March 4, 2024 • 33 mins
As Dr Roger Henderson aptly puts it, “...The one thing guaranteed to make my heart sink, if I'm walking down the high street, is to see someone with acne scarring... Because you know that, that was preventable.”
In this insightful episode, your hosts Dr George Moncrieff and Dr Roger Henderson discuss acne treatments, emphasising the crucial importance of preventing acne scarring.
From topical retinoids to isotretinoin, this episode equips healthcare professionals with essential knowledge and patient-centric approaches to addressing acne. You’ll learn:
- The essential information-gathering process at the onset of a consultation, laying the groundwork for selecting the most suitable treatment option(s).
- Insights into what treatment choices are available, how they work, who they are suitable for and what the benefits are.
- Proactive measures for the prevention of acne scarring, alongside an overview of scar types and management strategies.
- When to refer for isotretinoin and what you, as a primary care clinician can do to help the process of referral go smoothly.
- Acne management in patients with skin of colour and how it differs.
Whether you're a seasoned healthcare professional or a budding practitioner, this episode offers invaluable perspectives and practical insights into acne treatment.
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
Find out more: https://aproderm.com/aproderm-emollient-starter-pack/
LI: https://www.linkedin.com/company/fontus-health-ltd/
Got some feedback for us? Please rate and review Rash Decisions to help us keep creating educational podcasts for you.
Is there a dermatology topic you’d like us to explore? Email us at info@aproderm.com, and we’ll do our best to cover it.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
Hello, and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatments in aninteresting and hopefully informative way.
I'm Dr Roger Henderson, I'ma GP with a long-standing
interest in this area of health.
(00:25):
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
of the Dermatology Council for England.
Now today, George and I are going tobe talking about the treatment of acne
and discussing the possible options ofthis most common condition in detail.
And it's the second of two podcastsabout acne and if you were with us
(00:46):
for the first one, where we talkedabout the basics of the problem,
then we do hope you found it helpful.
To kick off this week's podcast then,George, let's not dive into medication
straight away, but perhaps let's firstchat about some general treatment
(01:09):
principles here to think of when we'vegot a patient in our surgery sitting in
front of us who's presented with acne.
I suppose I'd first of all wantto know what's been used to date,
and what are they currently using,including their skincare regimen,
and any over the counter treatmentsthat they might be using themselves.
(01:30):
So, you need to knowclearly what's going on.
I would be thinking, in women inparticular, about what contraception
they're using and if they're onsomething, for example, like a combined
pill I talked about last time, whichwill, make acne worse, some of the
first-generation combined pills.
And then in blokes, particularlyas we were talking about last time,
(01:51):
again, the very muscular fellow comingin with acne, is he actually taking
recreational or anabolic steroids?
And then as far as sort of trying tothink about my treatments, what I'm going
to actually prescribe, and of courseI spend time talking to them about the
pathogenesis of the acne, and avoidingmake-ups that clog up the pores, and not
picking at the spots, and diet and so on.
(02:14):
The first thing I think about itis the type of lesion, is it an
inflammatory type of acne predominantly,or more non-inflammatory, i.e.
have they just got open comedonesand very few papules and pustules,
or is it much more inflammatory?
And I think then, I'd want to sit backand try and get some handle on how much
impact it's having on my patient and whatpsychological impact it could be having.
(02:38):
I remember, I had a 14 year old girl camein once with her mother and I thought the
girl was walking in backwards because shehad this lovely, lovely hair completely
covering her face, and it just looked likeI was looking at the back of her head, and
she barely allowed me to look at her acne.
She was so embarrassed anddistressed by her self-image.
(03:01):
It was a real eye-opener forme, just how severe acne can be.
So, what really matters to me,is what matters to the patient.
And if I think it's mild and trivial, butif the patient doesn't, then it's not.
I'm guided by the patient.
So, I want to find out, what it isthat they're looking for, what's their
outcome that they're going for, and howmuch they're prepared to put up with the
(03:24):
inconvenience to achieve that outcome.
And then I can start planningmy treatments with them.
I think that's sensible and the,other little thing I would often think
about when talking initially to apatient, in my head is, why has this
patient chosen to come to me today?
It's not because they've been waitingsort of two or three weeks to get
to see me, but they're often livingwith that acne for quite a long time.
(03:47):
So, has there been a trigger, havethey been bullied or teased about it?
Are they wanting to be in a relationshipbut they can't be because they feel
their skin is holding them back?
Or do they just feel it's gettingworse and they've had enough?
That can be a really useful littlequestion to ask, you know, why
are you here to see me, today?
I mean, you can couch it in differentways, but you can usually tease
(04:08):
that information out of a patient.
I think that's an incrediblyimportant nugget, a really good bit
of advice from an experienced doctor.
I like that.
So, if we think about generalprinciples again, I sometimes try
and tease out, possible lines ofconversation with my acne patients.
So, with treatments, you know, Istart to think, okay, is this acne
(04:31):
mainly comedonal or is it pustular?
Is it not responding?
Have we tried treatments before?
Almost layer treatmentsaccording to how they present.
And I suspect you do the same as well.
I do, yes.
The first thing I'd say is thatthe first line treatment for
(04:52):
acne is a topical retinoid.
All but all patients with acne,bad enough to merit treatment,
should be on a topical retinoid.
Now the only caveat to that wouldbe, I wouldn't knowingly prescribe
it to somebody in pregnancy.
(05:13):
Between you and me, this isn't betweenyou and me because it's being broadcast,
but if my daughter-in-law, my daughterhappened to be using a topical retinoid
in pregnancy, would I be concerned?
Not a jot.
I would say you should stop.
There's no real need totreat acne in pregnancy.
We'll come on to that, but itisn't licensed in pregnancy.
But the amount that'sabsorbed, is barely detectable.
(05:37):
We're getting up from 6.6to 6.7 nanograms per litre.
It's a trivial increase, putthat into some context, if you
take isotretinoin by mouth, thelevel is 860 nanograms per litre.
So that's teratogenic, but does goingfrom 6.6 to 6.7 have any relevance?
I don't think so.
(05:58):
But of course, if they happento have a child with some
problem, can you prove it wasn't?
No.
I certainly don't think people, women ofchildbearing age can only use a topical
retinoid if they're using contraception.
I certainly don't feel that at all, butI would say, look, when you're pregnant
or if you get pregnant and you intendto continue with the pregnancy, you
shouldn't carry on with the topicalretinoid, but otherwise everybody
(06:20):
should be on a topical retinoid.
They're actually licensed from 12,but I'm happy for them to be used
in children younger than that,
off-licence.
So, that's
another topic perhaps.
So, all patients shouldbe on a topical retinoid.
They do cause some irritation,particularly when you start them.
They can cause the skin to feel red,dry, tight, even cracked and so on.
(06:45):
So, I do talk patients about buildingthem up very gently, very gradually
over a space of a few weeks and, theywill develop tolerance to them.
