervals.
Acne affects the lives of millions of individuals in the United States each day.
The potential physical and psychological effects are significant and require an effective therapeutic plan. Topical retinoids and benzoyl peroxide are mainstay therapies in the effective treatment of most cases of acne. Patient education and regular follow-up care visits that support therapeutic adherence are essential to optimal patient outcomes. Cases that require referral include patients presenting with severe acne, deep nodules, or cysts that could benefit from isotretinoin therapy, as well as patients suspected of having an underlying endocrine disorder.