So, if they could persevere with them,it stops causing that problem and then
they can tolerate it without any issue.
And they should build up graduallyuntil they're using it once a day.
Ideally at bedtime or in thenight, because some of them cause
(07:07):
photosensitivity, and they should treatall areas where they've ever had a spot.
They don't treat theexisting spots very well.
They're much better at treating themicrocomedone, that precursor lesion.
So, you use them to prevent the spotsthat would otherwise have come up in
a couple of weeks time, and they dotake a few weeks to start working.
If it's more mild -ish and notcovering a very large area of skin,
(07:32):
and it's mainly a little bit ofpapular changes and some pustular
changes and some closed comedones.
Then the best treatment forthat is benzoyl peroxide.
And that's a peroxide, so itworks by delivering bubbles
of oxygen through the skin.
And of course, the cutibacteriumis an obligate anaerobe, so
it's powerfully antiseptic.
(07:52):
Of course, being a peroxide, itwill bleach fabrics, and so you do
need to warn patients about that.
It's very important.
And I like the fixed combination Epiduo®,which contains my favourite topical
retinoid, adapalene, at 0.1% and 2.5%benzoyl peroxide, which is the ideal
concentration of BPO, benzoyl peroxide.
And they use that just once a day and thatcovers both the microcomedone precursor
(08:18):
lesion and the more inflammatory lesions.
If it's more widespread or notresponding to that, then I would think
about prescribing an oral antibioticfor a couple of months, but it's
really important that they continuewith the topical agents as well.
I don't know about you, butI haven't used a topical
(08:40):
antibiotic for acne for 20 years.
Yes, they're...
Yeah.
...easy to prescribe.
Yes, they don't cause thoseside effects, initially.
Yes, they work, but I think at toogreat a price, for both the patient's
health, as far as their microbiomeis concerned, and from the point of
view of antimicrobial stewardship.
(09:00):
So, I don't go in with topicalantibiotics, but I would count on
a systemic antibiotic, usually atetracycline, like lymecycline, one a day.
Critical thing there is to continuethe topicals and bring them back
after a couple of months to review.
Yeah, I mean, if we are using systemicantibiotics and I think, yes, you
(09:21):
and I perhaps are both much morereticent than many of our peers.
What duration should we belooking at using them for?
Well, I've seen so many patientswho've been on antibiotics
for 6, 10, even 20 years.
And there's a study by AlisonLayton from Harrogate, who is one
of the world authorities on acne.
(09:43):
She did a study in primary care lookingat patients presenting with acne, and
those individuals who have startedon treatment, I think less than a
quarter had any further consultationin their records in the next year
and that's really unacceptable.
I think if you start somebody ona treatment like an antibiotic, it
really is critical to bring them backand I'd say probably bring them back
(10:04):
about maybe two or ideally perhapsthree months after you started.
So, give them a threemonth supply and come back.
Get some photographs taken at thebeginning, because if it's no better
after three months, and they can bephotographs on the patients phone, so
that's easy enough you can compare.
If it's no better after threemonths, well, probably no point
carrying on, it's not going to work.
If it is better, then yeah, carry on andI think continue taking it for as long as
(10:28):
you can be sure it's continuing to help.
But if they are getting scars and they'restill needing an antibiotic, then I think
you need to consider more definitiveoptions, which we'll come on to.
So, review at three months or so.
I have had patients who have beenon them for several years, but I
really feel uncomfortable about that.
I don't like it.
No, I agree.
(10:48):
You mentioned scarring there and the onething guaranteed to make my heart sink,
if I'm walking down the high street,is to see someone with acne scarring.
Yep.
Absolutely.
Because you know that,that was preventable.
You know the impact that,that is having on them.
And you just think for whateverreason, that was an opportunity missed.
(11:09):
Now, bearing in mind, it is always bestto avoid scarring rather than trying
to treat scarring once it's occurred.
Are there treatments for, activescarring that are worth their salt?
Well, the best treatment is prevention.
So, the best thing is tocontrol the acne, aggressively.
There are four differenttypes of acne scarring.
(11:32):
There's hypotrophic, which I usually thinkcould be due to patients picking their
spots and just excavating a bit of skin.
But it may just be some dermal loss, fromthe inflammatory lesion, where you get
these slightly depressed areas of skin.
There's hypertrophic scarringwhere you get these small, white
bumps, different to pustules.
(11:54):
Firm, white bumps in the dermis and youcan miss them if you don't look for them.
And the way to find them is youstretch the skin and they suddenly
appear as a cluster of little whitedots, bigger than milia, about two
millimetres across, maybe, three.
And these are hypertrophic scars.
Those are scars, not visible ifyou don't look for them so easily.
Then of course you can get the icepick scar, which is where you get
(12:16):
deeply tethered tissue and it lookslike an ice picks driven down into
the skin, and you've got a holein the skin going down very deep.
And then finally acne goes forthe keloidal areas, in people who
get acne, typically young people.
So, the front of the sternum, and theshoulders and the ears and things.
These are sites where you get acne.
So, keloid is a very, very difficultscarring problem to manage.
(12:40):
Very high strength topical retinoids, thesort of triple strength topical retinoids,
do have some benefit for scarring.
But as far as treatment of scarringis concerned, I wouldn't treat
it until I'm confident the acneis completely controlled, and
has been controlled for a while.
So, you don't want to treatscarring and then find that they
(13:01):
get more scarring from, more acne.
So, you must have itcompletely controlled.
But lasers, the CO2 laser Ithink is the gold standard and
it can be very, very effective.
I've seen dramatic before and afterphotographs, of patients who've had
laser treatment for their scarring.
But the most effective treatment, forsomebody who's got bad acne, and is
scarring is, of course, isotretinoin.
(13:24):
And the lovely thing about isotretinoinis 80 plus percent of patients who have
a course of isotretinoin, which let'sface it only lasts about four or five
months usually, never have another spot.
No more acne.
No more antibiotics, no moredoctor's appointments, they're
left with a lovely complexion.
And of course, once they've finishedthe course, they can wait a year
(13:47):
for the skin to recover its normalstrength, if their acne is completely
controlled at that point, theycan go for some laser treatment.
I'm sure we'll come on toRoaccutane® in a second.
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Again, there are understandably some,some wariness among some of our colleagues
about certainly initiating Roaccutane®,and the vast majority would be initiated
in secondary care, unless you have someonelike yourself, with such experience.
(16:19):
But, avoidance of pregnancy being thereally number one thing to always watch
like a hawk, it [Roaccutane®] is arelatively straightforward treatment.
Absolutely.
It really is.
And, the European directive, I knowwe're not controlled by that any longer,
but in 2008 said that any physicianwith experience with retinoids, which
(16:41):
they went out of their way to confirm,that included topical retinoids,
should be available to prescribe andlicensed to prescribe oral retinoids.
Now, in the UK, there's a very, very cleardirective, underlined by the MHRA that,
that in the UK equals dermatologists.
There are three major concerns aboutoral retinoids, as you say, the first is
(17:05):
pregnancy and it's rightly controlled bythe Pregnancy Prevention Programme [PPP],
there's legislation to say that thathas to be adhered to, and it's rigorous.
You have to be absolutely certainthat your patient, a woman,
is not going to get pregnant.
It doesn't affect a man who'sresponsible for conception, it's only
women taking it during pregnancy,and it is severely teratogenic.
(17:26):
So, they need to be ideally on two formsof contraception, they need to have had
negative pregnancy tests before starting,they've got to sign a form to confirm
that they're not going to let themselvesget pregnant, and they've got to have
pregnancy tests every month beforethey're given a further one month supply.
It's very rigorous, appropriately so.
The second concern is, what impactit might have on mood, and does
(17:46):
it cause suicidal tendencies?
Well, I've coordinated over 700 coursesand I'd say virtually every patient did
report that their mood was down a bit.
It's a vitamin A like product.
Vitamin A is a fat-soluble vitamin.
They cross the blood-brain barrier.
We know it gets into the brain andwe know in rats it gets into part of
the hippocampus involved with mood.
(18:07):
So, no big surprise there,that it affects mood in humans.
I have to say though, the majorityof patients who come to see me are
so overwhelmed by the improvement intheir acne and their self-esteem that
they say, this is more than compensatedfor any slight drop in my mood.
But we have to watchcarefully for mood changes.
(18:29):
And interestingly, the risk ofsuicide is greatest about a year after
completing a course of isotretinoin.
And I wonder whether that may bein individuals whose acne has then
come back, having hoped that they'llnever have any more spots again.
But, it is a concern, there's astudy in the BMJ and there's a study
a couple of years ago, and there'sa study, I think it's in 2018, which
said that almost certainly acne,severe acne, causes depression,
(18:55):
causes anxiety, low self-esteem, poorself-image, and suicidal thoughts.
And individuals with acne, commit suicide.
We also know that individuals onisotretinoin have committed suicide.
They've often got very severe acne.
The number of people committingsuicides on acne is many fewer in
the individual taking isotretinoin,compared to the population with
(19:18):
acne, not taking Roaccutane®.
So, they came to the conclusion thatif someone's got bad acne, enough
to affect their mood, the besttreatment probably, is isotretinoin.
And that was endorsed by a paper publishedin the BAD Journal last year, very much
saying that the odds ratio of suicideand depression and things is greater on
antibiotics than it is on isotretinoin.
(19:40):
So, that's an interesting areaand unfortunately the media have
got the wrong end of the stick.
And there have been suicides and itis an area that needs to be looked
at carefully by people who arecompetent at looking at people with
mood changes, suicidal thoughts.
And then the final importantone I think is in blokes.
(20:01):
Loss of libido and impotence.
And that was only really recognisedabout five or six years ago.
And it can be a big issue,but it's rare, very rare.
Not too surprising because isotretinoindoes affect the androgen receptors.
So, that's probably howit's doing this effect.
So, it's something I would talk tomy patients about in some depth and
encourage them not to be put off by thatbecause it's most unlikely to happen.
(20:24):
But I ask you, would you go to adermatologist for advice on contraception?
Yes.
Would you go to a dermatologistif you're worried about your
mood or had suicidal thoughts?
Would you go to a dermatologist if you hadproblems with impotence or loss of libido?
That is not the areas where theyare, particularly specialised.
(20:44):
They would defer all ofthose back to the GP.
Yes, quite right too.
So, what is the sense?
I know general practice is not lookingfor work, but in fact, isotretinoin
is so brilliant at controlling acne.
Although general practice doesn'twant to increase its workload, in
fact, isotretinoin might give atemporary blip of work, prescribing
it, but the improved control and theeasy access that we offer means that
(21:08):
patients can have their acne sorted.
And you're not having 10 years, 20 yearsof acne treatments and appointments,
and patients becoming more scarred.
And cost-effective, the reductionin appointments and long courses
of antibiotics and topicaltreatments going on for years.
The cost is a no brainer.
It really is cost-effective.
(21:28):
So, I think the argument is one thatshould be had, and I think it is, quite
ridiculous that we are constrained bythe current rules in Great Britain.
I don't like thoserules, as you can gather.
I think that would be really interestingto an awful lot of people listening.
Staying on the pregnancy theme, thatwe've touched on with Roaccutane®.
(21:49):
As a general principle, you havesomeone who is pregnant with
acne and their acne is botheringthem enough to ask for treatment.
In our surgeries, what shouldwe be thinking about in those
cases when we do have a pregnantpatient with acne in front of us?
Well, your options are very limited.
You could certainly use azelaic acid.
(22:12):
Azelaic acid is produced naturallyby the pityrosporum yeast.
So, in Malassezia furfur, the pityriasisversicolor, the areas of depigmentation
in that rash are caused by azelaic acid.
And I sometimes use azelaic acid, forpost-inflammatory hyperpigmentation,
particularly in dark skin and inthings like melasma and so on.
(22:33):
Skinoren® 20%, it's fairly weak, but itwill certainly have some effect so you
can go in with that without too muchworry, I never worry about pityriasis
versicolor in pregnancy, for example.
I think benzoyl peroxide is fairly safe.
I don't think it's licensed for use inpregnancy, but I wouldn't be anxious about
my daughter using it, if she needed to.
That'd be perfectly acceptable.
(22:54):
So, I think benzoyl peroxide is okay.
I've talked all about diet and allthe other things you can talk about.
I personally wouldn't want touse a tetracycline in pregnancy
or a macrolide or a lincosamide.
There was a paper a couple of yearsago showing that lincosamides, things
like clindamycin orally, and I thinkit may even have been topically,
(23:15):
and certainly macrolides orally,things like erythromycin, can cause
congenital malformations, significantly.
So, I avoid erythromycin in pregnancy,I avoid clindamycin; I don't use
clindamycin topically anyway,and I would avoid tetracycline.
So, you've got a problem really,and I think that it's only
going to be a matter of time.
Of course, some of these treatmentsare not ideal in breastfeeding either.
(23:38):
So, it may be a bit longer, but itis a tricky area, and we haven't
got many options, unfortunately.
Yeah, it's an interesting one that.
You mentioned dark skin there, oneof the slight, bugbears of mine.
It is getting better, there's no questionit's getting better, but again, thinking
back, open a dermatology textbook andtry and find a non-Caucasian picture
(24:02):
of a skin condition and you just won't.
It can be really tricky, partlythrough, you know, lack of education
and partly through, just the sheer factthat the skin is so heavily pigmented.
It does make a difference withour diagnosis and being able to
assess our patients with acne.
So what about acne in patients withskin of colour, because it is an extra
(24:24):
layer of complexity sometimes, isn't it?
It really is, isn't it?
Well, first of all, they'remore vulnerable to getting
things like pomade acne.
They often use very thick oils for theirhair to make their hair manageable.
Now those pomades get onto their skin,it can block the pores and cause a
rather nasty inflammatory, localisedinflammatory reaction with acne.
Very dark skin is particularlyvulnerable to keloidal scarring, so
(24:49):
often you see keloidal scarring andtherefore it makes me feel more keen
to get on with managing it urgently andgetting the acne under good control.
And lower threshold for talkingabout and thinking about
isotretinoin, with that in mind.
But of course, the main problem is thepost-inflammatory hyperpigmentation
that they get and therefore it'simportant to control that inflammation.
(25:11):
And then often co-prescribe someazelaic acid for what it's worth to
try and reduce that inflammation.
Of course, with dark skin, you don't seethe acne so much, but it can be still
just as disfiguring and just as painful.
So it is challenging.
You're absolutely right.
But those are some of myinitial thoughts there.
Briefly, going back to antibiotics,it's worth remembering that if you
(25:31):
think of that pathogenesis of anacne lesion; the seborrhoea, the
infundibular hyperkeratosis blockingthe pore, the blocked pore, and
then the overgrowth of the bacteria.
Antibiotics have no impact on any of that.
And they don't kill the bacteriabecause they're resistant to it now.
Antibiotics just deal with thatinflammatory end of that spectrum
(25:53):
of pathogenesis, of the acne lesion.
So you're allowing the lesionto become inflamed before
you're using the antibiotic sideeffect of anti-inflammation.
But yeah, if it's inflamed andthey've got dark skin, I'd be quite
keen to consider an antibiotic tocalm down some of that inflammation.
So let's just keep on that theme ofthe post-inflammatory hyperpigmentation
(26:16):
which, you've touched on there, George.
Again, you mentioned a couple oftreatments, is there anything sort
of further in your mind to addto that as to what we should be
thinking when we're looking to treatpost-inflammatory hyperpigmentation
or once it's done, is it done?
Well, obviously avoid it, control it andtry and prevent it and anticipate it.
(26:38):
Yeah.
I think also worth warning the patientthat sunlight will make it even darker,
so they can use sunblock and keepit out of the sun, that would help.
And also advise them that it usually doesfade, but it fades over years, not months.
It takes a very long time for thatinflammation, but it usually will
calm down eventually with time.
(26:58):
The azelaic acid certainlyinterferes with melanogenesis, so
you can reduce it a bit with that.
Definitely don't go forthings like freezing.
You can end up with quite dramaticand marked hypopigmentation,
which will not be recoverable.
So, don't fall into the temptation oftrying a little gentle freeze or anything.
I think that would be afoolish thing to go for.
There are depigmenting treatmentscontaining things like hydroquinone.
(27:21):
And, if you wanted to go down thatline, I'd want to first be sure that
the acne was fairly well-controlled.
But if I had somebody leftwith difficult, disfiguring,
post-inflammatory hyperpigmentation,I might think about Kligman's formula.
Kligman came up with a formula of aretinoid, a weak steroid usually,
and hydroquinone in combination.
(27:43):
So, triple therapy, and it's not licensedin this country, but in fact you can
get hold of effectively Pigmanorm® orTri-Luma®, are the trade names, which you
can get hold of something very similarto that from a company called Dermatica.
You just go to dermatica.co.uk, I thinkit is, they're advised by dermatologists.
The patient can submit images andthen they have a bespoke treatment,
(28:07):
which can include that treatment.
But hydroquinone lost its licence inthe UK, and we're not supposed to be
prescribing hydroquinone because ofworries about ochronosis and things.
But it is a very effectivedepigmenting agent
Oh, that's really, really interesting.
Have you got any other tips or thoughts?
No, you've covered
Yeah, the trick is to not rowback, just try and avoid getting
(28:29):
there in the first place.
Now with all the pressures on primarycare, you know, which we all know far
too well, including pressure not torefer to secondary care, when should
we be thinking about referral to ourdermatology colleagues in hospital?
Well, if you're not prescribingisotretinoin, which I have to say is
(28:51):
probably virtually everybody in primarycare, that's the only way they're
going to get hold of that, currently.
And I'm not asking all my GPs togo out there and suddenly start
prescribing isotretinoin because itis a huge amount of work to do it
properly and to do it thoroughly.
So, the indication for referralfor isotretinoin is patients with
moderate or severe acne that's notbeing controlled by the agents that we
(29:12):
have available to us in primary care.
Or anyone who's got significant,ongoing active acne with
scarring, because they're probablygoing to get more scarring.
Or the patient who's got severepsychological response or an adverse
psychological response to theiracne, however mild the acne is.
So, even relatively mild acne,if you can't control it and the
(29:35):
patient is very distressed by it,then that's grounds for referral.
If you do refer with isotretinoin in mind,it would make the job of secondary care
massively more easy if you could furnishthe patient with up to date fasting
lipids and liver function blood tests.
And some people alsoinclude a full blood count.
That would mean that they are onestep ahead in their programme.
(29:57):
And of course, make sure that your womanof childbearing age is on established
contraception, before they end upseeing the specialist, so you should
be providing that and making sure thatthey are happy with their contraception.
Ideally, one of the anti-acne typepills like Dianette®, co-cyprindiol,
would be absolutely ideal.
(30:19):
Nexplanon® very good alternatives,just pure progesterone, which can
actually make acne marginally worse.
But because it gives such incrediblyreliable contraception, I don't
think anyone's ever conceivedwith an in date implant in place.
That's very reassuring for the doctorwho's prescribing the Roaccutane® under
the Pregnancy Prevention Programme.
So, the minor worsening of theiracne is more than compensated by the
(30:43):
excellent contraception they get.
But even the Mirena® coilcan make acne a bit worse.
So, they need to be on establishedcontraception before they go.
I think this is an area where,one, if you get to know your local
dermatologist quite well it's helpful,and two, bearing in mind waiting
(31:04):
times, the benefits of being able tosend a high quality photograph, to your
consultant and say, what do you think?
Not necessarily thinking about,Roaccutane®, but if you've got someone
who is not quite at that level andyou're trying everything, it can be
quite helpful if you just get that littlemessage back from the dermatologist
saying, well, have you tried X, Y, or Z,or I think I need to see this patient.
(31:28):
Yeah, if they're a woman and they've gotpolycystic ovaries, then manage that.
And, that's often going ontothose anti-acne pills, but I've
used metformin off-licence.
I've had patients onthat for up to 20 years.
Doesn't cause hypoglycaemia, and youneed to build it up gradually, so
they tolerate it and maybe go on tothe modified release if they're on
higher doses, but that can be highlyeffective at keeping that at bay.
(31:49):
I've even used spironolactone.
It's not licensed in this country, itis in America, and you have to use quite
high doses, like 100 or 200 milligrams.
But it does have a useful effect.
So, there are other things that we canuse and there are going to be a biological
for acne in the foreseeable future.
So, watch this space.
Yes, the cavalry, maywell be coming there.
I think that's a really goodplace to bring this episode to
(32:11):
a close, and George and I do hopethat you found it interesting and
helpful in your clinical practice.
So, Roger and I hope you'll join usagain next time where we'll be discussing
another key area of dermatology tohelp you look after the health of your
patient's skin as effectively as possible.
We'd also like to thank our sponsor,AproDerm® for all their help in putting
(32:32):
these Rash Decisions podcasts together.
We couldn't have done it without them.
So until the next time,it's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
Goodbye.
Hello, and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatments in aninteresting and hopefully informative way.
I'm Dr Roger Henderson, I'ma GP with a long-standing
interest in this area of health.
(00:25):
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
of the Dermatology Council for England.
Now today, George and I are going tobe talking about the treatment of acne
and discussing the possible options ofthis most common condition in detail.
And it's the second of two podcastsabout acne and if you were with us
(00:46):
for the first one, where we talkedabout the basics of the problem,
then we do hope you found it helpful.
To kick off this week's podcast then,George, let's not dive into medication
straight away, but perhaps let's firstchat about some general treatment
(01:09):
principles here to think of when we'vegot a patient in our surgery sitting in
front of us who's presented with acne.
I suppose I'd first of all wantto know what's been used to date,
and what are they currently using,including their skincare regimen,
and any over the counter treatmentsthat they might be using themselves.
(01:30):
So, you need to knowclearly what's going on.
I would be thinking, in women inparticular, about what contraception
they're using and if they're onsomething, for example, like a combined
pill I talked about last time, whichwill, make acne worse, some of the
first-generation combined pills.
And then in blokes, particularlyas we were talking about last time,
(01:51):
again, the very muscular fellow comingin with acne, is he actually taking
recreational or anabolic steroids?
And then as far as sort of trying tothink about my treatments, what I'm going
to actually prescribe, and of courseI spend time talking to them about the
pathogenesis of the acne, and avoidingmake-ups that clog up the pores, and not
picking at the spots, and diet and so on.
(02:14):
The first thing I think about itis the type of lesion, is it an
inflammatory type of acne predominantly,or more non-inflammatory, i.e.
have they just got open comedonesand very few papules and pustules,
or is it much more inflammatory?
And I think then, I'd want to sit backand try and get some handle on how much
impact it's having on my patient and whatpsychological impact it could be having.
(02:38):
I remember, I had a 14 year old girl camein once with her mother and I thought the
girl was walking in backwards because shehad this lovely, lovely hair completely
covering her face, and it just looked likeI was looking at the back of her head, and
she barely allowed me to look at her acne.
She was so embarrassed anddistressed by her self-image.
(03:01):
It was a real eye-opener forme, just how severe acne can be.
So, what really matters to me,is what matters to the patient.
And if I think it's mild and trivial, butif the patient doesn't, then it's not.
I'm guided by the patient.
So, I want to find out, what it isthat they're looking for, what's their
outcome that they're going for, and howmuch they're prepared to put up with the
(03:24):
inconvenience to achieve that outcome.
And then I can start planningmy treatments with them.
I think that's sensible and the,other little thing I would often think
about when talking initially to apatient, in my head is, why has this
patient chosen to come to me today?
It's not because they've been waitingsort of two or three weeks to get
to see me, but they're often livingwith that acne for quite a long time.
(03:47):
So, has there been a trigger, havethey been bullied or teased about it?
Are they wanting to be in a relationshipbut they can't be because they feel
their skin is holding them back?
Or do they just feel it's gettingworse and they've had enough?
That can be a really useful littlequestion to ask, you know, why
are you here to see me, today?
I mean, you can couch it in differentways, but you can usually tease
(04:08):
that information out of a patient.
I think that's an incrediblyimportant nugget, a really good bit
of advice from an experienced doctor.
I like that.
So, if we think about generalprinciples again, I sometimes try
and tease out, possible lines ofconversation with my acne patients.
So, with treatments, you know, Istart to think, okay, is this acne
(04:31):
mainly comedonal or is it pustular?
Is it not responding?
Have we tried treatments before?
Almost layer treatmentsaccording to how they present.
And I suspect you do the same as well.
I do, yes.
The first thing I'd say is thatthe first line treatment for
(04:52):
acne is a topical retinoid.
All but all patients with acne,bad enough to merit treatment,
should be on a topical retinoid.
Now the only caveat to that wouldbe, I wouldn't knowingly prescribe
it to somebody in pregnancy.
(05:13):
Between you and me, this isn't betweenyou and me because it's being broadcast,
but if my daughter-in-law, my daughterhappened to be using a topical retinoid
in pregnancy, would I be concerned?
Not a jot.
I would say you should stop.
There's no real need totreat acne in pregnancy.
We'll come on to that, but itisn't licensed in pregnancy.
But the amount that'sabsorbed, is barely detectable.
(05:37):
We're getting up from 6.6to 6.7 nanograms per litre.
It's a trivial increase, putthat into some context, if you
take isotretinoin by mouth, thelevel is 860 nanograms per litre.
So that's teratogenic, but does goingfrom 6.6 to 6.7 have any relevance?
I don't think so.
(05:58):
But of course, if they happento have a child with some
problem, can you prove it wasn't?
No.
I certainly don't think people, women ofchildbearing age can only use a topical
retinoid if they're using contraception.
I certainly don't feel that at all, butI would say, look, when you're pregnant
or if you get pregnant and you intendto continue with the pregnancy, you
shouldn't carry on with the topicalretinoid, but otherwise everybody
(06:20):
should be on a topical retinoid.
They're actually licensed from 12,but I'm happy for them to be used
in children younger than that,
off-licence.
So, that's
another topic perhaps.
So, all patients shouldbe on a topical retinoid.
They do cause some irritation,particularly when you start them.
They can cause the skin to feel red,dry, tight, even cracked and so on.
(06:45):
So, I do talk patients about buildingthem up very gently, very gradually
over a space of a few weeks and, theywill develop tolerance to them.
So, if they could persevere with them,it stops causing that problem and then
they can tolerate it without any issue.
And they should build up graduallyuntil they're using it once a day.
Ideally at bedtime or in thenight, because some of them cause
(07:07):
photosensitivity, and they should treatall areas where they've ever had a spot.
They don't treat theexisting spots very well.
They're much better at treating themicrocomedone, that precursor lesion.
So, you use them to prevent the spotsthat would otherwise have come up in
a couple of weeks time, and they dotake a few weeks to start working.
If it's more mild -ish and notcovering a very large area of skin,
(07:32):
and it's mainly a little bit ofpapular changes and some pustular
changes and some closed comedones.
Then the best treatment forthat is benzoyl peroxide.
And that's a peroxide, so itworks by delivering bubbles
of oxygen through the skin.
And of course, the cutibacteriumis an obligate anaerobe, so
it's powerfully antiseptic.
(07:52):
Of course, being a peroxide, itwill bleach fabrics, and so you do
need to warn patients about that.
It's very important.
And I like the fixed combination Epiduo®,which contains my favourite topical
retinoid, adapalene, at 0.1% and 2.5%benzoyl peroxide, which is the ideal
concentration of BPO, benzoyl peroxide.
And they use that just once a day and thatcovers both the microcomedone precursor
(08:18):
lesion and the more inflammatory lesions.
If it's more widespread or notresponding to that, then I would think
about prescribing an oral antibioticfor a couple of months, but it's
really important that they continuewith the topical agents as well.
I don't know about you, butI haven't used a topical
(08:40):
antibiotic for acne for 20 years.
Yes, they're...
Yeah.
...easy to prescribe.
Yes, they don't cause thoseside effects, initially.
Yes, they work, but I think at toogreat a price, for both the patient's
health, as far as their microbiomeis concerned, and from the point of
view of antimicrobial stewardship.
(09:00):
So, I don't go in with topicalantibiotics, but I would count on
a systemic antibiotic, usually atetracycline, like lymecycline, one a day.
Critical thing there is to continuethe topicals and bring them back
after a couple of months to review.
Yeah, I mean, if we are using systemicantibiotics and I think, yes, you
(09:21):
and I perhaps are both much morereticent than many of our peers.
What duration should we belooking at using them for?
Well, I've seen so many patientswho've been on antibiotics
for 6, 10, even 20 years.
And there's a study by AlisonLayton from Harrogate, who is one
of the world authorities on acne.
(09:43):
She did a study in primary care lookingat patients presenting with acne, and
those individuals who have startedon treatment, I think less than a
quarter had any further consultationin their records in the next year
and that's really unacceptable.
I think if you start somebody ona treatment like an antibiotic, it
really is critical to bring them backand I'd say probably bring them back
(10:04):
about maybe two or ideally perhapsthree months after you started.
So, give them a threemonth supply and come back.
Get some photographs taken at thebeginning, because if it's no better
after three months, and they can bephotographs on the patients phone, so
that's easy enough you can compare.
If it's no better after threemonths, well, probably no point
carrying on, it's not going to work.
If it is better, then yeah, carry on andI think continue taking it for as long as
(10:28):
you can be sure it's continuing to help.
But if they are getting scars and they'restill needing an antibiotic, then I think
you need to consider more definitiveoptions, which we'll come on to.
So, review at three months or so.
I have had patients who have beenon them for several years, but I
really feel uncomfortable about that.
I don't like it.
No, I agree.
(10:48):
You mentioned scarring there and the onething guaranteed to make my heart sink,
if I'm walking down the high street,is to see someone with acne scarring.
Yep.
Absolutely.
Because you know that,that was preventable.
You know the impact that,that is having on them.
And you just think for whateverreason, that was an opportunity missed.
(11:09):
Now, bearing in mind, it is always bestto avoid scarring rather than trying
to treat scarring once it's occurred.
Are there treatments for, activescarring that are worth their salt?
Well, the best treatment is prevention.
So, the best thing is tocontrol the acne, aggressively.
There are four differenttypes of acne scarring.
(11:32):
There's hypotrophic, which I usually thinkcould be due to patients picking their
spots and just excavating a bit of skin.
But it may just be some dermal loss, fromthe inflammatory lesion, where you get
these slightly depressed areas of skin.
There's hypertrophic scarringwhere you get these small, white
bumps, different to pustules.
(11:54):
Firm, white bumps in the dermis and youcan miss them if you don't look for them.
And the way to find them is youstretch the skin and they suddenly
appear as a cluster of little whitedots, bigger than milia, about two
millimetres across, maybe, three.
And these are hypertrophic scars.
Those are scars, not visible ifyou don't look for them so easily.
Then of course you can get the icepick scar, which is where you get
(12:16):
deeply tethered tissue and it lookslike an ice picks driven down into
the skin, and you've got a holein the skin going down very deep.
And then finally acne goes forthe keloidal areas, in people who
get acne, typically young people.
So, the front of the sternum, and theshoulders and the ears and things.
These are sites where you get acne.
So, keloid is a very, very difficultscarring problem to manage.
(12:40):
Very high strength topical retinoids, thesort of triple strength topical retinoids,
do have some benefit for scarring.
But as far as treatment of scarringis concerned, I wouldn't treat
it until I'm confident the acneis completely controlled, and
has been controlled for a while.
So, you don't want to treatscarring and then find that they
(13:01):
get more scarring from, more acne.
So, you must have itcompletely controlled.
But lasers, the CO2 laser Ithink is the gold standard and
it can be very, very effective.
I've seen dramatic before and afterphotographs, of patients who've had
laser treatment for their scarring.
But the most effective treatment, forsomebody who's got bad acne, and is
scarring is, of course, isotretinoin.
(13:24):
And the lovely thing about isotretinoinis 80 plus percent of patients who have
a course of isotretinoin, which let'sface it only lasts about four or five
months usually, never have another spot.
No more acne.
No more antibiotics, no moredoctor's appointments, they're
left with a lovely complexion.
And of course, once they've finishedthe course, they can wait a year
(13:47):
for the skin to recover its normalstrength, if their acne is completely
controlled at that point, theycan go for some laser treatment.
I'm sure we'll come on toRoaccutane® in a second.
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Again, there are understandably some,some wariness among some of our colleagues
about certainly initiating Roaccutane®,and the vast majority would be initiated
in secondary care, unless you have someonelike yourself, with such experience.
(16:19):
But, avoidance of pregnancy being thereally number one thing to always watch
like a hawk, it [Roaccutane®] is arelatively straightforward treatment.
Absolutely.
It really is.
And, the European directive, I knowwe're not controlled by that any longer,
but in 2008 said that any physicianwith experience with retinoids, which
(16:41):
they went out of their way to confirm,that included topical retinoids,
should be available to prescribe andlicensed to prescribe oral retinoids.
Now, in the UK, there's a very, very cleardirective, underlined by the MHRA that,
that in the UK equals dermatologists.
There are three major concerns aboutoral retinoids, as you say, the first is
(17:05):
pregnancy and it's rightly controlled bythe Pregnancy Prevention Programme [PPP],
there's legislation to say that thathas to be adhered to, and it's rigorous.
You have to be absolutely certainthat your patient, a woman,
is not going to get pregnant.
It doesn't affect a man who'sresponsible for conception, it's only
women taking it during pregnancy,and it is severely teratogenic.
(17:26):
So, they need to be ideally on two formsof contraception, they need to have had
negative pregnancy tests before starting,they've got to sign a form to confirm
that they're not going to let themselvesget pregnant, and they've got to have
pregnancy tests every month beforethey're given a further one month supply.
It's very rigorous, appropriately so.
The second concern is, what impactit might have on mood, and does
(17:46):
it cause suicidal tendencies?
Well, I've coordinated over 700 coursesand I'd say virtually every patient did
report that their mood was down a bit.
It's a vitamin A like product.
Vitamin A is a fat-soluble vitamin.
They cross the blood-brain barrier.
We know it gets into the brain andwe know in rats it gets into part of
the hippocampus involved with mood.
(18:07):
So, no big surprise there,that it affects mood in humans.
I have to say though, the majorityof patients who come to see me are
so overwhelmed by the improvement intheir acne and their self-esteem that
they say, this is more than compensatedfor any slight drop in my mood.
But we have to watchcarefully for mood changes.
(18:29):
And interestingly, the risk ofsuicide is greatest about a year after
completing a course of isotretinoin.
And I wonder whether that may bein individuals whose acne has then
come back, having hoped that they'llnever have any more spots again.
But, it is a concern, there's astudy in the BMJ and there's a study
a couple of years ago, and there'sa study, I think it's in 2018, which
said that almost certainly acne,severe acne, causes depression,
(18:55):
causes anxiety, low self-esteem, poorself-image, and suicidal thoughts.
And individuals with acne, commit suicide.
We also know that individuals onisotretinoin have committed suicide.
They've often got very severe acne.
The number of people committingsuicides on acne is many fewer in
the individual taking isotretinoin,compared to the population with
(19:18):
acne, not taking Roaccutane®.
So, they came to the conclusion thatif someone's got bad acne, enough
to affect their mood, the besttreatment probably, is isotretinoin.
And that was endorsed by a paper publishedin the BAD Journal last year, very much
saying that the odds ratio of suicideand depression and things is greater on
antibiotics than it is on isotretinoin.
(19:40):
So, that's an interesting areaand unfortunately the media have
got the wrong end of the stick.
And there have been suicides and itis an area that needs to be looked
at carefully by people who arecompetent at looking at people with
mood changes, suicidal thoughts.
And then the final importantone I think is in blokes.
(20:01):
Loss of libido and impotence.
And that was only really recognisedabout five or six years ago.
And it can be a big issue,but it's rare, very rare.
Not too surprising because isotretinoindoes affect the androgen receptors.
So, that's probably howit's doing this effect.
So, it's something I would talk tomy patients about in some depth and
encourage them not to be put off by thatbecause it's most unlikely to happen.
(20:24):
But I ask you, would you go to adermatologist for advice on contraception?
Yes.
Would you go to a dermatologistif you're worried about your
mood or had suicidal thoughts?
Would you go to a dermatologist if you hadproblems with impotence or loss of libido?
That is not the areas where theyare, particularly specialised.
(20:44):
They would defer all ofthose back to the GP.
Yes, quite right too.
So, what is the sense?
I know general practice is not lookingfor work, but in fact, isotretinoin
is so brilliant at controlling acne.
Although general practice doesn'twant to increase its workload, in
fact, isotretinoin might give atemporary blip of work, prescribing
it, but the improved control and theeasy access that we offer means that
(21:08):
patients can have their acne sorted.
And you're not having 10 years, 20 yearsof acne treatments and appointments,
and patients becoming more scarred.
And cost-effective, the reductionin appointments and long courses
of antibiotics and topicaltreatments going on for years.
The cost is a no brainer.
It really is cost-effective.
(21:28):
So, I think the argument is one thatshould be had, and I think it is, quite
ridiculous that we are constrained bythe current rules in Great Britain.
I don't like thoserules, as you can gather.
I think that would be really interestingto an awful lot of people listening.
Staying on the pregnancy theme, thatwe've touched on with Roaccutane®.
(21:49):
As a general principle, you havesomeone who is pregnant with
acne and their acne is botheringthem enough to ask for treatment.
In our surgeries, what shouldwe be thinking about in those
cases when we do have a pregnantpatient with acne in front of us?
Well, your options are very limited.
You could certainly use azelaic acid.
(22:12):
Azelaic acid is produced naturallyby the pityrosporum yeast.
So, in Malassezia furfur, the pityriasisversicolor, the areas of depigmentation
in that rash are caused by azelaic acid.
And I sometimes use azelaic acid, forpost-inflammatory hyperpigmentation,
particularly in dark skin and inthings like melasma and so on.
(22:33):
Skinoren® 20%, it's fairly weak, but itwill certainly have some effect so you
can go in with that without too muchworry, I never worry about pityriasis
versicolor in pregnancy, for example.
I think benzoyl peroxide is fairly safe.
I don't think it's licensed for use inpregnancy, but I wouldn't be anxious about
my daughter using it, if she needed to.
That'd be perfectly acceptable.
(22:54):
So, I think benzoyl peroxide is okay.
I've talked all about diet and allthe other things you can talk about.
I personally wouldn't want touse a tetracycline in pregnancy
or a macrolide or a lincosamide.
There was a paper a couple of yearsago showing that lincosamides, things
like clindamycin orally, and I thinkit may even have been topically,
(23:15):
and certainly macrolides orally,things like erythromycin, can cause
congenital malformations, significantly.
So, I avoid erythromycin in pregnancy,I avoid clindamycin; I don't use
clindamycin topically anyway,and I would avoid tetracycline.
So, you've got a problem really,and I think that it's only
going to be a matter of time.
Of course, some of these treatmentsare not ideal in breastfeeding either.
(23:38):
So, it may be a bit longer, but itis a tricky area, and we haven't
got many options, unfortunately.
Yeah, it's an interesting one that.
You mentioned dark skin there, oneof the slight, bugbears of mine.
It is getting better, there's no questionit's getting better, but again, thinking
back, open a dermatology textbook andtry and find a non-Caucasian picture
(24:02):
of a skin condition and you just won't.
It can be really tricky, partlythrough, you know, lack of education
and partly through, just the sheer factthat the skin is so heavily pigmented.
It does make a difference withour diagnosis and being able to
assess our patients with acne.
So what about acne in patients withskin of colour, because it is an extra
(24:24):
layer of complexity sometimes, isn't it?
It really is, isn't it?
Well, first of all, they'remore vulnerable to getting
things like pomade acne.
They often use very thick oils for theirhair to make their hair manageable.
Now those pomades get onto their skin,it can block the pores and cause a
rather nasty inflammatory, localisedinflammatory reaction with acne.
Very dark skin is particularlyvulnerable to keloidal scarring, so
(24:49):
often you see keloidal scarring andtherefore it makes me feel more keen
to get on with managing it urgently andgetting the acne under good control.
And lower threshold for talkingabout and thinking about
isotretinoin, with that in mind.
But of course, the main problem is thepost-inflammatory hyperpigmentation
that they get and therefore it'simportant to control that inflammation.
(25:11):
And then often co-prescribe someazelaic acid for what it's worth to
try and reduce that inflammation.
Of course, with dark skin, you don't seethe acne so much, but it can be still
just as disfiguring and just as painful.
So it is challenging.
You're absolutely right.
But those are some of myinitial thoughts there.
Briefly, going back to antibiotics,it's worth remembering that if you
(25:31):
think of that pathogenesis of anacne lesion; the seborrhoea, the
infundibular hyperkeratosis blockingthe pore, the blocked pore, and
then the overgrowth of the bacteria.
Antibiotics have no impact on any of that.
And they don't kill the bacteriabecause they're resistant to it now.
Antibiotics just deal with thatinflammatory end of that spectrum
(25:53):
of pathogenesis, of the acne lesion.
So you're allowing the lesionto become inflamed before
you're using the antibiotic sideeffect of anti-inflammation.
But yeah, if it's inflamed andthey've got dark skin, I'd be quite
keen to consider an antibiotic tocalm down some of that inflammation.
So let's just keep on that theme ofthe post-inflammatory hyperpigmentation
(26:16):
which, you've touched on there, George.
Again, you mentioned a couple oftreatments, is there anything sort
of further in your mind to addto that as to what we should be
thinking when we're looking to treatpost-inflammatory hyperpigmentation
or once it's done, is it done?
Well, obviously avoid it, control it andtry and prevent it and anticipate it.
(26:38):
Yeah.
I think also worth warning the patientthat sunlight will make it even darker,
so they can use sunblock and keepit out of the sun, that would help.
And also advise them that it usually doesfade, but it fades over years, not months.
It takes a very long time for thatinflammation, but it usually will
calm down eventually with time.
(26:58):
The azelaic acid certainlyinterferes with melanogenesis, so
you can reduce it a bit with that.
Definitely don't go forthings like freezing.
You can end up with quite dramaticand marked hypopigmentation,
which will not be recoverable.
So, don't fall into the temptation oftrying a little gentle freeze or anything.
I think that would be afoolish thing to go for.
There are depigmenting treatmentscontaining things like hydroquinone.
(27:21):
And, if you wanted to go down thatline, I'd want to first be sure that
the acne was fairly well-controlled.
But if I had somebody leftwith difficult, disfiguring,
post-inflammatory hyperpigmentation,I might think about Kligman's formula.
Kligman came up with a formula of aretinoid, a weak steroid usually,
and hydroquinone in combination.
(27:43):
So, triple therapy, and it's not licensedin this country, but in fact you can
get hold of effectively Pigmanorm® orTri-Luma®, are the trade names, which you
can get hold of something very similarto that from a company called Dermatica.
You just go to dermatica.co.uk, I thinkit is, they're advised by dermatologists.
The patient can submit images andthen they have a bespoke treatment,
(28:07):
which can include that treatment.
But hydroquinone lost its licence inthe UK, and we're not supposed to be
prescribing hydroquinone because ofworries about ochronosis and things.
But it is a very effectivedepigmenting agent
Oh, that's really, really interesting.
Have you got any other tips or thoughts?
No, you've covered
Yeah, the trick is to not rowback, just try and avoid getting
(28:29):
there in the first place.
Now with all the pressures on primarycare, you know, which we all know far
too well, including pressure not torefer to secondary care, when should
we be thinking about referral to ourdermatology colleagues in hospital?
Well, if you're not prescribingisotretinoin, which I have to say is
(28:51):
probably virtually everybody in primarycare, that's the only way they're
going to get hold of that, currently.
And I'm not asking all my GPs togo out there and suddenly start
prescribing isotretinoin because itis a huge amount of work to do it
properly and to do it thoroughly.
So, the indication for referralfor isotretinoin is patients with
moderate or severe acne that's notbeing controlled by the agents that we
(29:12):
have available to us in primary care.
Or anyone who's got significant,ongoing active acne with
scarring, because they're probablygoing to get more scarring.
Or the patient who's got severepsychological response or an adverse
psychological response to theiracne, however mild the acne is.
So, even relatively mild acne,if you can't control it and the
(29:35):
patient is very distressed by it,then that's grounds for referral.
If you do refer with isotretinoin in mind,it would make the job of secondary care
massively more easy if you could furnishthe patient with up to date fasting
lipids and liver function blood tests.
And some people alsoinclude a full blood count.
That would mean that they are onestep ahead in their programme.
(29:57):
And of course, make sure that your womanof childbearing age is on established
contraception, before they end upseeing the specialist, so you should
be providing that and making sure thatthey are happy with their contraception.
Ideally, one of the anti-acne typepills like Dianette®, co-cyprindiol,
would be absolutely ideal.
(30:19):
Nexplanon® very good alternatives,just pure progesterone, which can
actually make acne marginally worse.
But because it gives such incrediblyreliable contraception, I don't
think anyone's ever conceivedwith an in date implant in place.
That's very reassuring for the doctorwho's prescribing the Roaccutane® under
the Pregnancy Prevention Programme.
So, the minor worsening of theiracne is more than compensated by the
(30:43):
excellent contraception they get.
But even the Mirena® coilcan make acne a bit worse.
So, they need to be on establishedcontraception before they go.
I think this is an area where,one, if you get to know your local
dermatologist quite well it's helpful,and two, bearing in mind waiting
(31:04):
times, the benefits of being able tosend a high quality photograph, to your
consultant and say, what do you think?
Not necessarily thinking about,Roaccutane®, but if you've got someone
who is not quite at that level andyou're trying everything, it can be
quite helpful if you just get that littlemessage back from the dermatologist
saying, well, have you tried X, Y, or Z,or I think I need to see this patient.
(31:28):
Yeah, if they're a woman and they've gotpolycystic ovaries, then manage that.
And, that's often going ontothose anti-acne pills, but I've
used metformin off-licence.
I've had patients onthat for up to 20 years.
Doesn't cause hypoglycaemia, and youneed to build it up gradually, so
they tolerate it and maybe go on tothe modified release if they're on
higher doses, but that can be highlyeffective at keeping that at bay.
(31:49):
I've even used spironolactone.
It's not licensed in this country, itis in America, and you have to use quite
high doses, like 100 or 200 milligrams.
But it does have a useful effect.
So, there are other things that we canuse and there are going to be a biological
for acne in the foreseeable future.
So, watch this space.
Yes, the cavalry, maywell be coming there.
I think that's a really goodplace to bring this episode to
(32:11):
a close, and George and I do hopethat you found it interesting and
helpful in your clinical practice.
So, Roger and I hope you'll join usagain next time where we'll be discussing
another key area of dermatology tohelp you look after the health of your
patient's skin as effectively as possible.
We'd also like to thank our sponsor,AproDerm® for all their help in putting
(32:32):
these Rash Decisions podcasts together.
We couldn't have done it without them.
So until the next time,it's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
Goodbye.
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